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Bschor T, Nagel L, Unger J, Schwarzer G, Baethge C. Differential Outcomes of Placebo Treatment Across 9 Psychiatric Disorders: A Systematic Review and Meta-Analysis. JAMA Psychiatry 2024:2818945. [PMID: 38809560 PMCID: PMC11137661 DOI: 10.1001/jamapsychiatry.2024.0994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/11/2024] [Indexed: 05/30/2024]
Abstract
Importance Placebo is the only substance systematically evaluated across common psychiatric diagnoses, but comprehensive cross-diagnostic comparisons are lacking. Objective To compare changes in placebo groups in recent high-quality randomized clinical trials (RCTs) across a broad spectrum of psychiatric disorders in adult patients. Data Sources MEDLINE and the Cochrane Database of Systematic Reviews were systematically searched in March 2022 for the latest systematic reviews meeting predetermined high-quality criteria for 9 major psychiatric diagnoses. Study Selection Using these reviews, the top 10 highest-quality (ie, lowest risk of bias, according to the Cochrane Risk of Bias tool) and most recent placebo-controlled RCTs per diagnosis (totaling 90 RCTs) were selected, adhering to predetermined inclusion and exclusion criteria. Data Extraction and Synthesis Following the Cochrane Handbook, 2 authors independently carried out the study search, selection, and data extraction. Cross-diagnosis comparisons were based on standardized pre-post effect sizes (mean change divided by its SD) for each placebo group. This study is reported following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline. Main Outcome and Measure The primary outcome, pooled pre-post placebo effect sizes (dav) with 95% CIs per diagnosis, was determined using random-effects meta-analyses. A Q test assessed statistical significance of differences across diagnoses. Heterogeneity and small-study effects were evaluated as appropriate. Results A total of 90 RCTs with 9985 placebo-treated participants were included. Symptom severity improved with placebo in all diagnoses. Pooled pre-post placebo effect sizes differed across diagnoses (Q = 88.5; df = 8; P < .001), with major depressive disorder (dav = 1.40; 95% CI, 1.24-1.56) and generalized anxiety disorder (dav = 1.23; 95% CI, 1.06-1.41) exhibiting the largest dav. Panic disorder, attention-deficit/hyperactivity disorder, posttraumatic stress disorder, social phobia, and mania showed dav between 0.68 and 0.92, followed by OCD (dav = 0.65; 95% CI, 0.51-0.78) and schizophrenia (dav = 0.59; 95% CI, 0.41-0.76). Conclusion and Relevance This systematic review and meta-analysis found that symptom improvement with placebo treatment was substantial in all conditions but varied across the 9 included diagnoses. These findings may help in assessing the necessity and ethical justification of placebo controls, in evaluating treatment effects in uncontrolled studies, and in guiding patients in treatment decisions. These findings likely encompass the true placebo effect, natural disease course, and nonspecific effects.
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Affiliation(s)
- Tom Bschor
- Department of Psychiatry and Psychotherapy, University Hospital, Technical University of Dresden, Dresden, Germany
- Government Commission for Modern and Needs-Based Hospital Care, Berlin, Germany
| | - Lea Nagel
- Department of Psychiatry and Psychotherapy, University Hospital, Technical University of Dresden, Dresden, Germany
- Federal Joint Committee (G-BA), Berlin, Germany
| | - Josephine Unger
- Social Psychiatric Service, Berlin district of Reinickendorf, Berlin, Germany
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Christopher Baethge
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany
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Farhat LC, Flores JM, Avila-Quintero VJ, Polanczyk GV, Cipriani A, Furukawa TA, Bloch MH, Cortese S. Treatment Outcomes With Licensed and Unlicensed Stimulant Doses for Adults With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis. JAMA Psychiatry 2024; 81:157-166. [PMID: 37878348 PMCID: PMC10600727 DOI: 10.1001/jamapsychiatry.2023.3985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/18/2023] [Indexed: 10/26/2023]
Abstract
Importance Stimulants (methylphenidate and amphetamines) are often prescribed at unlicensed doses for adults with attention-deficit/hyperactivity disorder (ADHD). Whether dose escalation beyond US Food and Drug Administration recommendations is associated with positive risk benefits is unclear. Objective To investigate the impact, based on averages, of stimulant doses on treatment outcomes in adults with ADHD and to determine, based on averages, whether unlicensed doses are associated with positive risk benefits compared with licensed doses. Data Sources Twelve databases, including published (PubMed, Cochrane Library, Embase, Web of Sciences) and unpublished (ClinicalTrials.gov) literature, up to February 22, 2023, without language restrictions. Study Selection Two researchers independently screened records to identify double-blinded randomized clinical trials of stimulants against placebo in adults (18 years and older) with ADHD. Data Extraction and Synthesis Aggregate data were extracted and synthesized in random-effects dose-response meta-analyses and network meta-analyses. Main Outcome Measures Change in ADHD symptoms and discontinuations due to adverse events. Results A total of 47 randomized clinical trials (7714 participants; mean age, 35 (SD, 11) years; 4204 male [56%]) were included. For methylphenidate, dose-response curves indicated additional reductions of symptoms with increments in doses, but the gains were progressively smaller and accompanied by continued additional risk of adverse events dropouts. Network meta-analyses showed that unlicensed doses were associated with greater reductions of symptoms compared with licensed doses (standardized mean difference [SMD], -0.23; 95% CI, -0.44 to -0.02; very low certainty of evidence), but the additional gain was small and accompanied by increased risk of adverse event dropouts (odds ratio, 2.02; 95% CI, 1.19-3.43; moderate certainty of evidence). For amphetamines, the dose-response curve approached a plateau and increments in doses did not indicate additional reductions of symptoms, but there were continued increments in the risk of adverse event dropouts. Network meta-analysis did not identify differences between unlicensed and licensed doses for reductions of symptoms (SMD, -0.08; 95% CI, -0.24 to 0.08; very low certainty of evidence). Conclusions and Relevance Based on group averages, unlicensed doses of stimulants may not have positive risk benefits compared with licensed doses for adults with ADHD. In general, practitioners should consider unlicensed doses cautiously. Practitioners may trial unlicensed doses if needed and tolerated but should be aware that there may not be large gains in the response to the medication with those further increments in dose. However, the findings are averages and will not generalize to every patient.
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Affiliation(s)
- Luis C. Farhat
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - José M. Flores
- Division of Child & Adolescent Psychiatry, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles, California
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | | | - Guilherme V. Polanczyk
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, United Kingdom
| | - Toshi A. Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/ School of Public Health, Kyoto, Japan
| | - Michael H. Bloch
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Samuele Cortese
- Center for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Solent NHS Trust, Southampton, United Kingdom
- Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, New York
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Baggio S, Billieux J, Dirkzwager A, Iglesias K, Moschetti K, Perroud N, Schneider M, Vernaz N, Wolff H, Heller P. Protocol of a monocentric, double-blind, randomized, superiority, controlled trial evaluating the effect of in-prison OROS-methylphenidate vs. placebo treatment in detained people with attention-deficit hyperactivity disorder (BATIR). Trials 2024; 25:23. [PMID: 38178233 PMCID: PMC10765778 DOI: 10.1186/s13063-023-07827-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/23/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Attention-deficit hyperactivity disorder (ADHD) is characterized by difficulty paying attention, poor impulse control, and hyperactive behavior. It is associated with several adverse health and social outcomes and leads to an increased risk of criminality and recidivism. Worldwide, ADHD is thus highly prevalent in prisons. However, ADHD treatment has been neglected in such environments. Stimulant medications such as osmotic-release oral system methylphenidate (OROS-MPH) are first-line treatments in the general population, but they are under-prescribed in prisons due to concerns about abuse, even though such claims are not empirically supported. This project aims to compare the efficacy of a 3-month in-prison OROS-MPH vs. placebo treatment on the severity of core ADHD symptoms and relevant in- and post-prison outcomes. METHODS This study is a phase III, double-blinded, randomized, superiority, controlled trial of OROS-MPH vs. placebo. After randomization, the participants will receive 3 months of treatment with OROS-MPH or placebo (1:1 ratio) while incarcerated. Upon release, all participants will be offered the treatment (OROS-MPH) for 1 year but will remain blinded to their initial study group. The study will be conducted at the Division of Prison Health, Geneva, Switzerland, among incarcerated men (n = 150). Measures will include (1) investigator-rated ADHD symptoms, (2) acute events collected by the medical and prison teams, (3) assessment of the risk of recidivism, (4) medication side effects, (5) medication adherence, (6) study retention, (7) health care/prison costs, and (8) 1-year recidivism. Analyses will include bivariable and multivariable modeling (e.g., regression models, mixed-effects models, survival analyses) and an economic evaluation (cost-benefit analysis). DISCUSSION We expect that early identification and treatment of ADHD in prison will be an important public health opportunity and a cost-effective approach that is likely to reduce the vulnerability of incarcerated individuals and promote pathways out of criminal involvement. The study will also promote standards of care for people with ADHD in prison and provide recommendations for continuity of care after release. TRIAL REGISTRATION ClinicalTrials.gov NCT05842330 . Registered on June 5, 2023. Kofam.ch SNCTP000005388. Registered on July 17, 2023.
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Affiliation(s)
- Stéphanie Baggio
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
- Laboratory of Population Health (#PopHealthLab), University of Fribourg, Fribourg, Switzerland.
- Division of Prison Health, Geneva University Hospitals, Geneva, Switzerland.
| | - Joël Billieux
- Institute of Psychology, University of Lausanne, Lausanne, Switzerland
- Center for Excessive Gambling, Addiction Medicine, Lausanne University Hospitals (CHUV), Lausanne, Switzerland
| | - Anja Dirkzwager
- Netherlands Institute for the Study of Crime and Law Enforcement, Amsterdam, The Netherlands
| | - Katia Iglesias
- School of Health Sciences, HES-SO University of Applied Sciences and Arts of Western Switzerland, Fribourg, Switzerland
| | - Karine Moschetti
- Health Technology Assessment Unit, University Hospital of Lausanne, Lausanne, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Nader Perroud
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Psychiatric Specialties, Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Marie Schneider
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
- Medication adherence and Interprofessionality lab, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Nathalie Vernaz
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Hans Wolff
- Division of Prison Health, Geneva University Hospitals, Geneva, Switzerland
| | - Patrick Heller
- Division of Prison Health, Geneva University Hospitals, Geneva, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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Bieś R, Fojcik J, Warchala A, Trędzbor B, Krysta K, Piekarska-Bugiel K, Krzystanek M. The Risk of Methylphenidate Pharmacotherapy for Adults with ADHD. Pharmaceuticals (Basel) 2023; 16:1292. [PMID: 37765100 PMCID: PMC10537192 DOI: 10.3390/ph16091292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/06/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders. It was once thought to be a disorder affecting only children, but in those undiagnosed in childhood, symptoms do not disappear with age. There is now a growing recognition of the late diagnosis and treatment of adults with ADHD. The first-line drug in pharmacotherapy is methylphenidate, and information about its adverse effects, when used by adults, has not been as extensively described as in children. The aim of this article was to review the literature describing the risks of methylphenidate therapy for adults with ADHD. A total of 19 articles-15 clinical trials and 4 case reports presenting rare side effects resulting from methylphenidate therapy, such as reversible ischemic stroke, myocardial infarction, and psychotic episodes, were analyzed. The analysis from clinical trials included 3458 adult patients with ADHD and described the most common side effects, psychiatric adverse events, effects of methylphenidate treatment on sleep, laboratory results, body mass, and cardiovascular symptoms. Methylphenidate treatment is well tolerated, with side effects described, according to severity, as mild to moderate. We conclude that pharmacotherapy is not risk-free and methylphenidate, due to its side effects, may not be the first drug of choice for every patient.
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Affiliation(s)
- Rafał Bieś
- Medical Students’ Association, Department and Clinic of Psychiatric Rehabilitation, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland;
| | - Joanna Fojcik
- Department of Psychiatric Rehabilitation, Leszek Giec Upper-Silesian Medical Centre, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland
| | - Anna Warchala
- Department and Clinic of Psychiatric Rehabilitation, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland (K.K.)
| | - Beata Trędzbor
- Department and Clinic of Psychiatric Rehabilitation, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland (K.K.)
| | - Krzysztof Krysta
- Department and Clinic of Psychiatric Rehabilitation, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland (K.K.)
| | - Katarzyna Piekarska-Bugiel
- Department of Psychiatric Rehabilitation, Leszek Giec Upper-Silesian Medical Centre, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland
| | - Marek Krzystanek
- Department and Clinic of Psychiatric Rehabilitation, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland (K.K.)
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Cataldo M, Donnelly G, Cutler AJ, Childress A, Mikl J, Bhaskar S, Waxmonsky J. Analysis of Daily Sleep Diary Measures From Multilayer Extended-Release Methylphenidate (PRC-063) Studies in Children and Adults With ADHD. J Atten Disord 2022; 26:1870-1881. [PMID: 35786058 PMCID: PMC9606001 DOI: 10.1177/10870547221106238] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To compare the effect of a once-daily extended-release methylphenidate formulation (PRC-063) versus placebo on sleep, measured via daily electronic diary in two clinical trials in pediatric (6-12 years) and adult (≥18 years) patients with attention deficit hyperactivity disorder (ADHD). METHOD A diary was completed by adult patients or parents/caregivers of pediatric patients during two randomized, double-blind, placebo-controlled laboratory classroom studies. Following dose optimization of PRC-063, patients were randomized to 1 week of double-blind treatment with PRC-063 or placebo before attending a full-day laboratory classroom session. RESULTS In the studies, 148 pediatric patients and 239 adult patients were randomized to either PRC-063 or placebo. When compared with the diaries of placebo patients, the sleep diaries in both pediatric and adult patients showed no statistical difference in total sleep time, efficiency, or latency. CONCLUSION PRC-063 did not impact subjective measures of sleep versus placebo in pediatric and adult patients with ADHD.
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Affiliation(s)
- Marc Cataldo
- Purdue Pharma L.P., Stamford, CT, USA,Marc Cataldo, Purdue Pharma L.P., One Stamford Forum, 201 Tresser Boulevard, Stamford, CT 06901-3431, USA.
| | | | | | - Ann Childress
- Center for Psychiatry and Behavioral Medicine, Inc., Las Vegas, NV, USA
| | | | - Sailaja Bhaskar
- Imbrium Therapeutics L.P., a subsidiary of Purdue Pharma L.P., Stamford, CT, USA
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Rau KM, Shun SC, Hung SH, Chou HL, Ho CL, Chao TC, Liu CY, Lien CT, Hong MY, Wu CJ, Tsai LY, Jane SW, Hsieh RK. Management of cancer-related fatigue in Taiwan: an evidence-based consensus for screening, assessment and treatment. Jpn J Clin Oncol 2022; 53:46-56. [PMID: 36354095 PMCID: PMC9825724 DOI: 10.1093/jjco/hyac164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 10/08/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Cancer-related fatigue is one of the most common and persistent issues experienced by cancer patients. Cancer-related fatigue is a distinct form of fatigue that is subjective, long-lasting and unalleviated by rest or sleep. Studies have shown that almost all cancer patients experience severe fatigue that disrupts the quality of life and physical function, but cancer-related fatigue remains under-addressed in clinical care, and only about half of all patients receive treatment. METHODS To increase the awareness of cancer-related fatigue and improve current management, the Taiwan Society of Cancer Palliative Medicine and the Taiwan Oncology Nursing Society convened a consensus committee to develop recommendations for the screening, assessment and treatment of cancer-related fatigue. RESULTS Thirteen consensus recommendations were subsequently developed based on the best available evidence and the clinical experience of committee members. CONCLUSIONS These recommendations are expected to facilitate the standardization of cancer-related fatigue management across Taiwan and may also serve as a reference for other clinicians.
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Affiliation(s)
| | | | - Shih-Hsin Hung
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Ling Chou
- Department of Nursing, Asia Eastern University of Science and Technology, New Taipei City, Taiwan,Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan,School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Liang Ho
- Division of Hematology and Oncology, Tri-Service General Hospital, Taipei, Taiwan,Division of Oncology, National Defense Medical Center, Taipei, Taiwan
| | - Ta-Chung Chao
- Department of Oncology and Comprehensive Breast Health Center, Taipei Veterans General Hospital, Taipei, Taiwan,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Yu Liu
- Division of Transfusion Medicine, Department of Medicine and Comprehensive Breast Health Center, Taipei Veterans General Hospital, Taipei, Taiwan,Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Ting Lien
- Department of Nursing, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ming-Ying Hong
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Jung Wu
- Department of Radiation Oncology, Cathay General Hospital, Taipei, Taiwan,Department of Radiation Oncology, National Defense Medical Center, Taipei, Taiwan,Department of Biomedical Engineering, I-Shou University, Kaohsiung, Taiwan
| | - Li-Yun Tsai
- College of Nursing, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Sui-Whi Jane
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan,Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Ruey-Kuen Hsieh
- For reprints and all correspondence: Ruey-Kuen Hsieh, Department of Hematology and Oncology, MacKay Memorial Hospital, Taipei, Taiwan. No. 92, Sec. 2, Zhongshan N. Rd., Taipei City 10449, Taiwan. E-mail:
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Childress A, Cutler AJ, Marraffino AH, Bhaskar S, Donnelly G. Randomized, Double-Blind, Placebo-Controlled, Parallel-Group, Adult Laboratory Classroom Study of the Efficacy and Safety of PRC-063 (Extended-Release Methylphenidate) for the Treatment of ADHD. J Atten Disord 2022; 26:857-869. [PMID: 34189995 PMCID: PMC8859679 DOI: 10.1177/10870547211025610] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the efficacy, safety, and duration of action of the once-daily extended-release methylphenidate formulation PRC-063 for the treatment of ADHD in an adult laboratory classroom (ALC). METHOD After dose optimization with PRC-063 over 7 weeks, adults with ADHD were randomized to 1 week of double-blind treatment with PRC-063 or placebo that ended with an ALC evaluation. The primary outcome measure was Permanent Product Measure of Performance-Total (PERMP-T) score. RESULTS Of 288 subjects enrolled, 221 completed the ALC visit. PERMP-T score was significantly higher for PRC-063 versus placebo at every assessment from 1 to 16 hours post-dose at the ALC visit and when averaged over 16 hours post-dose (least-squares mean difference 16.3, 95% confidence interval 7.6-24.9). The most frequent adverse events during dose optimization were headache, decreased appetite, and insomnia. CONCLUSION PRC-063 provided rapid and sustained symptom relief in adults with ADHD and was well tolerated. NCT03618030.
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Affiliation(s)
- Ann Childress
- Center for Psychiatry and Behavioral Medicine, Inc., Las Vegas, NV, USA
| | - Andrew J. Cutler
- SUNY Upstate Medical University and Neuroscience Education Institute, Lakewood Ranch, FL, USA
| | | | - Sailaja Bhaskar
- Imbrium Therapeutics L.P., a subsidiary of Purdue Pharma L.P., Stamford, CT, USA
| | - Graeme Donnelly
- Purdue Pharma (Canada), Pickering, Ontario, Canada,Graeme Donnelly, Purdue Pharma (Canada), 575 Granite Ct, Pickering, Ontario L1W 3W8, Canada.
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Boesen K, Paludan-Müller AS, Gøtzsche PC, Jørgensen KJ. Extended-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev 2022; 2:CD012857. [PMID: 35201607 PMCID: PMC8869321 DOI: 10.1002/14651858.cd012857.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is a psychiatric diagnosis increasingly used in adults. The recommended first-line pharmacological treatment is central nervous system (CNS) stimulants, such as methylphenidate, but uncertainty remains about its benefits and harms. OBJECTIVES To assess the beneficial and harmful effects of extended-release formulations of methylphenidate in adults diagnosed with ADHD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, nine other databases and four clinical trial registries up to February 2021. We searched 12 drug regulatory databases for clinical trial data up to 13 May 2020. In addition, we cross-referenced all available trial identifiers, handsearched reference lists, searched pharmaceutical company databases, and contacted trial authors. SELECTION CRITERIA Randomised, double-blind, parallel-group trials comparing extended-release methylphenidate formulations at any dose versus placebo and other ADHD medications in adults diagnosed with ADHD. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We assessed dichotomous outcomes as risk ratios (RRs), and rating scales and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs). We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We meta-analysed the data using a random-effects model. We assessed three design characteristics that may impair the trial results' 'generalisability'; exclusion of participants with psychiatric comorbidity; responder selection based on previous experience with CNS stimulants; and risk of withdrawal effects. Our prespecified primary outcomes were functional outcomes, self-rated ADHD symptoms, and serious adverse events. Our secondary outcomes included quality of life, ADHD symptoms rated by investigators and by peers such as family members, cardiovascular variables, severe psychiatric adverse events, and other adverse events. MAIN RESULTS We included 24 trials (5066 participants), of which 21 reported outcome data for this review. We also identified one ongoing study. We included documents from six drug regulatory agencies covering eight trials. Twenty-one trials had an outpatient setting and three were conducted in prisons. They were primarily conducted in North America and Europe. The median participant age was 36 years. Twelve trials (76% of participants) were industry-sponsored, four (14% of participants) were publicly funded with industry involvement, seven (10% of participants) were publicly funded, and one had unclear funding. The median trial duration was eight weeks. One trial was rated at overall unclear risk of bias and 20 trials were rated at overall high risk of bias, primarily due to unclear blinding of participants and investigators, attrition bias, and selective outcome reporting. All trials were impaired in at least one of the three design characteristics related to 'generalisability'; for example, they excluded participants with psychiatric comorbidity such as depression or anxiety, or included participants only with a previous positive response to methylphenidate, or similar drugs. This may limit the trials' usefulness for clinical practice, as they may overestimate the benefits and underestimate the harms. Extended-release methylphenidate versus placebo (up to 26 weeks) For the primary outcomes, we found very low-certainty evidence that methylphenidate had no effect on 'days missed at work' at 13-week follow-up (mean difference (MD) -0.15 days, 95% confidence interval (CI) -2.11 to 1.81; 1 trial, 409 participants) or serious adverse events (risk ratio (RR) 1.43, CI 95% CI 0.85 to 2.43; 14 trials, 4078 participants), whereas methylphenidate improved self-rated ADHD symptoms (small-to-moderate effect; SMD -0.37, 95% CI -0.43 to -0.30; 16 trials, 3799 participants). For secondary outcomes, we found very low-certainty evidence that methylphenidate improved self-rated quality of life (small effect; SMD -0.15, 95% CI -0.25 to -0.05; 6 trials, 1888 participants), investigator-rated ADHD symptoms (small-to-moderate effect; SMD -0.42, 95% CI -0.49 to -0.36; 18 trials, 4183 participants), ADHD symptoms rated by peers such as family members (small-to-moderate effect; SMD -0.31, 95% CI -0.48 to -0.14; 3 trials, 1005 participants), and increased the risk of experiencing any adverse event (RR 1.27, 95% CI 1.19 to 1.37; 14 trials, 4214 participants). We rated the certainty of the evidence as 'very low' for all outcomes, primarily due to high risk of bias and 'indirectness of the evidence'. One trial (419 participants) had follow-up at 52 weeks and two trials (314 participants) included active comparators, hence long-term and comparative evidence is limited. AUTHORS' CONCLUSIONS We found very low-certainty evidence that extended-release methylphenidate compared to placebo improved ADHD symptoms (small-to-moderate effects) measured on rating scales reported by participants, investigators, and peers such as family members. Methylphenidate had no effect on 'days missed at work' or serious adverse events, the effect on quality of life was small, and it increased the risk of several adverse effects. We rated the certainty of the evidence as 'very low' for all outcomes, due to high risk of bias, short trial durations, and limitations to the generalisability of the results. The benefits and harms of extended-release methylphenidate therefore remain uncertain.
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Affiliation(s)
- Kim Boesen
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health at Charité, QUEST Center for Responsible Research, Berlin, Germany
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark
| | - Asger Sand Paludan-Müller
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | - Karsten Juhl Jørgensen
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
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Efficacy, Safety, and Tolerability of Centanafadine Sustained-Release Tablets in Adults With Attention-Deficit/Hyperactivity Disorder: Results of 2 Phase 3, Randomized, Double-blind, Multicenter, Placebo-Controlled Trials. J Clin Psychopharmacol 2022; 42:429-439. [PMID: 35652746 PMCID: PMC9426730 DOI: 10.1097/jcp.0000000000001575] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Centanafadine is an inhibitor of norepinephrine, dopamine, and serotonin reuptake transporters under investigation for the treatment of attention-deficit/hyperactivity disorder (ADHD). METHODS/PROCEDURES Two phase 3 randomized, double-blind, placebo-controlled, parallel-group studies of 200 mg/d or 400 mg/d centanafadine sustained-release tablets versus placebo included adults (18-55 years of age) with a diagnosis of ADHD. The primary and key secondary efficacy endpoints were the change from baseline at day 42 in the Adult ADHD Investigator Symptom Rating Scale (AISRS) total score and the Clinical Global Impression-Severity of Illness Scale, respectively. FINDINGS/RESULTS Subjects randomized in study 1 (centanafadine 200 mg/d, n = 149; centanafadine 400 mg/d, n = 149; placebo, n = 148) and study 2 (centanafadine 200 mg/d, n = 145; centanafadine 400 mg/d, n = 143; placebo, n = 142) had moderate to severe ADHD (mean AISRS total score, 38.7 [SD, 6.8] across both studies). At day 42, statistically significant least-squares mean differences in AISRS total score were observed in favor of centanafadine versus placebo in study 1 (200 mg/d: -3.16, P = 0.019; 400 mg/d: -2.74, P = 0.039) and study 2 (200 mg/d: -4.01, P = 0.002; 400 mg/d: -4.47, P = 0.001). Effect sizes versus placebo were -0.28 for 200 mg/d and -0.24 for 400 mg/d in study 1 and -0.37 for 200 mg/d and -0.40 for 400 mg/d in study 2. The overall rate of treatment-emergent adverse events (TEAEs) was low, but there was a small increase in TEAE occurrence with increasing dose. Incidences of serious TEAEs and abuse potential-related AEs were low. IMPLICATIONS/CONCLUSIONS These are the first large-scale studies to demonstrate the efficacy and safety profiles of 200 mg/d and 400 mg/d centanafadine in adults with ADHD.
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Gutiérrez-Casares JR, Quintero J, Jorba G, Junet V, Martínez V, Pozo-Rubio T, Oliva B, Daura X, Mas JM, Montoto C. Methods to Develop an in silico Clinical Trial: Computational Head-to-Head Comparison of Lisdexamfetamine and Methylphenidate. Front Psychiatry 2021; 12:741170. [PMID: 34803764 PMCID: PMC8595241 DOI: 10.3389/fpsyt.2021.741170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Regulatory agencies encourage computer modeling and simulation to reduce the time and cost of clinical trials. Although still not classified in formal guidelines, system biology-based models represent a powerful tool for generating hypotheses with great molecular detail. Herein, we have applied a mechanistic head-to-head in silico clinical trial (ISCT) between two treatments for attention-deficit/hyperactivity disorder, to wit lisdexamfetamine (LDX) and methylphenidate (MPH). The ISCT was generated through three phases comprising (i) the molecular characterization of drugs and pathologies, (ii) the generation of adult and children virtual populations (vPOPs) totaling 2,600 individuals and the creation of physiologically based pharmacokinetic (PBPK) and quantitative systems pharmacology (QSP) models, and (iii) data analysis with artificial intelligence methods. The characteristics of our vPOPs were in close agreement with real reference populations extracted from clinical trials, as did our PBPK models with in vivo parameters. The mechanisms of action of LDX and MPH were obtained from QSP models combining PBPK modeling of dosing schemes and systems biology-based modeling technology, i.e., therapeutic performance mapping system. The step-by-step process described here to undertake a head-to-head ISCT would allow obtaining mechanistic conclusions that could be extrapolated or used for predictions to a certain extent at the clinical level. Altogether, these computational techniques are proven an excellent tool for hypothesis-generation and would help reach a personalized medicine.
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Affiliation(s)
- José Ramón Gutiérrez-Casares
- Unidad Ambulatoria de Psiquiatría y Salud Mental de la Infancia, Niñez y Adolescencia, Hospital Perpetuo Socorro, Badajoz, Spain
| | - Javier Quintero
- Servicio de Psiquiatría, Hospital Universitario Infanta Leonor, Universidad Complutense, Madrid, Spain
| | - Guillem Jorba
- Anaxomics Biotech, Barcelona, Spain
- Research Programme on Biomedical Informatics (GRIB), Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
| | - Valentin Junet
- Anaxomics Biotech, Barcelona, Spain
- Institute of Biotechnology and Biomedicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | | | | | - Baldomero Oliva
- Research Programme on Biomedical Informatics (GRIB), Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
| | - Xavier Daura
- Institute of Biotechnology and Biomedicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
- Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
| | | | - Carmen Montoto
- Medical Department, Takeda Farmacéutica España, Madrid, Spain
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11
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Jaeschke RR, Sujkowska E, Sowa-Kućma M. Methylphenidate for attention-deficit/hyperactivity disorder in adults: a narrative review. Psychopharmacology (Berl) 2021; 238:2667-2691. [PMID: 34436651 PMCID: PMC8455398 DOI: 10.1007/s00213-021-05946-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/31/2021] [Indexed: 12/12/2022]
Abstract
RATIONALE Psychostimulants, including methylphenidate (MPH), are the mainstay of pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) in adults. Even though MPH is the most commonly used medication for ADHD these days, there are relatively few resources available that provide comprehensive insight into the pharmacological and clinical features of the compound. OBJECTIVE The aim of this paper is to provide an up-to-date outline of the pharmacology and clinical utility of MPH for ADHD in adult patients. METHODS While conducting the narrative review, we applied structured search strategies covering the two major online databases (MEDLINE and Cochrane Central Register of Controlled Trials). In addition, we performed handsearching of reference lists of relevant papers. RESULTS Methylphenidate exhibits multimodal mechanism of action, working primarily as a dopamine and noradrenaline reuptake inhibitor. It also protects the dopaminergic system against the ongoing 'wearing off' (by securing a substantial reserve pool of the neurotransmitter, stored in the presynaptic vesicles). In placebo-controlled trials, MPH was shown to be moderately effective both against the core ADHD symptoms (standardized mean difference [SMD], 0.49; 95% confidence interval [CI], 0.35-0.64), and the accompanying emotion regulation deficits (SMD, 0.34; 95% CI, 0.23-0.45). The most common adverse events related to long-term treatment with MPH are decreased appetite (~ 20%), dry mouth (15%), heart palpitations (13%), gastrointestinal infections (~ 10%), and agitation/feeling restless (~ 10%). CONCLUSIONS There is substantial body of evidence to suggest that MPH is an effective and safe treatment option for adults with ADHD.
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Affiliation(s)
- Rafał R Jaeschke
- Section of Affective Disorders, Department of Psychiatry, Jagiellonian University Medical College, ul. Kopernika 21a, 31-501, Kraków, Poland.
| | - Ewelina Sujkowska
- Department of Human Physiology, Institute of Medical Sciences, Medical College of Rzeszów University, ul. Kopisto 2a, 35-315, Rzeszów, Poland
| | - Magdalena Sowa-Kućma
- Department of Human Physiology, Institute of Medical Sciences, Medical College of Rzeszów University, ul. Kopisto 2a, 35-315, Rzeszów, Poland
- Centre for Innovative Research in Medical and Natural Sciences, Medical College of Rzeszów University, ul. Warzywna 1a, 35-310, Rzeszów, Poland
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12
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Cambron-Mellott MJ, Mikl J, Matos JE, Erensen JG, Beusterien K, Cataldo MJ, Hallissey B, Mattingly GW. Adult Patient Preferences for Long-Acting ADHD Treatments: A Discrete Choice Experiment. Patient Prefer Adherence 2021; 15:1061-1073. [PMID: 34054292 PMCID: PMC8158042 DOI: 10.2147/ppa.s311836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/24/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Treatment for attention deficit hyperactivity disorder (ADHD) requires a multifaceted approach including psychosocial interventions and pharmacological treatment. This study evaluates preferences for specific attributes associated with different long-acting stimulant treatment among US adults with ADHD. METHODS Patients completed an online, cross-sectional survey, incorporating a discrete choice experiment to assess preferences for attributes. RESULTS Analyses included 200 adults with ADHD (mean age 33.0 years; 60% self-reporting moderate severity); the mean (SD) Adult ADHD Self-Report Scale-v1.1 score was 45.9 (12.4). Overall, patients valued speed of onset most and risk of rebound least. Three population groups with distinct preferences were identified: side effect-driven (n=69, 35%), quick onset-driven (n=47, 24%) and quick onset and long duration-driven (n=84, 42%). CONCLUSION This study shows differences in how adults with ADHD value and assess benefit-risk trade-offs when considering the desired attributes of stimulant treatments, highlighting the importance of patient-physician shared decision-making to optimize the desired benefits of individualized treatment.
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Affiliation(s)
| | - Jaromir Mikl
- Purdue Pharma L.P./Adlon Therapeutics, L.P., Stamford, CT, USA
| | | | | | | | - Marc J Cataldo
- Purdue Pharma L.P./Adlon Therapeutics, L.P., Stamford, CT, USA
| | | | - Gregory W Mattingly
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Midwest Research Group, St. Charles, MO, USA
- St. Charles Psychiatric Associates, St. Charles, MO, USA
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13
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Lifetime evolution of ADHD treatment. J Neural Transm (Vienna) 2021; 128:1085-1098. [PMID: 33993352 DOI: 10.1007/s00702-021-02336-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
Attention-deficit hyperactivity disorder (ADHD), has been traditionally considered a neurodevelopmental disorder affecting children and adolescents characterized by inattention, hyperactivity, disruptive behavior, and impulsivity. Although still debated, it is evident that ADHD is also present in adulthood, but this diagnosis is rarely carried out, mainly for the frequent comorbidity with other psychiatric and/or substance abuse disorders. Given the need to shed more light on the pharmacological treatment of ADHD, we performed a naturalistic review to review and comment on the available literature of ADHD treatment across the lifespan. Indeed, stimulants are endowed of a prompt efficacy and safety, whilst non-stimulants, although requiring some weeks to be fully effective, are useful when a substance abuse history is detected. In any case, the pharmacological management of ADHD appears to be still largely influenced by the individual experience of the clinicians. Further longitudinal studies with a careful and detailed characterization of participants across different phases of the lifespan are also required to provide relevant confirmations (or denials) regarding pharmacological treatments amongst the different age groups.
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Elliott J, Johnston A, Husereau D, Kelly SE, Eagles C, Charach A, Hsieh SC, Bai Z, Hossain A, Skidmore B, Tsakonas E, Chojecki D, Mamdani M, Wells GA. Pharmacologic treatment of attention deficit hyperactivity disorder in adults: A systematic review and network meta-analysis. PLoS One 2020; 15:e0240584. [PMID: 33085721 PMCID: PMC7577505 DOI: 10.1371/journal.pone.0240584] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/29/2020] [Indexed: 01/18/2023] Open
Abstract
Background Attention deficit hyperactivity disorder (ADHD) affects approximately 3% of adults globally. Many pharmacologic treatments options exist, yet the comparative benefits and harms of individual treatments are largely unknown. We performed a systematic review and network meta-analysis to assess the relative effects of individual pharmacologic treatments for adults with ADHD. Methods We searched English-language published and grey literature sources for randomized clinical trials (RCTs) involving pharmacologic treatment of ADHD in adults (December 2018). The primary outcome was clinical response; secondary outcomes were quality of life, executive function, driving behaviour, withdrawals due to adverse events, treatment discontinuation, serious adverse events, hospitalization, cardiovascular adverse events, and emergency department visits. Data were pooled via pair-wise meta-analyses and Bayesian network meta-analyses. Risk of bias was assessed by use of Cochrane’s Risk of Bias tool, and the certainty of the evidence was assessed by use of the GRADE framework. Results Eighty-one unique trials that reported at least one outcome of interest were included, most of which were at high or unclear risk of at least one important source of bias. Notably, only 5 RCTs were deemed at overall low risk of bias. Included pharmacotherapies were methylphenidate, atomoxetine, dexamfetamine, lisdexamfetamine, guanfacine, bupropion, mixed amphetamine salts, and modafinil. As a class, ADHD pharmacotherapy improved patient- and clinician-reported clinical response compared with placebo (range: 4 to 15 RCTs per outcome); however, these findings were not conserved when the analyses were restricted to studies at low risk of bias, and the certainty of the finding is very low. There were few differences among individual medications, although atomoxetine was associated with improved patient-reported clinical response and quality of life compared with placebo. There was no significant difference in the risk of serious adverse events or treatment discontinuation between ADHD pharmacotherapies and placebo; however, the proportion of participants who withdrew due to adverse events was significantly higher among participants who received any ADHD pharmacotherapy. Few RCTs reported on the occurrence of adverse events over a long treatment duration. Conclusions Overall, despite a class effect of improving clinical response relative to placebo, there were few differences among the individual ADHD pharmacotherapies, and most studies were at risk of at least one important source of bias. Furthermore, the certainty of the evidence was very low to low for all outcomes, and there was limited reporting of long-term adverse events. As such, the choice between ADHD pharmacotherapies may depend on individual patient considerations, and future studies should assess the long-term effects of individual pharmacotherapies on patient-important outcomes, including quality of life, in robust blinded RCTs. Registration PROSPERO no. CRD 42015026049
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Affiliation(s)
- Jesse Elliott
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy Johnston
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Don Husereau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Shannon E. Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Caroline Eagles
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Alice Charach
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shu-Ching Hsieh
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Zemin Bai
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Alomgir Hossain
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Becky Skidmore
- Independent Information Specialist, Ottawa, Ontario, Canada
| | - Eva Tsakonas
- Independent Research Consultant, Montreal, Quebec, Canada
| | | | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - George A. Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
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15
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Retz W, Retz-Junginger P, Davydenko S, Rösler M. [Pharmacotherapy of attention deficit hyperactivity disorder in adults]. DER NERVENARZT 2020; 91:583-590. [PMID: 32232533 DOI: 10.1007/s00115-020-00891-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pharmacotherapy is a central component in the context of an overall therapeutic concept in the treatment of adults with attention deficit hyperactivity disorder (ADHD). In this concept psychosocial interventions with psychoeducation or specific psychotherapy measures also play an important role. In adults three compounds are currently approved for the pharmacological treatment of ADHD in Germany. The long-acting stimulants retarded methylphenidate preparations and lisdexamfetamine can be prescribed. Alternatively, the adrenergic uptake inhibitor atomoxetine can be used. In several meta-analyses good effectiveness and tolerance of these drugs on ADHD psychopathology has been shown. They also improve ADHD-related disorders of emotional regulation capability and disorganization in everyday life. Importantly, an improvement in everyday functionality and quality of life under medication could also be shown in several studies. In this review the evidence for pharmacotherapy of ADHD and its implementation into treatment of adult patients is presented.
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Affiliation(s)
- W Retz
- Neurozentrum, Forschungsgruppe ADHS, Universitätsklinikum des Saarlandes, Gebäude 90/III, 66421, Homburg/Saar, Deutschland.
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Mainz, Mainz, Deutschland.
| | - P Retz-Junginger
- Neurozentrum, Forschungsgruppe ADHS, Universitätsklinikum des Saarlandes, Gebäude 90/III, 66421, Homburg/Saar, Deutschland
| | - S Davydenko
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - M Rösler
- Neurozentrum, Forschungsgruppe ADHS, Universitätsklinikum des Saarlandes, Gebäude 90/III, 66421, Homburg/Saar, Deutschland
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16
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Mucci F, Avella MT, Marazziti D. ADHD with Comorbid Bipolar Disorders: A Systematic Review of Neurobiological, Clinical and Pharmacological Aspects Across the Lifespan. Curr Med Chem 2020; 26:6942-6969. [PMID: 31385763 DOI: 10.2174/0929867326666190805153610] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/05/2018] [Accepted: 11/15/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Attention deficit hyperactivity (ADHD) disorder is a neurodevelopmental disorder characterized by inattention, hyperactivity, disruptive behaviour, and impulsivity. Despite considered typical of children for a long time, the persistence of ADHD symptoms in adulthood gained increasing interest during the last decades. Indeed, its diagnosis, albeit controversial, is rarely carried out even because ADHD is often comorbid with several other psychiatric diosrders, in particular with bipolar disorders (BDs), a condition that complicates the clinical picture, assessment and treatment. AIMS The aim of this paper was to systematically review the scientific literature on the neurobiological, clinical features and current pharmacological management of ADHD comorbid with BDs across the entire lifespan, with a major focus on the adulthood. DISCUSSION The pharmacology of ADHD-BD in adults is still empirical and influenced by the individual experience of the clinicians. Stimulants are endowed of a prompt efficacy and safety, whilst non-stimulants are useful when a substance abuse history is detected, although they require some weeks in order to be fully effective. In any case, an in-depth diagnostic and clinical evaluation of the single individual is mandatory. CONCLUSION The comorbidity of ADHD with BD is still a controversial matter, as it is the notion of adult ADHD as a distinct nosological category. Indeed, some findings highlighted the presence of common neurobiological mechanisms and overlapping clinical features, although disagreement does exist. In any case, while expecting to disentangle this crucial question, a correct management of this comorbidity is essential, which requires the co-administration of mood stabilizers. Further controlled clinical studies in large samples of adult ADHD-BD patients appear extremely urgent in order to better define possible therapeutic guidelines, as well as alternative approaches for this potentially invalidating condition.
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Affiliation(s)
- Federico Mucci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Fondazione BRF, Istituto per la Ricerca Scientifica in Psichiatria e Neuroscienze, Lucca, Italy
| | - Maria Teresa Avella
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Donatella Marazziti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Fondazione BRF, Istituto per la Ricerca Scientifica in Psichiatria e Neuroscienze, Lucca, Italy
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17
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Lam AP, Matthies S, Graf E, Colla M, Jacob C, Sobanski E, Alm B, Rösler M, Retz W, Retz-Junginger P, Kis B, Abdel-Hamid M, Müller HHO, Lücke C, Huss M, Jans T, Berger M, Tebartz van Elst L, Philipsen A. Long-term Effects of Multimodal Treatment on Adult Attention-Deficit/Hyperactivity Disorder Symptoms: Follow-up Analysis of the COMPAS Trial. JAMA Netw Open 2019; 2:e194980. [PMID: 31150084 PMCID: PMC6547099 DOI: 10.1001/jamanetworkopen.2019.4980] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Knowledge about the long-term effects of multimodal treatment in adult attention-deficit/hyperactivity disorder (ADHD) is much needed. OBJECTIVE To evaluate the long-term efficacy of multimodal treatment for adult ADHD. DESIGN, SETTING, AND PARTICIPANTS This observer-masked, 1.5-year follow-up of the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a prospective, multicenter randomized clinical trial, compared cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) and methylphenidate (MPH) with placebo (2 × 2 factorial design). Recruitment started January 2007 and ended August 2010, and treatments were finalized in August 2011 with follow-up through March 2013. Overall, 433 adults with ADHD participated in the trial, and 256 (59.1%) participated in the follow-up assessment. Analysis began in November 2013 and was completed in February 2018. INTERVENTIONS After 1-year treatment with GPT or CM and MPH or placebo, no further treatment restrictions were imposed. MAIN OUTCOMES AND MEASURES The primary outcome was change in the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score from baseline to follow-up. Secondary outcomes included further ADHD rating scale scores, observer-masked ratings of the Clinical Global Impression scale, and self-ratings of depression on the Beck Depression Inventory. RESULTS At follow-up, 256 of 433 randomized patients (baseline measured in 419 individuals) participated. Of the 256 patients participating in follow-up, the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score was assessed for 251; the mean (SD) baseline age was 36.3 (10.1) years; 125 patients (49.8%) were men; and the sample was well-balanced with respect to prior randomization (GPT and MPH: 64 of 107; GPT and placebo: 67 of 109; CM and MPH: 70 of 110; and CM and placebo: 55 of 107). At baseline, the all-group mean ADHD Index of Conners Adult ADHD Rating Scale score was 20.6, which improved to adjusted means of 14.2 for the GPT arm and 14.7 for the CM arm at follow-up with no significant difference between groups (difference, -0.5; 95% CI, -1.9 to 0.9; P = .48). The adjusted mean decreased to 13.8 for the MPH arm and 15.2 for the placebo arm (difference, -1.4; 95% CI, -2.8 to -0.1; P = .04). As in the core study, MPH was associated with a larger reduction in symptoms than placebo at follow-up. These results remained unchanged when accounting for MPH intake at follow-up. Compared with participants in the CM arm, patients who participated in group psychotherapy were associated with less severe symptoms as measured by the self-reported ADHD Symptoms Total Score according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) of Conners Adult ADHD Rating Scale (AMD, -2.1; 95% CI, -4.2 to -0.1; P = .04) and in the subscale of reducing pure hyperactive symptoms, measured via the Diagnostic Checklist for the diagnosis of ADHD in adults (AMD, -1.3; 95% CI, -2.8 to 0.1; P = .08). Regarding the Clinical Global Impression scale assessment of effectiveness, the difference between GPT and CM remained significant at follow-up (odds ratio, 1.63; 95% CI, 1.03-2.59; P = .04). No differences were found for any comparison concerning depression as measured with the Beck Depression Inventory. CONCLUSIONS AND RELEVANCE Results from COMPAS demonstrate a maintained improvement in ADHD symptoms for adults 1.5 years after the end of a 52-week controlled multimodal treatment period. The results indicate that MPH treatment combined with GPT or CM provides a benefit lasting 1.5 years. Confirming the results of the core study, GPT was not associated with better results regarding the primary outcome compared with CM. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN54096201.
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Affiliation(s)
- Alexandra P. Lam
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Swantje Matthies
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Erika Graf
- Clinical Trials Unit, Institute of Medical Biometry and Statistics, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Michael Colla
- Clinic and Polyclinic for Psychiatry and Psychotherapy, University of Rostock, Rostock, Germany
| | - Christian Jacob
- Clinic for Psychiatry and Psychotherapy, Medius Clinic, Kirchheim, Germany
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Esther Sobanski
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Clinical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medicine Mainz, Mainz, Germany
| | - Barbara Alm
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Clinical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Rösler
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Wolfgang Retz
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Petra Retz-Junginger
- Institute for Forensic Psychology and Psychiatry, Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Bernhard Kis
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - Mona Abdel-Hamid
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - Helge H. O. Müller
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Caroline Lücke
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Michael Huss
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medicine Mainz, Mainz, Germany
| | - Thomas Jans
- Center of Mental Health, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany
| | - Mathias Berger
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
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Leffa DT, Panzenhagen AC, Salvi AA, Bau CHD, Pires GN, Torres ILS, Rohde LA, Rovaris DL, Grevet EH. Systematic review and meta-analysis of the behavioral effects of methylphenidate in the spontaneously hypertensive rat model of attention-deficit/hyperactivity disorder. Neurosci Biobehav Rev 2019; 100:166-179. [PMID: 30826386 DOI: 10.1016/j.neubiorev.2019.02.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 02/27/2019] [Accepted: 02/27/2019] [Indexed: 12/19/2022]
Abstract
The spontaneously hypertensive rats (SHR) are the most widely used model for ADHD. While face and construct validity are consolidated, questions remain about the predictive validity of the SHR model. We aim at summarizing the evidence for the predictive validity of SHR by evaluating its ability to respond to methylphenidate (MPH), the most well documented treatment for ADHD. A systematic review was carried out to identify studies evaluating MPH effects on SHR behavior. Studies (n=36) were grouped into locomotion, attention, impulsivity or memory, and a meta-analysis was performed. Meta-regression, sensitivity, heterogeneity, and publication bias analyses were also conducted. MPH increased attentional and mnemonic performances in the SHR model and decreased impulsivity in a dose-dependent manner. However, MPH did not reduce hyperactivity in low and medium doses, while increased locomotor activity in high doses. Thus, since the paradoxical effect of stimulant in reducing hyperactivity was not observed in the SHR model, our study does not fully support the predictive validity of SHR, questioning their validity as an animal model for ADHD.
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Affiliation(s)
- Douglas T Leffa
- Post-Graduate Program in Medicine: Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Laboratory of Pain Pharmacology and Neuromodulation: Pre-clinical studies - Pharmacology Department, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alana C Panzenhagen
- Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; ADHD Outpatient Program, Hospital de Clínicas de Porto Alegre, Brazil
| | - Artur A Salvi
- Laboratory of Pain Pharmacology and Neuromodulation: Pre-clinical studies - Pharmacology Department, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Claiton H D Bau
- Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; ADHD Outpatient Program, Hospital de Clínicas de Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gabriel N Pires
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Physiological Sciences, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Iraci L S Torres
- Laboratory of Pain Pharmacology and Neuromodulation: Pre-clinical studies - Pharmacology Department, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Animal Experimentation Unit - GPPG - Hospital de Clínicas de Porto Alegre - Porto, Alegre, Brazil
| | - Luis A Rohde
- ADHD Outpatient Program, Hospital de Clínicas de Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; National Institute of Developmental Psychiatry for Children and Adolescents, Brazil
| | - Diego L Rovaris
- Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; ADHD Outpatient Program, Hospital de Clínicas de Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Eugenio H Grevet
- ADHD Outpatient Program, Hospital de Clínicas de Porto Alegre, Brazil; Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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19
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Gomeni R, Fang LL, Bressolle-Gomeni F, Spencer TJ, Faraone SV, Babiskin A. A General Framework for Assessing In vitro/In vivo Correlation as a Tool for Maximizing the Benefit-Risk Ratio of a Treatment Using a Convolution-Based Modeling Approach. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:97-106. [PMID: 30659771 PMCID: PMC6389349 DOI: 10.1002/psp4.12378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/07/2018] [Indexed: 12/23/2022]
Abstract
The net benefit of a treatment can be defined by the relationship between clinical improvement and risk of adverse events: the benefit‐risk ratio. The optimization of the benefit‐risk ratio can be achieved by identifying the most adequate dose (and/or dosage regimen) jointly with the best‐performing in vivo release properties of a drug. A general in silico tool is presented for identifying the dose, the in vitro and the in vivo release properties that maximize the benefit‐risk ratio using convolution‐based modeling, an exposure‐response model, and a surface response analysis. A case study is presented to illustrate how the benefit‐risk ratio of methylphenidate for the treatment of attention deficit hyperactivity disorder can be maximized using the proposed strategy. The results of the analysis identified the characteristics of an optimized dose and in vitro/in vivo release suitable to provide a sustained clinical response with respect to the conventional dosage regimen and formulations.
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Affiliation(s)
| | - Lanyan Lucy Fang
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | | | - Andrew Babiskin
- Division of Quantitative Methods and Modeling, Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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20
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Stuhec M, Lukić P, Locatelli I. Efficacy, Acceptability, and Tolerability of Lisdexamfetamine, Mixed Amphetamine Salts, Methylphenidate, and Modafinil in the Treatment of Attention-Deficit Hyperactivity Disorder in Adults: A Systematic Review and Meta-analysis. Ann Pharmacother 2018; 53:121-133. [DOI: 10.1177/1060028018795703] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Psychostimulants are the first-line treatment in adults with attention-deficit hyperactivity disorder (ADHD). This meta-analysis aimed to evaluate the efficacy, acceptability, and tolerability of lisdexamfetamine (LDX), mixed amphetamine salts (MASs), modafinil (MDF), and methylphenidate (MPH) in comparison with placebo. Data Sources: We systematically searched PubMed/MEDLINE and Clinicaltrials.gov in May 2016, along with CENTRAL and EU Clinical Trials Register in February 2016, for the randomized, double-blind, placebo-controlled, parallel-group clinical trials conducted on adults diagnosed with ADHD. Study Selection and Data Extraction: Substantial comorbidity, substance abuse or dependence, and nonpharmacological interventions represented grounds for exclusion. Published reports were the sole source for data extraction. Improvement in ADHD symptoms was the primary outcome. Random-effects model meta-analysis was applied to calculate the standardized mean difference (SMD) with 95% CIs. Data Synthesis: The search retrieved 701 records, of which 20 studies were eligible for analysis. High effect size (expressed as SMD) in reducing ADHD symptoms was observed for LDX (−0.89; 95% CI = −1.09, −0.70), whereas MASs (−0.64; 95% CI = −0.83, −0.45) and MPH (−0.50; 95% CI = −0.58, −0.41) reduced symptoms moderately compared with placebo. No efficacy was shown for MDF (0.08; 95% CI; −0.18, 0.34). Relevance to Patient Care and Clinical Practice: In this meta-analysis, the efficacy, tolerability, and acceptability of psychostimulants were compared with that for placebo. Five of the included trials have not been evaluated in any of the previously published meta-analyses. Conclusions: The results suggest that LDX has the largest effect size and has a promising potential for treating adults with ADHD.
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Affiliation(s)
- Matej Stuhec
- Ormoz Psychiatric Hospital, Department of clinical pharmacy, Ormoz, Slovenia, European Union
- University of Ljubljana, Faculty of Pharmacy, Slovenia, European Union
| | - Petar Lukić
- University of Ljubljana, Faculty of Pharmacy, Slovenia, European Union
| | - Igor Locatelli
- University of Ljubljana, Faculty of Pharmacy, Slovenia, European Union
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21
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Hegerl U, Mergl R, Sander C, Dietzel J, Bitter I, Demyttenaere K, Gusmão R, González-Pinto A, Zorrilla I, Alocén AG, Sola VP, Vieta E, Juckel G, Zimmermann US, Bauer M, Sienaert P, Quintão S, Edel MA, Bolyos C, Ayuso-Mateos JL, López-García P, Kluge M. A multi-centre, randomised, double-blind, placebo-controlled clinical trial of methylphenidate in the initial treatment of acute mania (MEMAP study). Eur Neuropsychopharmacol 2018; 28:185-194. [PMID: 29174864 DOI: 10.1016/j.euroneuro.2017.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 09/19/2017] [Accepted: 11/03/2017] [Indexed: 11/29/2022]
Abstract
UNLABELLED Based on many clinical and preclinical findings the 'vigilance regulation model of mania' postulates that an unstable regulation of wakefulness is a pathogenetic factor in both mania and Attention Deficit Hyperactivity Disorder (ADHD) and induces hyperactivity and sensation seeking as an autoregulatory attempt to stabilize wakefulness. Accordingly, stimulant medications with their vigilance stabilizing properties could have rapid antimanic effects similar to their beneficial effects in ADHD. The MEMAP study - a multi-center, double-blind, placebo-controlled and randomized clinical trial (RCT) - assessed the antimanic efficacy and safety of a 2.5-day treatment with methylphenidate (20-40mg/day). Of 157 screened patients with acute mania, 42 were randomly assigned to receive 20-40mg per day of methylphenidate in one or two applications, or placebo. The primary outcome was the change in Young Mania Rating Scale (YMRS) sum scores from baseline to day 2.5 in the methylphenidate group compared to the placebo group. A group sequential design was chosen to justify early RCT termination based on efficacy or futility at an interim analysis after inclusion of 40 patients. In the interim analysis, the change from baseline in the YMRS total score at day 2.5 was not significantly different between both groups (F(1,37)=0.23; p=0.64). Thus, futility was declared for methylphenidate and the RCT was stopped. In summary, although methylphenidate was well tolerated and safe in the full analysis set, it failed to show efficacy in the treatment of acute mania. TRIAL REGISTRATION clinicaltrials.gov (URL: http://www.clinicaltrials.gov; registration number: NCT01541605).
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Affiliation(s)
- Ulrich Hegerl
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany.
| | - Roland Mergl
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Christian Sander
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Jens Dietzel
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
| | - Istvan Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | | | - Ricardo Gusmão
- Departamento de Psiquiatria, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; ISPUP, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Ana González-Pinto
- Department of Psychiatry, Hospital Santiago Apostol, Vitoria, Spain; Centro de Investigación Biomédica en Red de Salud Mental. CIBERSAM, Madrid, Spain
| | - Iñaki Zorrilla
- Department of Psychiatry, Hospital Santiago Apostol, Vitoria, Spain; Centro de Investigación Biomédica en Red de Salud Mental. CIBERSAM, Madrid, Spain
| | - Adriana García Alocén
- Department of Psychiatry, Hospital Santiago Apostol, Vitoria, Spain; Centro de Investigación Biomédica en Red de Salud Mental. CIBERSAM, Madrid, Spain
| | - Victor Perez Sola
- Centro de Investigación Biomédica en Red de Salud Mental. CIBERSAM, Madrid, Spain; Department of Psychiatry, Hospital del Mar, Barcelona, Spain
| | - Eduard Vieta
- Centro de Investigación Biomédica en Red de Salud Mental. CIBERSAM, Madrid, Spain; Department of Psychiatry, Hospital Clinic, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Georg Juckel
- Department of Psychiatry and Psychotherapy, University of Bochum, Bochum, Germany
| | - Ulrich S Zimmermann
- Department of Psychiatry and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | | | - Sónia Quintão
- Departamento de Psiquiatria, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; ISPUP, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Marc-Andreas Edel
- Department of Psychiatry and Psychotherapy, University of Bochum, Bochum, Germany
| | - Csilla Bolyos
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Jose Luis Ayuso-Mateos
- Centro de Investigación Biomédica en Red de Salud Mental. CIBERSAM, Madrid, Spain; Department of Psychiatry, Universidad Autonoma de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
| | - Pilar López-García
- Centro de Investigación Biomédica en Red de Salud Mental. CIBERSAM, Madrid, Spain; Department of Psychiatry, Universidad Autonoma de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
| | - Michael Kluge
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Leipzig, Germany
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22
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Wigal TL, Newcorn JH, Handal N, Wigal SB, Mulligan I, Schmith V, Konofal E. A Double-Blind, Placebo-Controlled, Phase II Study to Determine the Efficacy, Safety, Tolerability and Pharmacokinetics of a Controlled Release (CR) Formulation of Mazindol in Adults with DSM-5 Attention-Deficit/Hyperactivity Disorder (ADHD). CNS Drugs 2018; 32:289-301. [PMID: 29557078 PMCID: PMC5889769 DOI: 10.1007/s40263-018-0503-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mazindol is under investigation for the treatment of attention-deficit/hyperactivity disorder (ADHD) because of its alertness-enhancing properties. A novel controlled-release (CR) formulation of mazindol was developed to allow once-daily dosing. OBJECTIVE The aim of this study was to evaluate the efficacy of mazindol CR in adults with ADHD. DESIGN We conducted a randomized, double-blind, placebo-controlled 6-week trial. METHODS Subjects diagnosed with ADHD using the Mini-International Neuropsychiatric Structured Interview (MINI) and with an ADHD Rating Scale, Diagnostic and Statistical Manual of Mental Disorders 5th Edition (ADHD-RS-DSM5) score ≥ 28 were randomized to receive placebo or 1-3 mg/day of mazindol for 6 weeks. The primary endpoint was the reduction from baseline in the ADHD-RS-DSM5 score on Day 42. Secondary endpoints were response rates defined by change in ADHD-RS-DSM5 (≥ 30 or ≥ 50% reduction) and dichotomized Clinical Global Impression-Improvement (CGI-I) score (1 or 2). An exploratory endpoint of functional impairment, as measured by the Target Impairment Scale, examined individualized deficits in specific settings. Safety, tolerability, and pharmacokinetics were assessed. RESULTS Eighty-five participants were randomized (n = 43 active, 42 placebo); 75 completed. Weekly ADHD-RS-DSM5 measurements after mazindol differed from placebo beginning at Day 7, with a least squares mean difference (active-placebo) of - 13.2 at Day 42 and an effect size of 1.09. For the 30% or more reduction in ADHD-RS-DSM5 (minimal response), a significant difference (active-placebo) was seen starting at Day 7 and continuing to Day 42. For the CGI-I (1 or 2) and for the 50% or more reduction in ADHD-RS-DSM5 (measures of excellent response), the differences began at Day 14 and continued to Day 42. Functional impairment was significantly different in the proportion achieving at least a 50% reduction in target impairment score (42.9% mazindol vs 11.9% placebo) by Day 42. Dry mouth, nausea, fatigue, heart rate (HR) increased, decreased appetite, and constipation were more prevalent for mazindol versus placebo. Overall, mazindol CR had minimal effects on blood pressure and small effects on HR. CONCLUSION Mazindol CR was efficacious in the treatment of adults with ADHD, with a large effect size, and was well tolerated, supporting the progression to phase III. (Clinicaltrials.gov Registration No. NCT02808104).
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Affiliation(s)
- Tim L Wigal
- AVIDA Inc., 1600 Dove Street, Suite 305, Newport Beach, CA, 92660, USA.
| | - Jeffrey H Newcorn
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029-5674, USA
| | - Nelson Handal
- Dothan Behavioral Medicine Clinic, Harmonex Neuroscience Research, 408 Healthwest Drive, Dothan, AL, 36303, USA
| | - Sharon B Wigal
- AVIDA Inc., 1600 Dove Street, Suite 305, Newport Beach, CA, 92660, USA
| | - Ioulietta Mulligan
- Worldwide Clinical Trials, Waterfront House, Beeston Business Park, Beeston, Nottingham, NG9 1LA, UK
| | - Virginia Schmith
- Nuventra Pharma Sciences, 2525 Meridian Parkway, Suite 280, Durham, NC, 27713, USA
| | - Eric Konofal
- Pediatric Sleep Disorders Center, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris (APHP), 48 Boulevard Serurier, Paris, France
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23
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Edvinsson D, Ekselius L. Six-year outcome in subjects diagnosed with attention-deficit/hyperactivity disorder as adults. Eur Arch Psychiatry Clin Neurosci 2018; 268:337-347. [PMID: 29143159 PMCID: PMC5956008 DOI: 10.1007/s00406-017-0850-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 11/02/2017] [Indexed: 01/01/2023]
Abstract
There are very few studies on the long-term outcome in subjects diagnosed with ADHD as adults. The objective of the present study was to assess this and relate the outcome to whether there was current medication or not and to other potential predictors of favourable outcome. A prospective clinical cohort of adults diagnosed with ADHD according to DSM-IV criteria was followed-up on an average of 6 years after first evaluation (n = 124; mean age 42 years, 51% males). ADHD symptom trajectories were assessed as well as medication, global functioning, disability, health-related quality of life, and alcohol and drug consumption at follow-up. Ninety percent of those diagnosed were initially treated pharmacologically and half of them discontinued treatment. One-third reported remission, defined as not fulfilling any ADHD subtype and a GAF-value last year ≥ 70, which was not affected by comorbidity at baseline. Current medication was not associated with remission. Subjects evaluated and first diagnosed with ADHD as adults are functionally improved at follow-up 6 years later despite a high percentage of psychiatric comorbidity at baseline. Half dropped out of medication, and there was no difference in ADHD remission between subjects with on-going medication at follow-up or subjects without medication, although current medication was related to a higher degree of self-reported global improvement.
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Affiliation(s)
- Dan Edvinsson
- Department of Neuroscience, Psychiatry, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Lisa Ekselius
- Department of Neuroscience, Psychiatry, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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24
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Coghill DR, Banaschewski T, Soutullo C, Cottingham MG, Zuddas A. Systematic review of quality of life and functional outcomes in randomized placebo-controlled studies of medications for attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry 2017; 26:1283-1307. [PMID: 28429134 PMCID: PMC5656703 DOI: 10.1007/s00787-017-0986-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 04/03/2017] [Indexed: 10/31/2022]
Abstract
Children, adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) experience functional impairment and poor health-related quality of life (HRQoL) in addition to symptoms of inattention/hyperactivity-impulsivity. To synthesize qualitatively the published evidence from randomized, double-blind, placebo-controlled trials of the effectiveness of pharmacotherapy on functional impairment or HRQoL in patients with ADHD, a systematic PubMed searching and screening strategy was designed to identify journal articles meeting pre-specified criteria. Post hoc analyses and meta-analyses were excluded. HRQoL outcomes, functional outcomes and the principal ADHD symptom-based outcome were extracted from included studies. An effect size of 0.5 versus placebo was used as a threshold for potential clinical relevance (unreported effect sizes were calculated when possible). Of 291 records screened, 35 articles describing 34 studies were included. HRQoL/functioning was usually self-rated in adults and proxy-rated in children/adolescents. Baseline data indicated substantial HRQoL deficits in children/adolescents. Placebo-adjusted effects of medication on ADHD symptoms, HRQoL and functioning, respectively, were statistically or nominally significant in 18/18, 10/12 and 7/9 studies in children/adolescents and 14/16, 9/11 and 9/10 studies in adults. Effect sizes were ≥0.5 versus placebo for symptoms, HRQoL and functioning, respectively, in 14/16, 7/9 and 4/8 studies in children/adolescents; and 6/12, 1/6 and 1/8 studies in adults. Effect sizes were typically larger for stimulants than for non-stimulants, for symptoms than for HRQoL/functioning, and for children/adolescents than for adults. The efficacy of ADHD medication extends beyond symptom control and may help reduce the related but distinct functional impairments and HRQoL deficits in patients with ADHD.
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Affiliation(s)
- David R Coghill
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia.
- Department of Psychiatry, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia.
- Division of Neuroscience, University of Dundee, Dundee, UK.
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - César Soutullo
- Child and Adolescent Psychiatry Unit, Department of Psychiatry and Medical Psychology, University of Navarra Clinic, Pamplona, Spain
| | | | - Alessandro Zuddas
- Child and Adolescent Psychiatry Unit, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
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25
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Huss M, Duhan P, Gandhi P, Chen CW, Spannhuth C, Kumar V. Methylphenidate dose optimization for ADHD treatment: review of safety, efficacy, and clinical necessity. Neuropsychiatr Dis Treat 2017; 13:1741-1751. [PMID: 28740389 PMCID: PMC5505611 DOI: 10.2147/ndt.s130444] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a chronic psychiatric disorder characterized by hyperactivity and/or inattention and is often associated with a substantial impact on psychosocial functioning. Methylphenidate (MPH), a central nervous system stimulant, is commonly used for pharmacological treatment of adults and children with ADHD. Current practice guidelines recommend optimizing MPH dosage to individual patient needs; however, the clinical benefits of individual dose optimization compared with fixed-dose regimens remain unclear. Here we review the available literature on MPH dose optimization from clinical trials and real-world experience on ADHD management. In addition, we report safety and efficacy data from the largest MPH modified-release long-acting Phase III clinical trial conducted to examine benefits of dose optimization in adults with ADHD. Overall, MPH is an effective ADHD treatment with a good safety profile; data suggest that dose optimization may enhance the safety and efficacy of treatment. Further research is required to establish the extent to which short-term clinical benefits of MPH dose optimization translate into improved long-term outcomes for patients with ADHD.
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Affiliation(s)
- Michael Huss
- Child and Adolescent Psychiatry, University Medicine, Mainz, Germany
| | - Praveen Duhan
- Global Medical Affairs, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Preetam Gandhi
- Development Franchise, Established Medicine Neuroscience, Novartis Pharma AG, Basel, Switzerland
| | - Chien-Wei Chen
- Biostatistics Cardio-Metabolic & Established Medicine, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Carsten Spannhuth
- Development Franchise, Established Medicine Neuroscience, Novartis Pharma AG, Basel, Switzerland
| | - Vinod Kumar
- Established Medicines, Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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26
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Groß S, Figge C, Matthies S, Philipsen A. [ADHD in adulthood: Diagnostics and therapy]. DER NERVENARZT 2016; 86:1171-8; quiz 1179-80. [PMID: 26341837 DOI: 10.1007/s00115-015-4328-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Traditionally, attention deficit hyperactivity disorder (ADHD) was assumed to be a childhood disorder. In the meantime a persistence of symptoms into adulthood has been shown in 60% of those affected. Besides the core symptoms of inattentiveness, hyperactivity and impulsivity, adults with ADHD often suffer from comorbid disorders and functional impairment in multiple domains. In recent years diagnostic guidelines and standardized questionnaires have been developed, which facilitate the diagnostics of ADHD. In addition various therapeutic approaches have emerged and randomized controlled studies have demonstrated the efficacy. The aim of the article is to present the current standard of knowledge with respect to the diagnostics and treatment of ADHD.
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Affiliation(s)
- S Groß
- Universitätsklinik für Psychiatrie und Psychotherapie, Fakultät für Medizin und Gesundheitswissenschaften, Medizinischer Campus Universität Oldenburg, Hermann-Ehlers-Str. 7, 26160, Bad Zwischenahn, Deutschland
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27
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Linden M, Weddigen J. [Minimal cerebral dysfunctions and ADHD in adulthood]. DER NERVENARZT 2016; 87:1175-1184. [PMID: 26820459 DOI: 10.1007/s00115-015-0063-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) is of great importance not only in children but also in adults; however, despite extensive research there are still many unsolved questions with respect to the diagnosis. Patients not only suffer from attention deficits and hyperactivity but also a variety of other problems, such as dyspraxia, problems with stimulus discrimination, dysgrammatism, legasthenia, or motor coordination problems. Furthermore, there are also psychopathological disorders, such as problems with memory, formal thinking, emotional modulation, drive and vegetative stability, in the sense of a psycho-organic syndrome. Such syndromes have long been known in psychiatry under terms, such as complex capacity disorders, minimal cerebral dysfunction (MCD), minimal brain dysfunction (MBD), mild psycho-organic syndrome, psycho-organic axis syndrome, mild cognitive impairment, developmental disorder and developmental biological syndrome. Etiological data with respect to genetics and early childhood brain trauma support the notion of a psychobiological disorder for complex cerebral dysfunction in the sense of a psycho-organic syndrome. Depending on the individual life and work situation, these additional symptoms of ADHD are in many cases of greater relevance for life adjustment than the core symptoms, depending on the individual life and work situations. The concept of minimal cerebral dysfunction describes the ADHD problem better and has a direct bearing on the diagnosis, therapy and sociomedical care of the patients.
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Affiliation(s)
- M Linden
- Forschungsgruppe Psychosomatische Rehabilitation, Charité Universitätsmedizin Berlin, CBF, Hs II, E01, Hindenburgdamm 30, 12200, Berlin, Deutschland.
| | - J Weddigen
- Forschungsgruppe Psychosomatische Rehabilitation, Charité Universitätsmedizin Berlin, CBF, Hs II, E01, Hindenburgdamm 30, 12200, Berlin, Deutschland
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Konrad-Bindl DS, Gresser U, Richartz BM. Changes in behavior as side effects in methylphenidate treatment: review of the literature. Neuropsychiatr Dis Treat 2016; 12:2635-2647. [PMID: 27789952 PMCID: PMC5068472 DOI: 10.2147/ndt.s114185] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Our review of the scientific literature focused on an analysis of studies describing instances of methylphenidate treatment leading (or not) to behavioral changes in the pediatric, adolescent, and adult populations. MATERIALS AND METHODS We conducted a literature search in PubMed, Medline, and Google using the keywords "methylphenidate", "behavioral changes", "adverse effects", and "side effects". A total of 44 studies were identified as reporting on the effects and adverse effects of methylphenidate administration, and were included in the analysis. RESULTS Five studies specifically set out to study, record, and discuss changes in behavior. Eight studies did not set out to study behavioral effects, but record and discuss them. A total of 28 studies recorded behavioral effects, but failed to discuss these further. Three studies did not include behavioral effects. CONCLUSION This review records what data have been published in respect of changes in behavior in association with the use of methylphenidate. While there is some evidence to suggest that methylphenidate causes changes in behavior, the majority of the studies reviewed paid little or no attention to this issue. Based on the available data, it is impossible to determine the point at which such behavioral effects occur. The frequency of occurrence of behavioral effects is also impossible to determine with certainty. Based on the available data, it is not possible to rule out whether behavioral effects may persist or not persist once treatment is discontinued. In conclusion, despite countless publications and extensive administration, especially to children, we have insufficient data to judge the long-term effects and risks of methylphenidate taking.
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Affiliation(s)
| | - Ursula Gresser
- Department of Internal Medicine, University of Munich, Munich
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Abstract
OBJECTIVES Until recently, it was believed that attention deficit and hyperactivity disorder (ADHD) are outgrown by the end of adolescence and the beginning of adulthood. The purpose of this review is to describe the characteristics of the disease in adults, depict comorbidities that accompany it, and expand the scope over methods of diagnosis and treatment of these ages. METHODS A search was conducted in the PubMed/MEDLINE database for relevant key words 'ADHD', 'attention deficit', 'hyperactivity' and 'adult'. Secondary search parameters were 'comorbid', 'prevalence', 'epidemiology', 'therapy' and 'drug therapy'. Search was limited to 'English' and 'Humans'. RESULTS Over the years, the persistent nature of the disorder has been clarified, elucidating prevalence rate, gender differences and subtype shifts among adult ADHD population. Nevertheless, even today, there is only limited awareness of the existence of the disorder across one's lifespan, its consequences and the appropriate treatment. CONCLUSIONS Our results emphasise the growing awareness of adult psychosocial impairments due to ADHD symptoms and comorbidities, as well as the need for further collaboration among practitioners and mental health-care professionals to better identify the condition and allow for effective treatment.
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Affiliation(s)
- Gil Zalsman
- a Child and Adolescent Division , Geha Mental Health Center , Petah Tikva , Israel ;,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel ;,c Molecular Imaging and Neuropathology Division, Psychiatry Department , Columbia University , New York , NY , USA
| | - Tal Shilton
- a Child and Adolescent Division , Geha Mental Health Center , Petah Tikva , Israel
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Differences in maintenance of response upon discontinuation across medication treatments in attention-deficit/hyperactivity disorder. Eur Neuropsychopharmacol 2015; 25:1611-21. [PMID: 26169574 DOI: 10.1016/j.euroneuro.2015.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/28/2015] [Accepted: 06/12/2015] [Indexed: 11/22/2022]
Abstract
The attention-deficit/hyperactivity disorder (ADHD) treatment literature has been focused on onset-of-effect and short-term effect size, with little exploration of ADHD symptoms upon medication discontinuation. The objective of this narrative review and analysis was to better understand the relapse of ADHD symptoms upon discontinuation of medication treatment in children, adolescents, and adults with ADHD who have responded to medication treatment and to explore differences among different medications in maintaining treatment response. Randomized withdrawal studies of dexmethylphenidate hydrochloride (d-MPH), methylphenidate modified-release (MPH-LA), lisdexamphetamine dimesylate (LDX), guanfacine extended-release (GXR), and atomoxetine (ATX) in both children/adolescents and adults with ADHD were reviewed. The percentage of relapse was significantly higher and the time-to-relapse significantly shorter with placebo compared to active treatment in patients who were previously stable on 5 weeks to 1 year of active treatment, suggesting clinically significant benefit with continued long-term pharmacotherapy. However, percentage of relapse at each time point studied after discontinuing stimulants and GXR appears substantially higher than observed when discontinuing ATX, suggesting longer maintenance of response after discontinuing ATX than after stimulants and GXR. Additionally, slope of relapse percentages over time appears to be more rapid with stimulants or GXR than with ATX. These differences in maintenance of response among ATX, GXR, and stimulants may reflect differences in mechanisms of action and persistence of the medication effect. Alternatively, they may be due to methodological differences, including study design and response/relapse definitions. Continued investigation is needed regarding factors that affect risk of symptom relapse upon discontinuation of pharmacotherapy.
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Huss M, Ginsberg Y, Arngrim T, Philipsen A, Carter K, Chen CW, Gandhi P, Kumar V. Open-label dose optimization of methylphenidate modified release long acting (MPH-LA): a post hoc analysis of real-life titration from a 40-week randomized trial. Clin Drug Investig 2015; 34:639-49. [PMID: 25015027 PMCID: PMC4143596 DOI: 10.1007/s40261-014-0213-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES In the management of attention-deficit hyperactivity disorder (ADHD) in adults it is important to recognize that individual patients respond to a wide range of methylphenidate doses. Studies with methylphenidate modified release long acting (MPH-LA) in children have reported the need for treatment optimization for improved outcomes. We report the results from a post hoc analysis of a 5-week dose optimization phase from a large randomized, placebo-controlled, multicenter 40-week study (9-week double-blind dose confirmation phase, 5-week open-label dose optimization phase, and 26-week double-blind maintenance of effect phase). METHODS Patients entering the open-label dose optimization phase initiated treatment with MPH-LA 20 mg/day; up/down titrated to their optimal dose (at which there was balance between control of symptoms and side effects) of 40, 60, or 80 mg/day in increments of 20 mg/week by week 12 or 13. Safety was assessed by monitoring the adverse events (AEs) and serious AEs. Efficacy was assessed by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Attention-Deficit Hyperactivity Disorder Rating Scale (DSM-IV ADHD RS) and Sheehan Disability Scale (SDS) total scores. RESULTS At the end of the dose confirmation phase, similar numbers of patients were treated optimally with each of the 40, 60, and 80 mg/day doses (152, 177, and 160, respectively) for MPH-LA. Mean improvement from baseline in the dose confirmation phase in total scores of DSM-IV ADHD RS and SDS were 23.5 ± 9.90 and 9.7 ± 7.36, respectively. CONCLUSIONS Dose optimization with MPH-LA (40, 60, or 80 mg/day) improved treatment outcomes and was well-tolerated in adult ADHD patients.
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Affiliation(s)
- Michael Huss
- Child and Adolescent Psychiatry, University Medicine, Langenbeckstraβe 1, 55131 Mainz, Germany
| | - Ylva Ginsberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, Center for Mental Disorders, University Medical Center, Freiburg, Germany
| | | | - Chien-Wei Chen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ USA
| | | | - Vinod Kumar
- Novartis Pharmaceuticals Corporation, East Hanover, NJ USA
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Prediction of methylphenidate treatment outcome in adults with attention-deficit/hyperactivity disorder (ADHD). Eur Arch Psychiatry Clin Neurosci 2014; 264 Suppl 1:S35-43. [PMID: 25231833 DOI: 10.1007/s00406-014-0542-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/07/2014] [Indexed: 12/25/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent mental disorder of childhood, which often persists in adulthood. Methylphenidate (MPH) is one of the most effective medications to treat ADHD, but also few adult patients show no sufficient response to this drug. In this paper, we give an overview regarding genetic, neuroimaging, clinical and other studies which have tried to reveal the reasons for non-response in adults with ADHD, based on a systematic literature search. Although MPH is a well-established treatment for adults with ADHD, research regarding the prediction of treatment outcome is still limited and has resulted in inconsistent findings. No reliable neurobiological markers of treatment response have been identified so far. Some findings from clinical studies suggest that comorbidity with substance use disorders and personality disorders has an impact on treatment course and outcome. As MPH is widely used in the treatment of adults with ADHD, much more work is needed regarding positive and negative predictors of long-term treatment outcome in order to optimize the pharmacological treatment of adult ADHD patients.
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Geirs DP, Pottegård A, Halldórsson M, Zoëga H. A Nationwide Study of Attention-Deficit/Hyperactivity Disorder Drug Use among Adults in Iceland 2003-2012. Basic Clin Pharmacol Toxicol 2014; 115:417-22. [DOI: 10.1111/bcpt.12243] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/19/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Drifa Palin Geirs
- Centre of Public Health Sciences; Faculty of Medicine; University of Iceland; Reykjavík Iceland
| | - Anton Pottegård
- Clinical Pharmacology; Institute of Public Health; University of Southern Denmark; Odense Denmark
- Department of Clinical Chemistry & Pharmacology; Odense University Hospital; Odense Denmark
| | | | - Helga Zoëga
- Centre of Public Health Sciences; Faculty of Medicine; University of Iceland; Reykjavík Iceland
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Long-term (1 year) safety and efficacy of methylphenidate modified-release long-acting formulation (MPH-LA) in adults with attention-deficit hyperactivity disorder: a 26-week, flexible-dose, open-label extension to a 40-week, double-blind, randomised, placebo-controlled core study. CNS Drugs 2014; 28:951-62. [PMID: 25183661 PMCID: PMC4676085 DOI: 10.1007/s40263-014-0180-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Previously, in a 40-week, randomised, double-blind, placebo-controlled core study comprising three phases (9-week dose confirmation, 5-week open-label dose optimisation and 6-month maintenance of effect) in adults with attention-deficit/hyperactivity disorder (ADHD), methylphenidate modified-release long-acting formulation (MPH-LA) at 40-80 mg/day controlled ADHD symptoms as well as decreased functional impairment with a good tolerability profile (NCT01259492). Here, we report the long-term efficacy and safety from a 26-week, open-label extension phase of the same study (NCT01338818). METHODS Patients in the extension study (n = 298) initiated treatment with MPH-LA (20 mg/day), up-titrated in increments of 20 mg/week to reach individual patient's daily optimal dose of 40-80 mg. Adverse events (AEs) and serious adverse events (SAEs) were reported at the end of extension study for events monitored from (1) maintenance of effect phase baseline (core study; 12 months) and (2) extension study baseline (6 months). Mean changes in DSM-IV ADHD Rating Scale (DSM-IV ADHD RS) and Sheehan Disability Scale (SDS) total scores are reported for both the timelines. Efficacy was also evaluated using clinician-rated instruments, namely Clinical Global Impression-Improvement Scale (CGI-I) and Clinical Global Impression-Severity Scale (CGI-S). RESULTS No unexpected AEs were reported in the extension study. Incidence of SAEs reported during 6 months and 12 months were similar (0.7 %), and no deaths were reported. No SAEs were considered attributable to the drug at the end of 12 months. There were no reports of patients with QT, QTcB or QTcF >500 ms. The mean improvement in DSM-IV ADHD RS and SDS total scores at the end of 12 months were 0.9 and 1.4 points, respectively; and at the end of 6 months were 7.2 and 4.8, respectively. The proportion of patients with improvement in CGI-S scale was 31.4 % and 52.1 % at the end of 12 and 6 months, respectively. Overall, 69.4 % of patients showed clinical improvement in CGI-I scale at the end of 6 months. CONCLUSIONS In adult patients with ADHD, use of MPH-LA up to 1 year continued to be well tolerated while maintaining the clinical efficacy.
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Coles T, Coon C, DeMuro C, McLeod L, Gnanasakthy A. Psychometric evaluation of the Sheehan Disability Scale in adult patients with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat 2014; 10:887-95. [PMID: 24899807 PMCID: PMC4038420 DOI: 10.2147/ndt.s55220] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Inattention and impulsivity symptoms are common among adults with attention-deficit/hyperactivity disorder (ADHD), which can lead to difficulty concentrating, restlessness, difficulty completing tasks, disorganization, impatience, and impulsiveness. Many adults with ADHD find it difficult to focus and prioritize. Resulting outcomes, such as missed deadlines and forgotten engagements, may ultimately impact the ability to function at work, school, home, or in a social environment. The European Medicines Agency guidelines for evaluating medicinal products for ADHD recommend inclusion of both functional outcomes, such as school, social, or work functioning, and outcomes related to symptoms of ADHD in clinical studies of novel medication primary efficacy endpoints. Due to its performance in other disease areas and the relevance of its items as evidenced by content validity analyses, the Sheehan Disability Scale (SDS) was chosen to assess functional impairment in ADHD. The aim of this study was to investigate the psychometric properties of the SDS, used as a brief measure of functional impairment in a number of psychiatric disorders, in adult patients with ADHD. To the authors' knowledge, this is the first study to evaluate the reliability of the SDS (based on Cronbach's coefficient alpha and test-retest reliability), its validity (construct and known-groups validity), and its ability to detect change in this patient population. This study also established a preliminary responder definition for the SDS in this study population to determine when change can be considered clinically beneficial in a clinical trial setting. The psychometric results support the use of the SDS subscales (items 1-3) and total score (sum of items 1-3) in an ADHD population. In addition, the evaluation provides evidence for a three-point preliminary responder definition for the SDS and further evidence of its responsiveness in adults with ADHD. Altogether, the results indicate that the SDS is a simple and easy-to-score scale that would have great utility in future clinical trials for monitoring functional impairment in adults with ADHD.
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Affiliation(s)
- Theresa Coles
- Patient-Reported Outcomes, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Cheryl Coon
- Patient-Reported Outcomes, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Carla DeMuro
- Patient-Reported Outcomes, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Lori McLeod
- Patient-Reported Outcomes, RTI Health Solutions, Research Triangle Park, NC, USA
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