Compliance with stimulants for attention-deficit/hyperactivity disorder: issues and approaches for improvement

Effect of methylphenidate formulation for attention deficit hyperactivity disorder on patterns and outcomes of treatment

OBJECTIVES

The aim of this study was to assess whether once-daily Concerta extended-release (XR) methylphenidate (MPH) is associated with: (1) better compliance; (2) decreased likelihood of accidents/injuries; and (3) lower health-care resource use over a 1-year period than 3-times-daily immediate-release (IR) MPH in children with attention deficit hyperactivity disorder (ADHD).

METHODS

Multivariate regression analyses were performed using an administrative database. Inclusion criteria were: (1) an age of 6-12 years at the date of first prescription for XR/IR MPH (index date); (2) patient-level data available for least 6 months before and 12 months after the index date; (3) no ADHD medications in the 6-month prior period; and (4) no XR MPH use by the IR MPH group.

RESULTS

IR MPH: n=344, mean age 9.55 years, 76% male; XR MPH: n=1431, mean age 9.78 years, 75% male. XR MPH patients were less likely to discontinue, less likely to switch, and more likely to persist (i.e., no gaps >14 days) with therapy (p <0.0001). Children receiving XR MPH were less likely to experience an accident or injury (OR=0.58, 95% CI 0.353-0.945). Use of XR MPH was associated with significantly fewer emergency room visits and general practitioner visits per patient, on average, over 1 year.

CONCLUSIONS

These data support the use of XR MPH with its simplified dosing regimen for children with ADHD.

Managing attention deficit/hyperactivity disorder: unmet needs and future directions

The management of attention deficit/hyperactivity disorder (ADHD) requires a multimodal approach. Although shared-care protocols are suggested, uptake by general practice has been tentative. Behavioural management, both on its own and in combination with pharmacotherapy, reduces core symptoms and associated behaviours, such as oppositional defiant disorder (ODD). Links with education and social support are also important for helping children and their families. Psychostimulants have shown to be effective in the treatment of ADHD, however, their short duration of action highlights potential limitations. Other drugs used in the management of ADHD and comorbid disorders include antidepressants, clonidine and its analogues, newer atypical neuroleptics, and atomoxetine, a novel, non-stimulant therapy that has potential to fulfil some unmet treatment needs. Further research is needed in preschool children, girls, those with epilepsy, young adults, and in those with associated sleep disturbance. Selected rating scales and careful history taking, allied to close links with schools, are vital for the initial and ongoing assessment of ADHD and its comorbidities.

Non-stimulant medications in the treatment of ADHD

BACKGROUND

Stimulants are the first-line medication in the psychopharmacological treatment of attention-deficit hyperactivity disorder (ADHD). However, 10 to 30% of all children and adults with ADHD either do not respond to or do not tolerate treatment with stimulants.

OBJECTIVE

To describe alternative treatment approaches with various non-stimulant agents, especially atomoxetine.

METHOD

General review of empirically based literature concerning efficacy and safety of the substances.

RESULTS

A large and still increasing body of data supports the usefulness of atomoxetine, a once daily dosing, and new selective noradrenalin reuptake inhibitor, with few side effects. Atomoxetine has been licensed in the US for use in ADHD across the lifespan, and is currently under consideration in Europe. Other non-stimulant substances, such as tricyclic antidepressants (TCAs) and alpha-2-adrenergic agonists, which are used to treat ADHD, are also reviewed. TCAs have been well studied and shown to be efficacious in the treatment of ADHD, but are limited by side effects. The number of studies documenting the efficacy of alpha-2-adrenergic agonists is still limited. Some experimental studies support a potential role of cholinergic drugs such as acetylcholinesterase inhibitors (tacrine, donepezil) as well as novel nicotinic analogues (ABT-418).

CONCLUSION

Non-stimulant agents have been shown to be effective in treatment of ADHD. Especially, atomoxetine seems promising and newline drugs are in development.

Children's persistence with methylphenidate therapy: a population-based study

OBJECTIVE

To examine persistence with methylphenidate (MPH) therapy among children and youth in the general population.

METHOD

We conducted a retrospective analysis of longitudinally organized, individual-specific anonymous data from linked prescription and health databases covering the population of British Columbia for 1990 through 1996. No prescriptions being filled for 4 months indicated cessation of one bout of therapy.

RESULTS

Among 16,945 identified MPH patients aged 19 years or under, overall duration of therapy was 584 days, and the average number of prescriptions received was 6.6. One-third of patients received 2 or fewer prescriptions, while 18% followed a chronic, continuous course. Among patients receiving more than 2 prescriptions, 50% of discrete therapy bouts lasted 4 months or less, and one-third of cases had multiple bouts of therapy (range 2 to 6 bouts). Younger age (that is, children aged 0 to 8 years, vs those aged 10 to 19 years), male sex, and receipt of initial prescription from a psychiatrist were associated with greater persistence.

CONCLUSIONS

Enormous variability in persistence with MPH therapy and often-occurring low rates of persistence raises questions about the diligence with which MPH patients are selected, prepared, and followed in the general population. Special attention to the needs of older children and to the needs of girls is required, and discontinuities during children's therapy courses require explication.

Influence of methylphenidate on eating in obese men

OBJECTIVE

Rapid synaptic dopamine transport or reduced brain dopamine receptor signaling may influence energy intake. Methylphenidate, a dopamine reuptake inhibitor, increases brain synaptic dopamine and produces anorexia, suggesting that it may reduce energy intake. We investigated the effects of two doses of short-acting methylphenidate on energy intake over one meal in obese adult males.

RESEARCH METHODS AND PROCEDURES

Nine obese males (>85th BMI percentile) ingested a placebo or a moderate dose (0.5 mg/kg) or a high dose (1.0 mg/kg) of methylphenidate in a within-subject double-blind acute laboratory study. One hour after ingestion, pizza consumption was measured in a naturalistic laboratory setting.

RESULTS

Participants reduced energy intake by 23% for the moderate dose vs. the placebo (p < 0.02), but there was no significant difference for the high dose vs. the moderate dose (p > 0.05). Participants consumed 34% fewer kilocalories after ingesting the lowest effective dose of methylphenidate compared with placebo (725.7 +/- 404.5 vs.1095 +/- 271.1 kcal, p < 0.01). Seven of nine subjects responded to the moderate dose. The increase in perceived drug effect above placebo was correlated with the reduction in energy intake for both the moderate (r = -0.85, p = 0.004) and the high (r = -0.75 p = 0.021) doses. Hunger scores were not different across drug doses or placebo before drug administration.

DISCUSSION

Methylphenidate reduced energy intake of a highly palatable food over one meal by one-third in obese adult males. Dopamine transport inhibition may be an effective component of a comprehensive treatment for obesity.

Latina mothers' stances on stimulant medication: complexity, conflict, and compromise

This study was undertaken to understand and describe Latina mothers' cognitions and attitudes toward the use of medication for their young children's behavior problems under the premise that these factors are determinants of noncompliance and inadequate adherence to medication treatments. Quantitative and qualitative data were extracted from a multimethod study of professional help seeking. Participants were 62 mothers from Cuba, Puerto Rico, and the Dominican Republic. Findings indicated that mothers overwhelmingly preferred treatment options other than medication primarily because they understood medication to be addictive, dulling of cognitive processes, and inappropriate for behavior problems. Inadequate adherence was common and logically consistent with maternal cognitions. Maternal choices with respect to the use of medication were transactional and quite complex in nature and changed over time. The strongest agents in this process were schools and the mothers' immediate family. Implications for clinical practice are presented.