1
|
Nanda A, Janga LSN, Sambe HG, Yasir M, Man RK, Gogikar A, Mohammed L. Adverse Effects of Stimulant Interventions for Attention Deficit Hyperactivity Disorder (ADHD): A Comprehensive Systematic Review. Cureus 2023; 15:e45995. [PMID: 37900465 PMCID: PMC10601982 DOI: 10.7759/cureus.45995] [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: 08/15/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Attention deficit hyperactivity disorder (ADHD) is a fairly common psychiatric disorder among children. It has substantial consequences in terms of quality of life for those experiencing it and their families. In managing ADHD symptoms medication plays an essential role, including stimulants such as methylphenidate being a key component. Nevertheless, concerns have been raised about possible adverse reactions connected to these drugs. Thus, in this systematic review, an extensive analysis was conducted aiming at understanding any negative repercussions specifically from prolonged exposure to these medications among patients diagnosed with ADHD. The methodology entailed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. While capturing relevant data through a meticulous search in various databases, filtered according to preset inclusion and exclusion criteria, 13 studies were considered for analysis. Conclusions indicate that the administration of stimulant medications can potentially translate into a small rise in blood pressure along with increased heart rate particularly when amphetamines are taken. However, no reports of notable serious cardiovascular events have emerged. In the domain of neuropsychiatry, it appears that long-term usage of methylphenidate generally bears no serious consequences, even though a hike in risk levels related to the occurrence of psychotic episodes was detected among those treated with amphetamines. Several gastrointestinal side effects including decreased appetite and stomach pain were reported, however, findings regarding ocular abnormalities or growth-related effects stood inconclusive. Therefore, based on this data the consensus is that stimulant medications do generate manageable and mild negative outcomes within the ADHD population. It is vital however to highlight the need for careful observation and further scientific inquiry to achieve a better grasp on both immediate as well as long-term implications involved.
Collapse
Affiliation(s)
- Ankita Nanda
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Hembashima G Sambe
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohamed Yasir
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ruzhual K Man
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amaresh Gogikar
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
2
|
Shahidullah JD, Roberts H, Parkhurst J, Ballard R, Mautone JA, Carlson JS. State of the Evidence for Use of Psychotropic Medications in School-Age Youth. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1454. [PMID: 37761415 PMCID: PMC10528957 DOI: 10.3390/children10091454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023]
Abstract
Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.
Collapse
Affiliation(s)
- Jeffrey D. Shahidullah
- Department of Psychiatry & Behavioral Sciences, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Holly Roberts
- Department of Psychology, Munroe-Meyer Institute, University of Nebraska Medical Center, Omaha, NE 68198, USA;
| | - John Parkhurst
- Pritzker Department of Psychiatry & Behavioral Sciences, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (J.P.); (R.B.)
| | - Rachel Ballard
- Pritzker Department of Psychiatry & Behavioral Sciences, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (J.P.); (R.B.)
| | - Jennifer A. Mautone
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19146, USA;
| | - John S. Carlson
- Department of Counseling, Educational Psychology, & Special Education, Michigan State University, East Lansing, MI 48824, USA
| |
Collapse
|
3
|
Pujalte GGA, Narducci DM, Smith MS, King R, Logan K, Callender SS, Liebman CA, Kane SF, Israel MP, Wolf SF, Nuti R, Khodaee M. Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine. Clin J Sport Med 2023; 33:195-208. [PMID: 37185161 DOI: 10.1097/jsm.0000000000001152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 05/17/2023]
Abstract
ABSTRACT Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.
Collapse
Affiliation(s)
- George G A Pujalte
- Department of Family Medicine and Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Dusty Marie Narducci
- Department of Family Medicine, University of South Florida College of Medicine, Tampa, Florida
| | - Michael Seth Smith
- Sports Medicine Institute, Department of Orthopaedics, Florida Health, Gainesville, Florida
| | - Rebecca King
- Primary Care National Landing, Virginia Hospital Center, Arlington, Virginia
| | - Kelsey Logan
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Shelley Street Callender
- Departments of Pediatrics and Family Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Catherine A Liebman
- Department Family Medicine and Community Health, Penn Health, Philadelphia, Pennsylvania
| | - Shawn F Kane
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael P Israel
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sigrid F Wolf
- Division of Orthopaedic Surgery and Sports Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Morteza Khodaee
- AF Williams Family Medicine Clinic, UCHealth, Denver, Colorado
| |
Collapse
|
4
|
Hammerness P, Berger A, Angelini MC, Wilens TE. Cardiovascular Considerations for Stimulant Class Medications. Child Adolesc Psychiatr Clin N Am 2022; 31:437-448. [PMID: 35697394 DOI: 10.1016/j.chc.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The cardiovascular (CV) impact of stimulants has been examined for decades, with investigations ranging from small sample targeted studies of heart rate (HR) and blood pressure (BP), to large scale epidemiologic investigations. The preponderance of evidence is reassuring, albeit generally based on healthy samples using variable methodology, excluding those at theoretic high risk (eg, comorbid cardiac illness). Screening for theoretically vulnerable patients are recommended, as well as monitoring for CV symptoms and BP/HR, with shared inquiry/further evaluation if concerned. Future investigations to support the identification of risk are needed, while attention to stimulant-associated CV risk is an opportunity for clinicians to engage in general CV risk identification and intervention.
Collapse
Affiliation(s)
- Paul Hammerness
- Psychiatry Services, Southcoast Health, 101 Page Street, New Bedford, MA, USA.
| | - Amy Berger
- Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Michael C Angelini
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Timothy E Wilens
- Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| |
Collapse
|
5
|
Masi G, Pfanner C, Liboni F, Lenzi F, Villafranca A, D’Acunto G, Fantozzi P, Falcone F, Simonelli V, Muratori P, Levantini V, Favole I, Amianto F, Davico C, Vitiello B. Acute Tolerability of Methylphenidate in Treatment-Naïve Children with ADHD: An Analysis of Naturalistically Collected Data from Clinical Practice. Paediatr Drugs 2022; 24:147-154. [PMID: 35137333 PMCID: PMC8940796 DOI: 10.1007/s40272-022-00492-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The acute tolerability of methylphenidate (MPH) in children with attention-deficit/hyperactivity disorder (ADHD) has been studied mainly in research samples. Taking advantage of the mandatory test-dose procedure required for starting MPH in Italy, this study aimed to assess the incidence of intolerable adverse events after initial exposure to MPH in routine clinical practice. METHODS The medical records of 480 consecutively treated, previously drug-naïve children and adolescents with ADHD (90% male, mean age 10.6 ± 3.0 years) were retrospectively analyzed. All children received an initial single dose of MPH immediate release (5 or 10 mg) followed by a 4-hour direct medical observation. Heart rate and blood pressure were measured at dosing and 1, 2, and 3 hours afterwards. If the first dose was well tolerated, the child continued treatment with MPH 5-20 mg daily, and was reassessed a week later. RESULTS Eleven patients (2.3%, 95% CI 1.1-4.1) interrupted treatment within a week of initiation because of the following adverse events: irritability (n = 3), tics worsening (n = 3), reduced appetite (n = 1), enuresis (n = 1), hallucinations (n = 1), hyperfocus (n = 1), and 'rebound' behavioral worsening (n = 1). The most common adverse events were reduced appetite (20%), irritability (14.2%), headache (10.6%), sleep problems (9.4%), stomachache (9.4%), and tics (5%). Intellectual disability increased the risk of any adverse event in general and of irritability in particular. No cardiovascular symptom was clinically reported. However, routine assessments of vital signs during the first 3 hours after the first dose of MPH showed that 9% of the children had a 20% increase in heart rate, 8.8% had a 20% increase in diastolic blood pressure and 4.5% had a 20% increase in systolic blood pressure. Of these, 25.2% still had an elevated heart rate 1 week later. CONCLUSIONS Among stimulant-naïve children in clinical practice, the incidence of acute MPH intolerance can be estimated to be between 1.2 and 4.1%. An asymptomatic elevation in cardiovascular parameters can be observed in about 1 out of 10 children and warrants monitoring during ongoing treatment.
Collapse
Affiliation(s)
- Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Chiara Pfanner
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Francesca Liboni
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Francesca Lenzi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Arianna Villafranca
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Giulia D’Acunto
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Pamela Fantozzi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Francesca Falcone
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valerio Simonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Pietro Muratori
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Valentina Levantini
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Irene Favole
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | | | - Chiara Davico
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
| | - Benedetto Vitiello
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy.
| |
Collapse
|
6
|
García Ron A, Rodriguez Mesa M, Arias Vivas E, Bote Gascon M. The impact of methylphenidate treatment on the functional and structural properties of the left ventricle: A medium-term prospective study. An Pediatr (Barc) 2021; 96:43-50. [PMID: 34937681 DOI: 10.1016/j.anpede.2020.12.017] [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: 09/08/2020] [Accepted: 12/23/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Although methylphenidate (MPH) used for treatment of attention deficit hyperactivity disorder (ADHD) are considered safe in healthy children and adolescents in the short and medium term, there is a widespread concern about long-term cardiovascular safety. MATERIAL AND METHODS Interventional, prospective, longitudinal and comparative study with a crossover design to evaluate the cardiovascular impact of the treatment with MPH in healthy children and adolescents diagnosed with ADHD. A protocol for the cardiovascular evaluation was established at a basal point, after the first and the second year of the beginning with treatment based on the monitoring of blood pressure (BP) and echocardiographic follow-up of the systolic and diastolic functions, and structural cardiac properties. RESULTS 73 patients completed the study, with an average age of 9 ± 2.6 years, 75.3% were male and the majority were thin (64.4%). We found an increase in Systolic and Diastolic BP of 3.7 ± 9 mmHg (P = 0.004) and 2 ± 11,5 mmHg respectively. There were no severe cardiovascular events. We didn't find any echocardiographic alterations namely on the structural properties or parameters of systolic function. Regarding diastolic function, a significant increase in the isovo-lumic relaxation time (IVRT) (P = 0.046) and deceleration time (P = 0.016) was observed. However, no significant alterations in the parameters related to distensibility of the LV neither in the early diastolic pressure were found. CONCLUSION Further studies are needed to evaluate the impact of psychostimulants as a modifiable long-term Cardiovascular Risk Factor.
Collapse
Affiliation(s)
- Adrián García Ron
- Unidad de Neuropediatría, Instituto del Niño y del Adolescente, Hospital Clínico San Carlos, Madrid, Spain.
| | | | - Eva Arias Vivas
- Unidad de Neuropediatría, Instituto del Niño y del Adolescente, Hospital Clínico San Carlos, Madrid, Spain
| | - Marta Bote Gascon
- Unidad de Neuropediatría, Instituto del Niño y del Adolescente, Hospital Clínico San Carlos, Madrid, Spain
| |
Collapse
|
7
|
Omidi N, Mojtaba Ghorashi S, Zahedi Tajrishi F, Effatpanah M, Khatami F, Rafie Khorgami M. Effects of methylphenidate on blood pressure, QT-interval, and cardiac output in ADHD diagnosed children: A three months' follow-up study. IJC HEART & VASCULATURE 2021; 34:100805. [PMID: 34141860 PMCID: PMC8188377 DOI: 10.1016/j.ijcha.2021.100805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/29/2021] [Accepted: 05/20/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Attention-deficit hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood. It's been suggested that both the condition and the medications used to treat it can affect the cardiovascular system. This study aims to determine whether methylphenidate has the significant effects in cardiac indices. METHODS In this prospective study, 100 newly ADHD-diagnosed children aged 6 to 11 whom all on methylphenidate were included. The demographic, clinical data including the blood pressure and heart rate (HR), echocardiographic, and QT-interval were recorded at baseline and after three months of follow-up. RESULTS After the follow-up period, we observed no abnormal systolic, diastolic, or mean arterial pressure in any of the participants based on their age, height, and gender (p < 0.001). However, the mean of all these variables was significantly increased (p 〈0 0 1). Mean pulse pressure was also higher than baseline but it wasn't statistically significant (p = 0.059). No significant change was observed in echocardiographic parameters and QT. CONCLUSION Short-term treatment of ADHD in children with methylphenidate does not have a meaningful relationship with hypertension and increased corrected QT interval. However, an increase in blood pressure and corrected QT interval within a non-pathological range suggests that longer follow-ups may reveal an association.
Collapse
Affiliation(s)
- Negar Omidi
- Cardiac Primary Prevention Research Center, Cardiovascular Disease Research Institute, Tehran Heart Center (THC), Tehran University of Medical Sciences, Tehran, Iran
| | - Seyyed Mojtaba Ghorashi
- Cardiovascular Disease Research Institute, Tehran Heart Center (THC), Tehran University of Medical Sciences, Tehran, Iran
| | - Farbod Zahedi Tajrishi
- Cardiac Primary Prevention Research Center, Cardiovascular Disease Research Institute, Tehran Heart Center (THC), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Effatpanah
- Department of Psychiatry, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Farnaz Khatami
- Department of Community Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rafie Khorgami
- Rajaie Cardiovascular Medical and Research Center (RCMRC), Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
8
|
Uebel-von Sandersleben H, Dangel O, Fischer R, Ruhmann M, Huss M. Effectiveness and safety of dexamphetamine sulfate (Attentin ®) in the routine treatment of children and adolescents with ADHD: results from a 12-month non-interventional study. Scand J Child Adolesc Psychiatr Psychol 2021; 9:73-86. [PMID: 33928056 PMCID: PMC8077785 DOI: 10.21307/sjcapp-2021-009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Randomized controlled trials have shown that dexamphetamine sulfate (DEX) is efficacious in the treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents; however, data on the effectiveness and safety of DEX in routine practice are scarce. Objective This study investigated the long-term effectiveness and safety of Attentin® (immediate-release DEX) in children and adolescents with ADHD in routine practice. Methods ATTENTION was a multicenter, prospective, observational, non-interventional study that enrolled pediatric patients with ADHD (aged 6-17 years) with a clinically inadequate response to previous methylphenidate (MPH) treatment. Patients were assessed at baseline and two follow-up visits after approx. 6 and 12 months of DEX treatment. The primary endpoint was the investigator-rated ADHD rating scale IV (ADHD-RS-IV) total score change from baseline to the first follow-up visit. Results The study enrolled 140 patients (mean age: 11.2 years). Significant reductions in ADHD-RS-IV total scores were observed in the titration phase and were maintained up to the second follow-up visit. The mean ADHD-RS-IV total score change from baseline to the first follow-up visit was -11.9 (27.1 vs. 13.4, p < .001). Beneficial effects of DEX were observed on both ADHD-RS-IV subscales ('hyperactivity/impulsivity' and 'inattention') and in both children and adolescents. Clinical response, defined as a reduction in the ADHD-RS-IV total score of at least 30% at the first follow-up visit, was observed in 78.1% of patients. Patients reported an average onset of action of 36.2 minutes and an average duration of action of 6.5 hours after intake of the first dose of DEX in the morning. DEX was well tolerated. Small significant increases in mean systolic and diastolic blood pressure compared to baseline were observed. Conclusions Attentin® is an effective and well-tolerated long-term treatment for pediatric ADHD patients with a clinically inadequate response to previous MPH treatment.
Collapse
Affiliation(s)
- Henrik Uebel-von Sandersleben
- University Medical Center Göttingen, Department of Child and Adolescent Psychiatry and Psychotherapy, Göttingen, Germany
| | - Oliver Dangel
- MEDICE Arzneimittel Pütter GmbH & Co KG; Iserlohn, Germany
| | - Roland Fischer
- MEDICE Arzneimittel Pütter GmbH & Co KG; Iserlohn, Germany
| | | | | |
Collapse
|
9
|
García Ron A, Rodriguez Mesa M, Arias Vivas E, Bote Gascon M. [The impact of methylphenidate treatment on the functional and structural properties of the left ventricle: A medium-term prospective study]. An Pediatr (Barc) 2021; 96:S1695-4033(20)30537-3. [PMID: 33551293 DOI: 10.1016/j.anpedi.2020.12.014] [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: 09/08/2020] [Revised: 12/17/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Although methylphenidate (MPH) used for treatment of Attention deficit hyperactivity disorder (ADHD) are considered safe in healthy children and adolescents in the short and medium term, there is a widespread concern about long-term cardiovascular safety. MATERIAL AND METHODS Interventional, prospective, longitudinal and comparative study with a crossover design to evaluate the cardiovascular impact of the treatment with MPH in healthy children and adolescents diagnosed with ADHD. A protocol for the cardiovascular evaluation was established at a basal point, after the first and the second year of the beginning with treatment based on the monitoring of Blood pressure (BP) and echocardiographic follow-up of the systolic and diastolic functions, and structural cardiac properties. RESULTS 73 patients completed the study, with an average age of 9+/- 2.6 years, 75.3% were male and the majority were thin (64.4%). We found an increase in Systolic and Diastolic BP of 3.7±9mmHg (P).004) and 2±11,5mmHg respectively. There were no severe cardiovascular events. We didn't find any echocardiographic alterations namely on the structural properties or parameters of systolic function. Regarding diastolic function, a significant increase in the isovolumic relaxation time (IVRT) (P=.046) and deceleration time (P=.016) was observed. However, no significant alterations in the parameters related to distensibility of the LV neither in the early diastolic pressure were found. CONCLUSION Further studies are needed to evaluate the impact of psychostimulants as a modifiable long-term Cardiovascular Risk Factor.
Collapse
Affiliation(s)
- Adrián García Ron
- Unidad de Neuropediatría, Instituto del Niño y del Adolescente, Hospital Clínico San Carlos, Madrid, España.
| | | | - Eva Arias Vivas
- Unidad de Neuropediatría, Instituto del Niño y del Adolescente, Hospital Clínico San Carlos, Madrid, España
| | - Marta Bote Gascon
- Unidad de Neuropediatría, Instituto del Niño y del Adolescente, Hospital Clínico San Carlos, Madrid, España
| |
Collapse
|
10
|
Querido AL, van Hulst RA. Diving and attention deficit hyperactivity disorder. Diving Hyperb Med 2019; 49:41-47. [PMID: 30856666 DOI: 10.28920/dhm49.1.41-47] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 01/07/2019] [Indexed: 12/18/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) is a psychiatric condition that affects attention, concentration, impulse control and awareness. Not only these symptoms, but also the medications used to treat ADHD (psychostimulants) pose a risk to both the diver and his or her buddy. This article presents guidelines for recreational diving in combination with ADHD and psychostimulants. These guidelines are based solely on 'expert' opinion and were adopted at a meeting of the Dutch Association for Diving Medicine in 2017.
Collapse
Affiliation(s)
- Abraham L Querido
- Praktijk Querido, Larenseweg 14, Hilversum, The Netherlands.,Corresponding author: Abraham L Querido, Praktijk Querido, Larenseweg 14, Hilversum, The Netherlands,
| | - Robert A van Hulst
- Department of Experimental Intensive Care and Anaesthesiology/Hyperbaric Medicine, Academic Medical Center, Amsterdam
| |
Collapse
|
11
|
Martin CA, Nuzzo PA, Ranseen JD, Kleven MS, Guenthner G, Williams Y, Walsh SL, Dwoskin LP. Lobeline Effects on Cognitive Performance in Adult ADHD. J Atten Disord 2018; 22:1361-1366. [PMID: 23966351 PMCID: PMC4062608 DOI: 10.1177/1087054713497791] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In preclinical studies, lobeline inhibited hyperactivity induced by nicotine and amphetamine, and improved performance and learning in studies utilizing radial-arm maze and spatial-discrimination water maze. This laboratory proof-of-concept study investigated lobeline as a treatment for ADHD symptoms in adults (31.11 ± 7.08 years). METHOD Using cognitive tasks and self-report measures, the effects of lobeline (0, 7.5, 15, or 30 mg, s.l.) and methylphenidate (0, 15, or 30 mg, p.o.) were assessed in nine volunteers with ADHD. RESULTS Evidence suggested that lobeline could modestly improve working memory in adults with ADHD, but no significant improvement in attention was observed. Lobeline administration was associated with mild adverse side effects (nausea). CONCLUSION Further investigation of lobeline on working memory may be warranted.
Collapse
|
12
|
Oxley C, Moghraby OS, Samuel R, Joyce DW. Improving the quality of physical health monitoring in CAMHS for children and adolescents prescribed medication for ADHD. BMJ Open Qual 2018; 7:e000213. [PMID: 29756071 PMCID: PMC5942444 DOI: 10.1136/bmjoq-2017-000213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 04/05/2018] [Indexed: 11/15/2022] Open
Abstract
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterised by a persistent, pervasive pattern of inattention, impulsivity and hyperactivity. Stimulant medication such as methylphenidate has an established evidence base in the treatment of children and adolescents with ADHD. However, it is also associated with a risk of side effects which may include decreased appetite, increased blood pressure and possible reduced growth. Monitoring physical health in children and adolescents prescribed medication for ADHD is a key clinical responsibility and includes a number of parameters as outlined in the National Institute for Health and Care Excellence Guidelines. Ascertaining the centiles of physical observations is essential to put these into developmental context and accurately inform treatment decisions. This quality improvement project aimed to improve physical health monitoring in children and adolescents prescribed stimulant medication for ADHD within a large specialist urban inner-city Child and Adolescent Mental Health Service (CAMHS) in South London and Maudsley NHS Foundation Trust. Baseline data were obtained to establish the quality of physical monitoring including blood pressure, height, weight and centiles. Targeted interventions included the development of a novel web-based application designed to calculate and record centiles. We report an improvement in total proportion compliance with physical health monitoring from 24% to 75%. The frequency of recording baseline blood pressure centiles increased from 0% to 62%; recording baseline height centiles increased from 37% to 81% and recording baseline weight centiles increased from 37% to 81%. Improvement in the delivery of high-quality care was achieved and sustained through close collaboration with clinicians involved in the treatment pathway in order to elicit and respond effectively to feedback for improvement and codevelop interventions which were highly effective within the clinical system. We believe this model to be replicable in other CAMHS services and ADHD clinics to improve the delivery of high-quality clinical care.
Collapse
Affiliation(s)
- Cristal Oxley
- Department of Child and Adolescent Psychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - Omer S Moghraby
- Department of Child and Adolescent Psychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - Rani Samuel
- Department of Child and Adolescent Psychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - Dan W Joyce
- Department of Child and Adolescent Psychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
13
|
Clavenna A, Bonati M. Pediatric pharmacoepidemiology - safety and effectiveness of medicines for ADHD. Expert Opin Drug Saf 2017; 16:1335-1345. [DOI: 10.1080/14740338.2017.1389894] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Antonio Clavenna
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| |
Collapse
|
14
|
Adesman A, Blaufox AD. Re: "Stimulants and Pediatric Cardiovascular Risk" by Zito and Burcu (J Child Psychopharmacol 27: 538-545, 2017). J Child Adolesc Psychopharmacol 2017; 27:559-560. [PMID: 28820637 DOI: 10.1089/cap.2016.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Andrew Adesman
- 1 Developmental and Behavioral Pediatrics, Cohen Children's Medical Center of New York , Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Andrew D Blaufox
- 2 Pediatric Cardiac Electrophysiology, Cohen Children's Medical Center of New York , Hofstra Northwell School of Medicine, New Hyde Park, New York
| |
Collapse
|
15
|
Groenman AP, Schweren LJS, Dietrich A, Hoekstra PJ. An update on the safety of psychostimulants for the treatment of attention-deficit/hyperactivity disorder. Expert Opin Drug Saf 2017; 16:455-464. [PMID: 28277842 DOI: 10.1080/14740338.2017.1301928] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Methylphenidate is the first-line pharmacological treatment of attention-deficit/hyperactivity disorder (ADHD). Although methylphenidate has a well-established evidence base for treating ADHD, its long-term benefits are unclear. Areas covered: Physical adverse effects, psychiatric adverse events and brain development Expert opinion: Some physical adverse events have been described (e.g. sleep disturbances, growth reduction, loss of appetite), although most are of transient nature. Psychiatric adverse events seem more related to the diagnosis ADHD itself, and not stimulant treatment. Concluding, short-to-mid-term use (i.e., up to 2 years) stimulants are relatively safe, but much less is known about longer-term efficacy and safety of these drugs.
Collapse
Affiliation(s)
- Annabeth P Groenman
- a Department of Child and Adolescent Psychiatry , University of Groningen, University Medical Center Groningen , Groningen , Netherlands
| | | | - Andrea Dietrich
- a Department of Child and Adolescent Psychiatry , University of Groningen, University Medical Center Groningen , Groningen , Netherlands
| | - Pieter J Hoekstra
- a Department of Child and Adolescent Psychiatry , University of Groningen, University Medical Center Groningen , Groningen , Netherlands
| |
Collapse
|
16
|
Hennissen L, Bakker MJ, Banaschewski T, Carucci S, Coghill D, Danckaerts M, Dittmann RW, Hollis C, Kovshoff H, McCarthy S, Nagy P, Sonuga-Barke E, Wong ICK, Zuddas A, Rosenthal E, Buitelaar JK. Cardiovascular Effects of Stimulant and Non-Stimulant Medication for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis of Trials of Methylphenidate, Amphetamines and Atomoxetine. CNS Drugs 2017; 31:199-215. [PMID: 28236285 PMCID: PMC5336546 DOI: 10.1007/s40263-017-0410-7] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Many children and adolescents with attention deficit/hyperactivity disorder (ADHD) are treated with stimulant and non-stimulant medication. ADHD medication may be associated with cardiovascular effects. It is important to identify whether mean group effects translate into clinically relevant increases for some individual patients, and/or increase the risk for serious cardiovascular adverse events such as stroke or sudden death. OBJECTIVES To evaluate potential cardiovascular effects of these treatments, we conducted a systematic review and meta-analysis of the effects of methylphenidate (MPH), amphetamines (AMP), and atomoxetine (ATX) on diastolic and systolic blood pressure (DBP, SBP) and heart rate (HR) in children and adolescents with ADHD. METHODS We conducted systematic searches in electronic databases (PsychINFO, EMBASE and Medline) to identify published trials which involved individuals who were (i) diagnosed with ADHD and were aged between 0-18 years; (ii) treated with MPH, AMP or ATX and (iii) had their DBP and SBP and/or HR measured at baseline (pre) and the endpoint (post) of the study treatment. Studies with an open-label design or a double-blind randomised control design of any duration were included. Statistical analysis involved calculating differences between pre- and post-treatment measurements for the various cardiovascular parameters divided by the pooled standard deviation. Further, we assessed the percentage of clinically relevant increased BP or HR, or documented arrhythmias. RESULTS Eighteen clinical trials met the inclusion criteria (10 for MPH, 5 for AMP, and 7 for ATX) with data from 5837 participants (80.7% boys) and average duration of 28.7 weeks (range 4-96 weeks). All three medications were associated with a small, but statistically significant pre-post increase of SBP (MPH: standard mean difference [SMD] 0.25, 95% confidence interval [CI] 0.08-0.42, p < 0.01; AMP: SMD 0.09, 95% CI 0.03-0.15, p < 0.01; ATX: SMD 0.16, 95% CI 0.04-0.27, p = 0.01). MPH did not have a pre-post effect on DBP and HR. AMP treatment was associated with a small but statistically significant pre-post increase of DBP (SMD 0.16, CI 0.03-0.29, p = 0.02), as was ATX treatment (SMD 0.22, CI 0.10-0.34, p < 0.01). AMP and ATX were associated with a small to medium statistically significant pre-post increase of HR (AMP: SMD 0.37, CI 0.13-0.60, p < 0.01; ATX: SMD 0.43, CI 0.26-0.60, p < 0.01). The head-to-head comparison of the three medications did not reveal significant differences. Sensitivity analyses revealed that AMP studies of <18 weeks reported higher effect sizes on DBP compared with longer duration studies (F(1) = 19.55, p = 0.05). Further, MPH studies published before 2007 reported higher effect sizes on SBP than studies after 2007 (F(1) = 5.346, p = 0.05). There was no effect of the following moderators: type of medication, doses, sample size, age, gender, type of ADHD, comorbidity or dropout rate. Participants on medication reported 737 (12.6%) other cardiovascular effects. Notably, 2% of patients discontinued their medication treatment due to any cardiovascular effect. However, in the majority of patients, the cardiovascular effects resolved spontaneously, medication doses were changed or the effects were not considered clinically relevant. There were no statistically significant differences between the medication treatments in terms of the severity of cardiovascular effects. CONCLUSIONS Statistically significant pre-post increases of SBP, DBP and HR were associated with AMP and ATX treatment in children and adolescents with ADHD, while MPH treatment had a statistically significant effect only on SBP in these patients. These increases may be clinically significant for a significant minority of individuals that experience larger increases. Since increased BP and HR in general are considered risk factors for cardiovascular morbidity and mortality during adult life, paediatric patients using ADHD medication should be monitored closely and regularly for HR and BP.
Collapse
Affiliation(s)
- Leonie Hennissen
- Department of Cognitive Neuroscience (204), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, P.O. Box 9101, 9100 HB, Nijmegen, The Netherlands
| | - Mireille J Bakker
- Department of Cognitive Neuroscience (204), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, P.O. Box 9101, 9100 HB, Nijmegen, The Netherlands
| | - Tobias Banaschewski
- Paediatric Psychopharmacology, Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Sara Carucci
- Child and Adolescent Neuropsychiatric Unit, Department of Biomedical Sciences, University of Cagliari and "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy
| | - David Coghill
- Division of Neuroscience, School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
- Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Marina Danckaerts
- Child and Adolescent Psychiatry, Department of Neurosciences, KU Leuven, Louvain, Belgium
| | - Ralf W Dittmann
- Paediatric Psychopharmacology, Department of Child and Adolescent Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Chris Hollis
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
| | - Hanna Kovshoff
- Department of Psychology, University of Southampton, Highfield, Southampton, UK
| | | | - Peter Nagy
- Vadaskert Child and Adolescent Psychiatric Hospital, Budapest, Hungary
| | - Edmund Sonuga-Barke
- Department of Psychology, University of Southampton, Highfield, Southampton, UK
| | - Ian C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1 N 1AX, UK
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, China
| | - Alessandro Zuddas
- Child and Adolescent Neuropsychiatric Unit, Department of Biomedical Sciences, University of Cagliari and "A. Cao" Microcitemico Paediatric Hospital, Cagliari, Italy
| | - Eric Rosenthal
- Department of Paediatric Cardiology, Evelina London Children's Hospital, St Thomas' Hospital, London, UK
| | - Jan K Buitelaar
- Department of Cognitive Neuroscience (204), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, P.O. Box 9101, 9100 HB, Nijmegen, The Netherlands.
- Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, The Netherlands.
| |
Collapse
|
17
|
Meyer T, Becker A, Sundermann J, Rothenberger A, Herrmann-Lingen C. Attention deficit-hyperactivity disorder is associated with reduced blood pressure and serum vitamin D levels: results from the nationwide German Health Interview and Examination Survey for Children and Adolescents (KiGGS). Eur Child Adolesc Psychiatry 2017; 26:165-175. [PMID: 27197525 DOI: 10.1007/s00787-016-0852-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 04/15/2016] [Indexed: 01/03/2023]
Abstract
Alterations in blood pressure in attention-deficit/hyperactivity disorder (ADHD), specifically during dopaminergic stimulant intake, are not fully understood. It has been reported that vitamin D deficiency might modify dopaminergic pathways and thus influence ADHD symptoms. Using data from the nationwide German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study, we compared blood pressure and vitamin D levels in healthy controls to both diagnosed ADHD patients and suspected ADHD subjects, as defined by a value of ≥7 on the hyperactivity-inattention subscale of the Strengths and Difficulties Questionnaire. In a total cohort of n = 6922 study participants aged 11-17 years, mean arterial blood pressure was significantly higher in controls (86.7 ± 8.2 mmHg) than in the two groups of confirmed (85.5 ± 7.8 mmHg, p = 0.004, n = 430) and suspected ADHD patients (84.6 ± 8.2, p < 0.001, n = 399). In addition, we found an inverse association between vitamin D and blood pressure in both ADHD groups (p < 0.003). Regression analyses adjusted for age, sex, body-mass index, psychotropic medication use, and serum vitamin D levels confirmed that low blood pressure was a significant and independent predictor of ADHD. Furthermore, we observed that vitamin D mediated the effect of systolic blood pressure on ADHD diagnosis (b = 0.007, 95 % confidence interval [CI] 0.001-0.013, p = 0.021, R 2 = 0.050). In a large and representative national sample of German adolescents, we found a significant association between low blood pressure and ADHD symptoms. In addition, we observed that circulating vitamin D mediated the inverse relation between blood pressure and ADHD, although the effect size was very low. These findings highlight the role of dysregulated pathways of the autonomic nervous system in ADHD.
Collapse
Affiliation(s)
- Thomas Meyer
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany.
- Department of Psychosomatic Medicine and Psychotherapy, and German Centre for Cardiovascular Research, University of Göttingen, Von-Siebold-Str. 5, Göttingen, Germany.
| | - Andreas Becker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
| | - Jessika Sundermann
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
| | - Aribert Rothenberger
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
| | - Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
- Department of Psychosomatic Medicine and Psychotherapy, and German Centre for Cardiovascular Research, University of Göttingen, Von-Siebold-Str. 5, Göttingen, Germany
| |
Collapse
|
18
|
Strawn JR, Dobson ET, Giles LL. Primary Pediatric Care Psychopharmacology: Focus on Medications for ADHD, Depression, and Anxiety. Curr Probl Pediatr Adolesc Health Care 2017; 47:3-14. [PMID: 28043839 PMCID: PMC5340601 DOI: 10.1016/j.cppeds.2016.11.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The evidence base for psychopharmacologic interventions in youth with depressive and anxiety disorders as well as attention/deficit hyperactivity disorder (ADHD) has dramatically increased over the past two decades. Psychopharmacologic interventions commonly utilized in the pediatric primary care setting-selective serotonin (norepinephrine) reuptake inhibitors (SSRIs/SSNRIs), stimulants and α2 agonists-are reviewed. General pharmacologic principles are summarized along with class-related side effects and tolerability concerns (e.g., suicidality and activation in antidepressant-treated youth as well as insomnia, irritability, anorexia in stimulant-treated pediatric patients). Selected landmark trials of antidepressant medications in youth with depressive disorders [Treatment of Adolescent Depression Study (TADS) and the Treatment of SSRI-Resistant Depression Study (TADS)] and anxiety disorders [Child/Adolescent Anxiety Multimodal Study (CAMS) and Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS)] are described in addition to the Multimodal Treatment of ADHD Study. Finally, available data are presented that are related to prediction of treatment outcomes in youth with depressive disorders, anxiety disorders, and ADHD.
Collapse
Affiliation(s)
| | - Eric T Dobson
- University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Lisa L Giles
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT; Department of Psychiatry and Behavioral Health, Primary Children׳s Hospital, Salt Lake City, UT
| |
Collapse
|
19
|
Sayer GR, McGough JJ, Levitt J, Cowen J, Sturm A, Castelo E, McCracken JT. Acute and Long-Term Cardiovascular Effects of Stimulant, Guanfacine, and Combination Therapy for Attention-Deficit/Hyperactivity Disorder. J Child Adolesc Psychopharmacol 2016; 26:882-888. [PMID: 27483130 PMCID: PMC5178010 DOI: 10.1089/cap.2015.0264] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES This study examines cardiovascular (CV) effects of guanfacine immediate-release (GUAN-IR), dexmethylphenidate extended-release (DMPH), and their combination (COMB) during acute and long-term treatment of youth with attention-deficit/hyperactivity disorder. METHODS Two hundred seven participants aged 7-14 years enrolled in an 8-week double-blind randomized trial of GUAN-IR (1-3 milligrams (mg)/day), DMPH (5-20 mg/day), or COMB with fixed-flexible dosing and titrated to optimal behavioral response. Heart rate, systolic blood pressure (BP), diastolic BP, and electrocardiograms were assessed at baseline, end of blinded optimization, and over a 1-year open-label maintenance phase. RESULTS During acute titration, GUAN-IR decreased heart rate, systolic BP, and diastolic BP; DMPH increased heart rate, systolic BP, diastolic BP, and corrected QT (QTc) interval; COMB increased diastolic BP, but had no effects on heart rate, systolic BP, or QTc. During maintenance, GUAN-IR-associated decreases in heart rate and DMPH-associated increases in systolic BP returned to baseline values. Other variables across the three groups remained unchanged from the end of blinded titration. There were no discontinuations due to CV adverse events. CONCLUSION GUAN-IR, DMPH, and COMB were well tolerated and safe. Expected changes in CV parameters during acute titration were seen in GUAN-IR and DMPH groups, with COMB values falling intermediately between the two other treatment groups. No serious CV events occurred in any participant. GUAN-IR- and DMPH-associated CV changes generally returned to baseline with sustained therapy. These data suggest that COMB treatment might attenuate long-term CV effects of GUAN-IR and stimulant monotherapy, possibly reducing risk of the small but statistically significant changes associated with either single treatment. Clinicaltrials.gov Identifier: NCT00429273.
Collapse
Affiliation(s)
- Gregory R. Sayer
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - James J. McGough
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Jennifer Levitt
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Jennifer Cowen
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Alexandra Sturm
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Edward Castelo
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - James T. McCracken
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| |
Collapse
|
20
|
Kovshoff H, Banaschewski T, Buitelaar JK, Carucci S, Coghill D, Danckaerts M, Dittmann RW, Falissard B, Grimshaw DG, Hollis C, Inglis S, Konrad K, Liddle E, McCarthy S, Nagy P, Thompson M, Wong IC, Zuddas A, Sonuga-Barke EJ. Reports of Perceived Adverse Events of Stimulant Medication on Cognition, Motivation, and Mood: Qualitative Investigation and the Generation of Items for the Medication and Cognition Rating Scale. J Child Adolesc Psychopharmacol 2016; 26:537-47. [PMID: 27007169 PMCID: PMC4991592 DOI: 10.1089/cap.2015.0218] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE There is no questionnaire to specifically monitor perceived adverse events of methylphenidate (MPH) on cognition, motivation, and mood. The current study therefore had two goals. First, to harvest accounts of such putative events from transcripts of interviews in samples enriched for such potential experiences. Second, to use the derived data to generate items for a new questionnaire that can be used for monitoring such events in medication trials or routine clinical care. METHODS Following a literature search aimed at identifying associations between MPH and cognition and/or motivation, a qualitative semistructured interview was designed to focus specifically on the domains of cognition (i.e., reasoning, depth/breadth of thinking, intellectual capacity, and creativity) and motivation (i.e., drive, effort, and attitudes toward rewards/incentives). Interviews were conducted with 45 participants drawn from the following four groups: (a) clinicians, child and adolescent psychiatrists, and pediatricians specializing in attention-deficit/hyperactivity disorder (ADHD) (n = 15); (2) teachers, with experience of teaching at least 10 medicated children with ADHD (n = 10); (3) parents of children with ADHD (n = 8) treated with MPH; and (4) adolescents/adults with ADHD (n = 12). Purposeful sampling was used to selectively recruit ADHD participants whose histories suggested a degree of vulnerability to MPH adverse events. Data were analyzed using a deductive approach to content analysis. RESULTS While we probed purposefully for cognitive and motivational adverse events, a third domain, related to mood, emerged from the reports. Therefore, three domains, each with a number of subdomains, were identified from the interview accounts: (i) Cognition (six subdomains; attention/concentration, changes in thinking, reduced creativity, sensory overload, memory, slower processing speed); (ii) motivation (four subdomains; loss of intrinsic motivation for goal-directed activities, external locus of control, lack of effort/engagement in daily tasks, increased focus on incentives); and (iii) mood (three subdomains; dampening of spontaneity/flat affect, mood dysregulation, increased anxiety/edginess). On the basis of these reports, 34 items were specified and incorporated into a prototype questionnaire, which was piloted and refined on the basis of field-testing. CONCLUSIONS Items were identified that capture potential/perceived cognitive, motivational, and mood-related adverse events of MPH. The items generated will allow us to further develop and psychometrically examine their prevalence, and the extent to which they are associated with medication adherence, treatment outcome, impairment, and other reported adverse events (e.g., loss of appetite/cardiovascular effects).
Collapse
Affiliation(s)
- Hanna Kovshoff
- Academic Unit of Psychology, University of Southampton, Southampton, United Kingdom
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jan K. Buitelaar
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behavior, Department of Cognitive Neuroscience & Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, the Netherlands
| | - Sara Carucci
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari,Italy
| | - David Coghill
- Division of Neuroscience, School of Medicine, University of Dundee, Dundee, United Kingdom
- Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Marina Danckaerts
- Department of Neurosciences, Research Group Psychiatry, KU Leuven, Belgium
| | - Ralf W. Dittmann
- Paediatric Psychopharmacology, Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Bruno Falissard
- INSERM U1178, University Paris-Sud, University Paris-Descartes, AP-HP, Paris, France
| | | | - Chris Hollis
- Institute of Mental Health, Faculty of Medicine and Health Sciences, University of Nottingham, United Kingdom
| | - Sarah Inglis
- Tayside Clinical Trials Unit, University of Dundee, Dundee, United Kingdom
| | - Kerstin Konrad
- Clinical Child Neuropsychology, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Hospital RWTH Aachen, Aachen, Germany
- Institute of Neuroscience & Medicine (INM3), Research Centre Juelich, Germany
| | - Elizabeth Liddle
- Institute of Mental Health, Faculty of Medicine and Health Sciences, University of Nottingham, United Kingdom
| | | | - Peter Nagy
- Vadaskert Child and Adolescent Psychiatric Hospital, Budapest, Hungary
| | - Margaret Thompson
- Academic Unit of Psychology, University of Southampton, Southampton, United Kingdom
| | - Ian C.K. Wong
- UCL School of Pharmacy, London, United Kingdom
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine University of Hong Kong, China
| | - Alessandro Zuddas
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari,Italy
| | - Edmund J.S. Sonuga-Barke
- Academic Unit of Psychology, University of Southampton, Southampton, United Kingdom
- Department of Experimental Clinical & Health Psychology, Ghent University, Ghent, Belgium
| |
Collapse
|
21
|
Giles LL, Martini DR. Challenges and Promises of Pediatric Psychopharmacology. Acad Pediatr 2016; 16:508-18. [PMID: 27064142 DOI: 10.1016/j.acap.2016.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 03/05/2016] [Accepted: 03/28/2016] [Indexed: 01/27/2023]
Abstract
Most prescriptions for psychotropic medications are written by primary care physicians, yet pediatricians, many of whom are teaching residents and medical students about pediatric psychopharmacology, often feel inadequately trained to treat mental health concerns. Over the past several decades, the number, size, and quality of psychopharmacologic studies in youth has greatly increased. Here we review the current evidence for efficacy and safety of each of the major pharmacologic drug classes in youth (psychostimulants, antidepressants, mood stabilizers, and antipsychotics). Psychostimulants have a robust body of literature supporting their evidence as first-line treatment for attention-deficit/hyperactivity disorder. Selective serotonin reuptake inhibitors (SSRIs) have documented efficacy for pediatric depression and multiple different anxiety disorders with childhood onset. Combining cognitive-behavioral therapy with SSRI treatment enhances treatment benefit and minimizes adverse events of medication. Mood stabilizers, including lithium and anticonvulsant medications, have a less robust strength of evidence and come with more problematic side effects. However, they are increasingly prescribed to youth, often to treat irritability, mood lability, and aggression, along with treatment of bipolar disorder. Antipsychotics have long been a mainstay of treatment for childhood-onset schizophrenia, and in recent years, the evidence base for providing antipsychotics to youth with bipolar mania and autistic disorder has grown. Most concerning with antipsychotics are the metabolic side effects, which appear even more problematic in youth than adults. By better understanding the evidence-based psychopharmacologic interventions, academic pediatricians will be able to treat patients and prepare future pediatrician to address the growing mental health care needs of youth.
Collapse
Affiliation(s)
- Lisa L Giles
- Departments of Pediatrics and Psychiatry, University of Utah School of Medicine and Department of Psychiatry and Behavioral Health, Primary Children's Hospital, Salt Lake City, Utah.
| | - D Richard Martini
- Departments of Pediatrics and Psychiatry, University of Utah School of Medicine and Department of Psychiatry and Behavioral Health, Primary Children's Hospital, Salt Lake City, Utah
| |
Collapse
|
22
|
Stevens JR, Rodgers JJ, Stern TA. Idiosyncratic Adverse Reactions to Psychotropic Medications. Psychiatr Ann 2016. [DOI: 10.3928/00485713-20160622-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
23
|
Adamo N, Seth S, Coghill D. Pharmacological treatment of attention-deficit/hyperactivity disorder: assessing outcomes. Expert Rev Clin Pharmacol 2016; 8:383-97. [PMID: 26109097 DOI: 10.1586/17512433.2015.1050379] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A substantial body of evidence has supported the efficacy and safety of pharmacological treatment available for attention deficit/hyperactivity disorder (ADHD). There is increasing agreement that the important treatment outcomes for ADHD extend beyond improvement in core symptoms and that a more generic (or global) concept of remission is the overarching goal of treatment. However, there is no consensus on the best definition of remission or on how best to conceptualize and measure broader treatment outcomes. In this article, we provide an overview of the various methods and approaches to measuring treatment outcomes for ADHD with respect to symptoms, impairment, quality of life, adverse events and safety as well as cognition. We will describe the ways that they may be used within routine clinical practice and think ahead about the kinds of studies that are required to move the field forward.
Collapse
Affiliation(s)
- Nicoletta Adamo
- National Health Service Tayside, Child and Adolescent Mental Health Service, Dundee, UK
| | | | | |
Collapse
|
24
|
Zhang C, Kutyifa V, Moss AJ, McNitt S, Zareba W, Kaufman ES. Long-QT Syndrome and Therapy for Attention Deficit/Hyperactivity Disorder. J Cardiovasc Electrophysiol 2015; 26:1039-44. [PMID: 26149510 PMCID: PMC4607606 DOI: 10.1111/jce.12739] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/18/2015] [Accepted: 06/03/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Stimulants are the mainstay therapy for attention deficit/hyperactivity disorder (ADHD) and are associated with adrenergic side effects. There are limited data on the clinical course of patients treated for ADHD who have long-QT syndrome (LQTS), for which β-blockade is the goal of therapy. METHODS LQTS patients from the Rochester-based LQTS Registry (open-enrollment between 1979 and 2003; follow-up from 1979 to present) treated with stimulant or nonstimulant ADHD medications (n = 48) were compared to a 2:1 age-, gender-, and QTc-duration matched LQTS control group not exposed to ADHD medications (n = 96). Kaplan-Meier and Cox proportional hazards regression analyses were used to evaluate risk of cardiac events (syncope, aborted cardiac arrest, and sudden cardiac death) in LQTS patients treated with ADHD medications. RESULTS During a mean follow-up of 7.9 ± 5.4 years after initiation of ADHD medication at a mean age 10.7 ±7.3 years, there was a 62% cumulative probability of cardiac events in the ADHD treatment group compared to 28% in the matched LQTS control group (P < 0.001). Time-dependent use of ADHD medication was associated with an increased risk for cardiac events (HR = 3.07; P = 0.03) in the multivariate Cox model adjusted for time-dependent β-blocker use and prior cardiac events. Subgroup gender analyses showed that time-dependent ADHD medication was associated with an increased risk in male LQTS patients (HR = 6.80, P = 0.04). CONCLUSIONS LQTS patients treated with ADHD medications have increased risk for cardiac events, particularly syncope, and this risk is augmented in males. The findings highlight the importance of heightened surveillance for LQTS patients on ADHD medications.
Collapse
Affiliation(s)
- Claire Zhang
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Valentina Kutyifa
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Arthur J Moss
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Scott McNitt
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Wojciech Zareba
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Elizabeth S Kaufman
- MetroHealth Campus of Case Western Reserve University, Heart and Vascular Research Center, Cleveland, Ohio, USA
| |
Collapse
|
25
|
Kaltman JR, Berul CI. Attention-Deficit Hyperactivity Disorder and Long-QT Syndrome: Risky Business. J Cardiovasc Electrophysiol 2015; 26:1045-7. [PMID: 26102514 DOI: 10.1111/jce.12744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jonathan R Kaltman
- Division of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA.,Division of Cardiovascular Sciences, The National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Charles I Berul
- Division of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA
| |
Collapse
|
26
|
Hypertension in Young People: Epidemiology, Diagnostic Assessment and Therapeutic Approach. High Blood Press Cardiovasc Prev 2015; 22:381-8. [PMID: 26153401 DOI: 10.1007/s40292-015-0114-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 06/26/2015] [Indexed: 10/23/2022] Open
Abstract
High blood pressure (BP) still remains one of the most relevant cardiovascular risk factors, also due to its persistently high prevalence and growing incidence in the general adult and elderly population. Since almost all hypertension-related cardiovascular complications, mostly including coronary artery disease, myocardial infarction, ischemic stroke, and congestive heart failure, occurred in adult and elderly individuals, evidence on both prevalence and clinical management of hypertension in young individuals are lacking. Therefore, the clinical impact of high BP levels in young populations remains to be explored. In the recent years, the attitude of the scientific community has changed and more attention was devoted to young individuals with hypertension, also in view of the fact that early identification of these subjects may prevent developing of established hypertension in adulthood. In addition, unhealthy lifestyle habits have progressively involved children and adolescents worldwide, thus contributing to further increase the risk of developing hypertension in young individuals. On the basis of these considerations, the present review is aimed at providing a brief reappraisal of the major aspects of hypertension in the young age, as well as at promoting interest and discussion on this important issue.
Collapse
|
27
|
Turtle EJ, Sule AA, Webb DJ, Bath LE. Aortic dissection in children and adolescents with Turner syndrome: risk factors and management recommendations. Arch Dis Child 2015; 100:662-6. [PMID: 25573747 DOI: 10.1136/archdischild-2014-307080] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/10/2014] [Indexed: 01/15/2023]
Abstract
There is a general lack of awareness of the risk of aortic dissection in Turner syndrome (TS) from both patients with TS and their physicians. Patients often ignore symptoms for up to 24 h before seeking medical advice, significantly increasing their risk of death. A clinical profile of those at risk of dissection is emerging and includes the presence of congenital heart defects, aortic dilatation and hypertension. MRI has revolutionised the visualisation of cardiovascular anatomy in TS but remains underutilised, especially in children and adolescents, and there is currently little guidance on blood pressure (BP) assessment or hypertension management. Children and adolescents with TS at risk of dissection could be easily identified by timely imaging and BP assessment. This would allow medical management or surgical intervention to be put in place to reduce the risk of this major, and often fatal, complication. Since guidance is lacking, we have reviewed the literature on the risk factors for dissection in TS during childhood and adolescence, and make recommendations on the assessment and management of these patients.
Collapse
Affiliation(s)
- E J Turtle
- Edinburgh Centre for Endocrinology, Western General Hospital, Edinburgh, UK
| | - A A Sule
- Tan Tock Seng Hospital, Singapore, Singapore
| | - D J Webb
- Queen's Medical Research Institute, University of Edinburgh/BHF Centre for Cardiovascular Science, Edinburgh, UK
| | - L E Bath
- Edinburgh Centre for Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK
| |
Collapse
|
28
|
Hammerness PG, Karampahtsis C, Babalola R, Alexander ME. Attention-deficit/hyperactivity disorder treatment: what are the long-term cardiovascular risks? Expert Opin Drug Saf 2015; 14:543-51. [PMID: 25648243 DOI: 10.1517/14740338.2015.1011620] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION This drug safety review provides an update on the long-term cardiovascular risks of therapeutic stimulant class medication for children and adults with attention-deficit/hyperactivity disorder (ADHD). AREAS COVERED Relevant literature on the long-term (defined as ≥ 12 months) cardiovascular effects of stimulant class medications for ADHD was sought using PubMed searches for clinical literature, epidemiological reports, as well as reviews of post-marketing data and clinical guidelines/consensus statements. Comparison was made to the non-stimulant atomoxetine. EXPERT OPINION Long-term cardiovascular risks of stimulants for healthy children and adults with ADHD are limited to minor mean elevations in blood pressure (≤ 7 mmHg) and heart rate (≤ 10 bpm). In a sizeable minority of individuals these elevations are greater and/or reach a clinical threshold. Subjective complaints may also be anticipated during long-term treatment, yet without an increase in serious cardiac outcomes above background rates per age. Future research is needed on possible latent or cumulative cardiovascular risks in healthy individuals, as well as the longer-term cardiovascular safety in vulnerable populations.
Collapse
|
29
|
Lamberti M, Italiano D, Guerriero L, D'Amico G, Siracusano R, Ingrassia M, Germanò E, Calabrò MP, Spina E, Gagliano A. Evaluation of acute cardiovascular effects of immediate-release methylphenidate in children and adolescents with attention-deficit hyperactivity disorder. Neuropsychiatr Dis Treat 2015; 11:1169-74. [PMID: 26056451 PMCID: PMC4431494 DOI: 10.2147/ndt.s79866] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Attention-deficit hyperactivity disorder is a frequent condition in children and often extends into adulthood. Use of immediate-release methylphenidate (MPH) has raised concerns about potential cardiovascular adverse effects within a few hours after administration. This study was carried out to investigate acute effects of MPH on electrocardiogram (ECG) in a pediatric population. A total of 54 consecutive patients with attention-deficit hyperactivity disorder (51 males and 3 females; mean age =12.14±2.6 years, range 6-19 years), receiving a new prescription of MPH, underwent a standard ECG 2 hours before and after the administration of MPH 10 mg per os. Basal and posttreatment ECG parameters, including mean QT (QT interval when corrected for heart rate [QTc]), QTc dispersion (QTd) interval duration, T-peak to T-end (TpTe) intervals, and TpTe/QT ratio were compared. Significant modifications of both QTc and QTd values were not found after drug administration. QTd fluctuated slightly from 25.7±9.3 milliseconds to 25.1±8.4 milliseconds; QTc varied from 407.6±12.4 milliseconds to 409.8±12.7 milliseconds. A significant variation in blood pressure (systolic blood pressure 105.4±10.3 vs 109.6±11.5; P<0.05; diastolic blood pressure 59.2±7.1 vs 63.1±7.9; P<0.05) was observed, but all the data were within normal range. Heart rate moved from 80.5±15.5 bpm to 87.7±18.8 bpm. No change in TpTe values was found, but a statistically significant increase in TpTe/QTc intervals was found with respect to basal values (0.207±0.02 milliseconds vs 0.214±0.02 milliseconds; P<0.01). The findings of this study show no significant changes in ECG parameters. TpTe values can be an additional parameter to evaluate borderline cases.
Collapse
Affiliation(s)
- Marco Lamberti
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy ; Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Italiano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Laura Guerriero
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy
| | - Gessica D'Amico
- Division of Pediatric Cardiology, Department of Pediatrics, University of Messina, Messina, Italy
| | - Rosamaria Siracusano
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy ; Institution of Clinical Physiology, CNR, Pisa, Italy
| | - Massimo Ingrassia
- Division of Psychology, Department of Humanities and Social Sciences, University of Messina, Messina, Italy
| | - Eva Germanò
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy
| | - Maria Pia Calabrò
- Division of Pediatric Cardiology, Department of Pediatrics, University of Messina, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonella Gagliano
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy
| |
Collapse
|
30
|
Abstract
Pharmacotherapy of attention deficit-hyperactivity disorder (ADHD) is a well-established and effective treatment modality. However, ADHD medications are not without side effects. Understanding the prevalence of adverse events and effective management of risks associated with stimulants and other medications used to treat ADHD is central to broad applicability and effective treatment. This review discusses the literature on the prevalence of adverse events and management strategies employed. We searched online MEDLINE/PubMed and Cochrane databases for articles using several keywords relating to adverse events associated with ADHD medication management. We discuss the relevant data on the significance and prevalence of side effects and adverse events, highlight recent updates in the field, and suggest approaches to clinical management.
Collapse
Affiliation(s)
- Benjamin N Schneider
- Division of Child & Adolescent Psychiatry, UCLA Semel Institute for Neuroscience & Human Behavior, 760 Westwood Plaza, Suite 68-251A, Los Angeles, CA, 90024, USA,
| | | |
Collapse
|
31
|
Kelly AS, Rudser KD, Dengel DR, Kaufman CL, Reiff MI, Norris AL, Metzig AM, Steinberger J. Cardiac autonomic dysfunction and arterial stiffness among children and adolescents with attention deficit hyperactivity disorder treated with stimulants. J Pediatr 2014; 165:755-9. [PMID: 25015574 PMCID: PMC5880029 DOI: 10.1016/j.jpeds.2014.05.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 04/09/2014] [Accepted: 05/27/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare markers of cardiovascular health in youth diagnosed with attention deficit hyperactivity disorder (ADHD) by the use of stimulant medication with healthy controls. STUDY DESIGN Children and adolescents (n = 85; mean age 11.2 ± 2.8 years; 66 boys) diagnosed with ADHD using a stimulant and 53 siblings without ADHD (mean age 11.1 ± 3.8 years; 28 boys) were included in this cross-sectional study. Measured variables included blood pressure, heart rate (HR), HR variability: SD of the RR interval and low frequency to high frequency ratio, carotid-radial pulse wave velocity, carotid artery augmentation index (AIx), radial artery AIx, brachial artery flow-mediated dilation, and digital reactive hyperemic index. RESULTS Compared with control patients, participants with ADHD had greater resting systolic blood pressure (3.9 mm Hg, 95% CI [1.2-6.7], P = .005), diastolic blood pressure (5.5 mm Hg, 95% CI [3.2-7.8], P < .001), HR (9.2 beats/min, 95% CI [6.0-12.3], P < .001), low frequency to high frequency ratio (0.55, 95% CI [0.22-0.89], P = .001), carotid AIx (7.2%, 95% CI [1.9-12.5], P = .008), and pulse wave velocity (0.36 m/s, 95% CI [-0.05, 0.78], P = .089), and lower SD of the RR interval (-33.7 milliseconds, 95% CI [-46.1, -21.3], P < .001). Neither flow-mediated dilation nor reactive hyperemic index was significantly different. CONCLUSIONS Children and adolescents being treated with a stimulant medication for ADHD exhibited signs of altered cardiac autonomic function, characterized by increased sympathetic tone, and showed evidence of arterial stiffening.
Collapse
Affiliation(s)
- Aaron S. Kelly
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Kyle D. Rudser
- Division of Biostatistics, School of Public Health and Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN
| | | | | | - Michael I. Reiff
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
| | - Anne L. Norris
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
| | - Andrea M. Metzig
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
| | - Julia Steinberger
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
| |
Collapse
|
32
|
|
33
|
Berg A, Bråtane E, Odland HH, Brudvik C, Rosland B, Hirth A. [Cardiovascular risk assessment for the use of ADHD drugs in children]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:710-4. [PMID: 24721858 DOI: 10.4045/tidsskr.13.0565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Drug therapy for ADHD (Attention Deficit Hyperactivity Disorder) has generally been regarded as safe. ECG screening of healthy children and adolescents before initiating this type of treatment appears to be usual in Norway, despite recommendations that ECGs should only be undertaken in individuals who are at risk. The purpose of this article is to clarify relevant guidelines for cardiovascular risk assessment for the use of ADHD drugs in children and adolescents, as well as to propose practical recommendations. METHOD The article is based on a literature search in PubMed completed on 1 October 2013, and on the author's own clinical experience and discretionary assessments. RESULTS The use of CNS stimulants and atomoxetine is associated with a slight rise in blood pressure and pulse rate, as well as small changes in QT interval. A small percentage of patients (5-10%) experience a clinically significant rise in blood pressure and pulse rate. Sudden death does not appear to occur more frequently in children and adolescents taking ADHD drugs in therapeutic doses than in children and adolescents who do not use such drugs. There is little knowledge available on the long-term effects of ADHD drugs on the cardiovascular system of otherwise healthy individuals, or on the risk related to the use of ADHD drugs in children and adolescents with cardiac disease. The drugs are thought to increase the risk of sudden cardiac death in some arrhythmia syndromes. INTERPRETATION Our assessment is that caution should be exercised in the use of ADHD drugs in children with potentially dangerous cardiac arrhythmias. We recommend clinical examination and a thorough medical history review in order to identify individuals at risk before initiating drug therapy, and also suggest that it is not necessary for healthy children to be given an ECG examination before introducing ADHD drugs. In children with known cardiac disease, arrhythmia or risk factors for cardiac disease, ADHD treatment should be undertaken in consultation with a medical specialist with competence in pediatric cardiology.
Collapse
Affiliation(s)
- Ansgar Berg
- Barneklinikken Haukeland universitetssykehus og Klinisk institutt 2 Universitetet i Bergen
| | | | | | | | | | - Asle Hirth
- Barneklinikken Haukeland universitetssykehus
| |
Collapse
|
34
|
Dias TGC, Kieling C, Graeff-Martins AS, Moriyama TS, Rohde LA, Polanczyk GV. Developments and challenges in the diagnosis and treatment of ADHD. BRAZILIAN JOURNAL OF PSYCHIATRY 2014; 35 Suppl 1:S40-50. [PMID: 24142127 DOI: 10.1590/1516-4446-2013-s103] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder, often associated with other psychiatric comorbidities, functional impairments, and poor long-term outcomes. The objective of this selected review is to describe current advances and challenges in the diagnosis and treatment of ADHD. The disorder is associated with neurobiological underpinnings and is highly heterogeneous in various aspects, such as symptom profiles, cognitive impairments, and neurobiological and genetic features. The efficacy and safety of short-term pharmacological treatments across the life cycle is well studied, but further research investigating long-term treatment, impact of treatment in preschoolers, and non-pharmacological interventions is needed. Future research is also needed to better characterize the neurodevelopmental pathways of the disorder, linking clinical and neurobiological information, less investigated populations, and new interventions.
Collapse
Affiliation(s)
- Taciana G Costa Dias
- Universidade de São Paulo, Department of Psychiatry, School of Medicine, São PauloSP, Brazil
| | | | | | | | | | | |
Collapse
|
35
|
Stevens JR, Jarrahzadeh T, Brendel RW, Stern TA. Strategies for the prescription of psychotropic drugs with black box warnings. PSYCHOSOMATICS 2013; 55:123-33. [PMID: 24360525 DOI: 10.1016/j.psym.2013.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/21/2013] [Accepted: 08/26/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The Black Box Warning (BBW) is the Food and Drug Administration's highest level of drug warning. It signifies that a medication has serious (or potentially life-threatening) side effects and is prominently displayed on a medication's package insert. It literally consists of the medication warning and is surrounded by a bold black border. OBJECTIVE This article aims to review data related to BBWs on psychotropic medications currently used in clinical practice, with special attention to clinical situations and questions relevant to consultation-liaison psychiatrists. RESULTS We review 3 clinical advisories or BBWs for psychotropic medications (i.e., antidepressant medication and suicidality in the pediatric population, stimulant medication and sudden death in the pediatric population, and antipsychotic medication and increased mortality in the elderly) and discuss the effect they have had on prescribing practices. We provide a table of current BBWs relevant to psychotropic medications. CONCLUSIONS BBWs can have unintended and far-reaching consequences, albeit with a limited ability to target specific populations and practice patterns. Although it is critical for clinicians to be aware of these serious potential side effects and to inform patients about these warnings, medications with boxed warnings remain Food and Drug Administration-approved and may have critically important therapeutic roles.
Collapse
Affiliation(s)
- Jonathan R Stevens
- Henry Ford Health Systems, Dearborn, MI; Wayne State University, Detroit, MI.
| | | | - Rebecca Weintraub Brendel
- Red Sox Foundation and Massachusetts General Hospital (MGH), Home Base Program, Boston, MA; Harvard Medical School (HMS), Boston, MA
| | - Theodore A Stern
- Harvard Medical School (HMS), Boston, MA; Avery D. Weisman Psychiatry Consultation Service at MGH, Boston, MA
| |
Collapse
|
36
|
Bange F, Le Heuzey MF, Acquaviva E, Delorme R, Mouren MC. [Cardiovascular risks and management during Attention Deficit Hyperactivity Disorder treatment with methylphenidate]. Arch Pediatr 2013; 21:108-12. [PMID: 24309201 DOI: 10.1016/j.arcped.2013.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 11/30/2022]
Abstract
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common of the pediatric neuropsychiatric disorders. Methylphenidate is an important element of therapeutic strategies for ADHD. Clinicians are interested in the safety of methylphenidate. Because this drug raises heart rate and blood pressure, concerns have been raised about its cardiovascular safety. Concerns were based on case reports of sudden cardiac death in methylphenidate users, plausible pharmacological pathways involving well-established stimulant effects on heart rate and blood pressure. Until recently, data were limited to a number of observational studies too small to examine serious cardiac events. In the past two years, large retrospective, population-based cohort studies were performed. These studies did not show any evidence that methylphenidate was associated with an increase in risk of myocardial infarction, sudden cardiac death, or stroke. Treatment of children with methylphenidate is not significantly associated with an increase in the short term or mid-term risk of severe cardiac events. For many, available data now will be seen as reassuring. But gaps persist in the methodical and comprehensive assessments of the safety of methylphenidate. Analyses cannot be generalized to children with long-term use of stimulants. Furthermore, long-term effects of slight increases in heart rate or blood pressure are unknown. Stimulant administration continues to have a detectable adrenergic effect even after years of treatment. In the MTA study, greater cumulative stimulant exposure was associated with a higher heart rate at years 3 and 8. Although less severe, such adverse cardiac events are nonetheless alarming to patients. This adrenergic effect may have clinical implications, especially for individual patients with underlying heart abnormalities and it deserves further investigation. More research is necessary to optimize a safe use of methylphenidate regarding its cardiovascular effects. In light of the controversies surrounding the increase in the number of children being diagnosed with ADHD, the broad use of methylphenidate in these patients, and cardiovascular concerns about it, this article addresses topics of clinical significance. For ease of use by practitioners, the article summarizes the guidelines stated by the European Medicines Agency over the appropriate pretreatment evaluation and cardiovascular assessment. It advocates a thorough history and physical examination before initiating methylphenidate to treat patients with ADHD, with an emphasis on the identification of risk factors for sudden death. A cardiac sub-specialist consultation is mandatory in case of history or physical examination findings. In other cases, an electrocardiographic screening is recommended in order to check out previously unrecognized heart disease.
Collapse
Affiliation(s)
- F Bange
- Service de psychiatrie de l'enfant et de l'adolescent, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France.
| | - M-F Le Heuzey
- Service de psychiatrie de l'enfant et de l'adolescent, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - E Acquaviva
- Service de psychiatrie de l'enfant et de l'adolescent, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - R Delorme
- Service de psychiatrie de l'enfant et de l'adolescent, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - M-C Mouren
- Service de psychiatrie de l'enfant et de l'adolescent, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| |
Collapse
|
37
|
Bink M, Popma A, Bongers IL, van Boxtel GJM, Denissen A, van Nieuwenhuizen C. Cardiac Reactivity and Stimulant Use in Adolescents with Autism Spectrum Disorders with Comorbid ADHD Versus ADHD. J Autism Dev Disord 2013; 45:481-94. [DOI: 10.1007/s10803-013-1929-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
38
|
Ambulatory Blood Pressure Monitoring in a Cohort of Children Referred with Suspected Hypertension: Characteristics of Children with and without Attention Deficit Hyperactivity Disorder. Int J Hypertens 2013; 2013:419208. [PMID: 23970957 PMCID: PMC3736467 DOI: 10.1155/2013/419208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 07/04/2013] [Indexed: 11/17/2022] Open
Abstract
Childhood hypertension's increasing prevalence has generally been linked to the obesity epidemic. We observed that a significant proportion of children referred to our pediatric center with documented office hypertension are nonobese and have a history of attention deficit hyperactivity disorder (ADHD). To define the extent of this anecdotal observation, we performed a retrospective analysis of ambulatory blood pressure monitoring (ABPM) tests which in our center are routinely performed in newly referred children suspected of hypertension. Twenty-one percent (48 of 227 new referrals) had a history of ADHD, and 81% of them were treated with psychostimulant medications at the time of their ABPM test. Children in this group had a significantly lower average BMI z-score compared with the rest of the children (0.18 versus 0.75) and were significantly more likely to have abnormally elevated wake systolic loads on ABPM (38% versus 4%). The overall proportion of children with any abnormality on ABPM was comparable in both groups (46% versus 40%). Conclusion. A significant proportion of children suspected of hypertension have ADHD which may be related to higher wake systolic BP values. The prevalence of hypertension among children with ADHD will have to be determined in prospective studies.
Collapse
|
39
|
Linn D, Murray A, Smith T, Fuentes D. Clinical considerations for the management of pediatric patients with attention-deficit/hyperactivity disorder. Ment Health Clin 2013. [DOI: 10.9740/mhc.n145467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a chronic health condition presenting with symptoms of hyperactivity, impulsivity, and/or inattention in early childhood, adolescence and adulthood. Many patients will persist with associated symptoms throughout their life and may require long term treatment to maintain adequate control.
Objective: The purpose of this article is to review the current literature in regards to diagnosis, treatment, and management of ADHD in the pediatric and adolescent population.
Methods: A search was conducted using PubMed, Medline, Ovid, and CINHAL with a focus on studies and reviews in the English language from 2008 – 2013, featuring pediatric/adolescent patients across the ages of 4–17 years using the terms: “management”, “attention-deficit”, “hyperactivity”, and “treatment.” Literature referenced prior to the five-year time frame outlined herein provided foundational information on diagnostics and medications.
Discussion: Stimulants, in conjunction with behavioral therapy, are standard first line treatments used in ADHD. While stimulant medications have been shown to be effective in treating symptoms associated with ADHD, there are a variety of concerns that may prevent their use. These concerns are related to adverse consequences, many of which are not supported by concrete evidence. Other pharmacotherapy options such as norepinephrine reuptake inhibitors and selective alpha-2 adrenergic agonists are typically reserved as second line options. The use of novel and emerging complementary therapies will also be explored.
Conclusion: Patients diagnosed with ADHD must be thoroughly evaluated when making decisions regarding treatment. Many studies and reviews support the efficacy of pharmacotherapy in treatment of ADHD; however, there is insufficient evidence regarding long-term safety of the medications. Further research is warranted to evaluate current treatment options and associated risks and benefits to guide the clinician in optimal management of these patients.
Collapse
Affiliation(s)
- Dustin Linn
- 1 Assistant Professor of Pharmacy Practice, Manchester University College of Pharmacy, Fort Wayne, IN
| | - Andrea Murray
- 1 Assistant Professor of Pharmacy Practice, Manchester University College of Pharmacy, Fort Wayne, IN
| | - Thomas Smith
- 1 Assistant Professor of Pharmacy Practice, Manchester University College of Pharmacy, Fort Wayne, IN
| | - David Fuentes
- 2 Department Chair of Pharmacy Practice, Associate Professor of Pharmacy Practice, Manchester University College of Pharmacy, Fort Wayne, IN
| |
Collapse
|
40
|
Martens MA, Seyfer DL, Andridge RR, Foster JEA, McClure KE, Coury DL. Caregiver survey of pharmacotherapy to treat attention deficit/hyperactivity disorder in individuals with Williams syndrome. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:1700-1709. [PMID: 23500164 DOI: 10.1016/j.ridd.2013.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/06/2013] [Accepted: 02/08/2013] [Indexed: 06/01/2023]
Abstract
Williams syndrome (WS) is a genetic condition characterized by a unique neurocognitive and behavioral profile, including increased incidence of attention deficit/hyperactivity disorder (ADHD). The purpose of the present study was to examine the perceived helpfulness and side effects of medications used to treat ADHD (methylphenidate class, amphetamine class, atomoxetine) in individuals with WS. This was accomplished with a survey of parents/caregivers of individuals with WS through the Williams Syndrome Association. Five-hundred twelve (512) parents/caregivers responded to the survey regarding their child's/adult child's use of ADHD medications. Twenty-seven percent (27%) of the individuals had been prescribed a medication for ADHD, most commonly a methylphenidate class medication. OROS-methylphenidate was reported as the most helpful methylphenidate class formulation, with 74% reporting it at least somewhat helpful. Survey participants reported similar side effects as typically developing controls, but to a greater degree. Irritability was the most commonly endorsed side effect of an ADHD medication (38%). Individuals reported use of stimulant medications in the presence and absence of underlying cardiac conditions, with 56% of ADHD medication users reporting supravalvular aortic stenosis, 36% pulmonary artery stenosis, and 25% systemic hypertension. Individuals taking ADHD medications were more likely to report dental problems (p=0.004). Additional studies are needed to further investigate these findings and examine short-versus long-acting stimulant medications and dosage effects.
Collapse
Affiliation(s)
- Marilee A Martens
- The Nisonger Center, The Ohio State University, Columbus, OH 43210, USA.
| | | | | | | | | | | |
Collapse
|
41
|
Hammerness P, Zusman R, Systrom D, Surman C, Baggish A, Schillinger M, Shelley-Abrahamson R, Wilens TE. A cardiopulmonary study of lisdexamfetamine in adults with attention-deficit/hyperactivity disorder. World J Biol Psychiatry 2013; 14:299-306. [PMID: 22559155 DOI: 10.3109/15622975.2012.678884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Due to concerns about the safety of stimulants for ADHD, novel assessments of the cardiopulmonary impact of these agents are needed. METHODS An open design of lisdexamfetamine (LDX) in 15 adults with DSM-IV ADHD. Following a psychiatric evaluation and medical history, subjects underwent echocardiography (TTE) and cardiopulmonary exercise testing (CPET). LDX was titrated to 70 mg daily over 6 weeks, followed by monthly visits to 6 months. Change in TTE and CPET measures were examined following up to 6 months of LDX. RESULTS At endpoint, there were no significant alterations in indices of cardiac systolic performance, or in metabolic and ventilatory variables at maximum exertion (P values >0.05). We found significant mean changes in resting LV systolic dimension and Doppler diastolic indices. Change in heart rate recovery at 1 min met statistical significance (P = 0.05). CONCLUSIONS We did not detect clinically meaningful changes in cardiac structure and function or in metabolic and ventilatory variables at maximum exertion in ADHD adults receiving open LDX. The clinical significance of changes in resting LV dimension and indices of diastolic function are not in the direction of cardiomyopathy. Future large sample controlled study can examine these findings, as well as stimulants' impact on heart rate recovery.
Collapse
Affiliation(s)
- Paul Hammerness
- Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital (MGH), Cambridge, MA 02138, USA.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Stevens JR, Wilens TE, Stern TA. Using stimulants for attention-deficit/hyperactivity disorder: clinical approaches and challenges. Prim Care Companion CNS Disord 2013; 15:12f01472. [PMID: 23930227 DOI: 10.4088/pcc.12f01472] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/22/2012] [Indexed: 01/20/2023] Open
|
43
|
Cortese S, Holtmann M, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Dittmann RW, Graham J, Taylor E, Sergeant J. Practitioner review: current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents. J Child Psychol Psychiatry 2013; 54:227-46. [PMID: 23294014 DOI: 10.1111/jcpp.12036] [Citation(s) in RCA: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well-tolerated, there are common, although less severe, as well as rare but severe adverse events AEs during treatment with ADHD drugs. The aim of this review is to provide evidence- and expert-based guidance concerning the management of (AEs) with medications for ADHD. METHODS For ease of use by practitioners and clinicians, the article is organized in a simple question and answer format regarding the prevalence and management of the most common AEs. Answers were based on empirical evidence from studies (preferably meta-analyses or systematic reviews) retrieved in PubMed, Ovid, EMBASE and Web of Knowledge through 30 June 2012. When no empirical evidence was available, expert consensus of the members of the European ADHD Guidelines Group is provided. The evidence-level of the management recommendations was based on the SIGN grading system. RESULTS The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviours and psychotic symptoms. CONCLUSION Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment.
Collapse
Affiliation(s)
- Samuele Cortese
- Phyllis Green and Randolph Cowen Institute for Pediatric Neuroscience, Child Study Center of the NYU Langone Medical Center, New York, NY, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Ramos Olazagasti MA, Klein RG, Mannuzza S, Belsky ER, Hutchison JA, Lashua-Shriftman EC, Castellanos FX. Does childhood attention-deficit/hyperactivity disorder predict risk-taking and medical illnesses in adulthood? J Am Acad Child Adolesc Psychiatry 2013; 52:153-162.e4. [PMID: 23357442 PMCID: PMC3662801 DOI: 10.1016/j.jaac.2012.11.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 11/14/2012] [Accepted: 11/20/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To test whether children with attention-deficit/hyperactivity disorder (ADHD), free of conduct disorder (CD) in childhood (mean = 8 years), have elevated risk-taking, accidents, and medical illnesses in adulthood (mean = 41 years); whether development of CD influences risk-taking during adulthood; and whether exposure to psychostimulants in childhood predicts cardiovascular disease. We hypothesized positive relationships between childhood ADHD and risky driving (in the past 5 years), risky sex (in the past year), and between risk-taking and medical conditions in adulthood; and that development of CD/antisocial personality (APD) would account for the link between ADHD and risk-taking. We report causes of death. METHOD Prospective 33-year follow-up of 135 boys of white ethnicity with ADHD in childhood and without CD (probands), and 136 matched male comparison subjects without ADHD (comparison subjects; mean = 41 years), blindly interviewed by clinicians. RESULTS In adulthood, probands had relatively more risky driving, sexually transmitted disease, head injury, and emergency department admissions (p< .05-.01). Groups did not differ on other medical outcomes. Lifetime risk-taking was associated with negative health outcomes (p = .01-.001). Development of CD/APD accounted for the relationship between ADHD and risk-taking. Probands without CD/APD did not differ from comparison subjects in lifetime risky behaviors. Psychostimulant treatment did not predict cardiac illness (p = .55). Probands had more deaths not related to specific medical conditions (p = .01). CONCLUSIONS Overall, among children with ADHD, it is those who develop CD/APD who have elevated risky behaviors as adults. Over their lifetime, those who did not develop CD/APD did not differ from comparison subjects in risk-taking behaviors. Findings also provide support for long-term safety of early psychostimulant treatment.
Collapse
|
45
|
Arcieri R, Germinario EAP, Bonati M, Masi G, Zuddas A, Vella S, Chiarotti F, Panei P. Cardiovascular measures in children and adolescents with attention-deficit/hyperactivity disorder who are new users of methylphenidate and atomoxetine. J Child Adolesc Psychopharmacol 2012; 22:423-431. [PMID: 23362511 DOI: 10.1089/cap.2012.0014] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the cardiovascular effects of drugs used for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents treated in community care centers in Italy. METHODS This study was an open, prospective, observational study of youth with ADHD treated with atomoxetine (ATX) and methylphenidate (MPH). Measurements of blood pressure and heart rate, and electrocardiogram (ECG) assessment were performed at baseline and at regular intervals up to 24 months. RESULTS By June 2010, 1758 youth were enrolled in the Italian ADHD National Registry. Statistically significant increases were observed in cardiovascular measures: in the MPH group after 6 months in heart rate (+2.01, p = 0.01); in the ATX group after 6 months in diastolic pressure (+1.60, p = 0.01) and in heart rate (+2.93, p = 0.001), and after 12 months in heart rate (+3.26, p = 0.003). Compared with the baseline, 59 patients had an alteration of ECG during the follow-up period. Although at 12 months, the probability of detecting an abnormal ECG was higher in the MPH group than in the ATX group, only 2 out of 30 cases at 6 months with altered ECG were considered to have experienced serious adverse events. One case was treated with ATX and one with MPH, and arrhythmia was the detected abnormality. CONCLUSIONS Treatment with MPH and ATX in youth appears to have a small but significant impact on the cardiovascular system. The long-term impact of these medications is unknown. Several clinically meaningless ECG alterations were observed mostly in MPH-treated youth. We therefore suggest evaluating cardiovascular risks at baseline.
Collapse
Affiliation(s)
- Romano Arcieri
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Rothenberger A, Rothenberger LG. Updates on treatment of attention-deficit/hyperactivity disorder: facts, comments, and ethical considerations. Curr Treat Options Neurol 2012; 14:594-607. [PMID: 22968494 PMCID: PMC3501189 DOI: 10.1007/s11940-012-0197-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OPINION STATEMENT Within the last 2 years the bulk of information on evidence based treatments in ADHD was reviewed quite intensively and new empirical studies could be added. This update reports comprehensively about actual and essential facts in the field related to brain development and sensitive periods, predictors of treatment, safety of medication, value of naturalistic studies, new drugs and complementary medicine, behavioral interventions including neurofeedback and psychosocial treatment, treatment of comorbidity, and ethical considerations including preventive aspects. The updated combination of well selected evidence based treatments (ie, pharma plus non-pharma) seems to be clinically and ethically recommended as also suggested by the European and American guidelines on ADHD.
Collapse
Affiliation(s)
- Aribert Rothenberger
- Child and Adolescent Psychiatry, University Medicine Göttingen, von-Siebold-Str. 5, 37075, Göttingen, Germany,
| | | |
Collapse
|
47
|
Angriman M, Bruni O, Cortese S. Does Restless Legs Syndrome increase cardiovascular risk in Attention-Deficit/Hyperactivity Disorder? Med Hypotheses 2012; 80:39-42. [PMID: 23111202 DOI: 10.1016/j.mehy.2012.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 09/11/2012] [Accepted: 10/05/2012] [Indexed: 01/10/2023]
Abstract
Preliminary evidence suggests a possible association between Attention-Deficit/Hyperactivity Disorder and Restless Legs Syndrome with or without Periodic Limb Movements during Sleep. When comorbid, Restless Legs Syndrome/Periodic Limb Movements during Sleep might aggravate Attention-Deficit/Hyperactivity Disorder symptoms. Pharmacological treatment of Attention-Deficit/Hyperactivity Disorder may be associated, at least in some cases, with adverse cardiovascular events, including clinically significant elevation in heart rate and systemic blood pressure. However, the characteristics of patients with Attention-Deficit/Hyperactivity Disorder at risk for cardiovascular events during pharmacological treatment are poorly understood. Here, we hypothesize that Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comorbid with Attention-Deficit/Hyperactivity Disorder increase cardiovascular risk via imbalance in activity of the autonomic nervous system. Such an imbalance of the could be related to alterations of sleep microarchitecture also detected by cyclic alternating pattern analysis. If empirical studies confirm our hypothesis, the clinician would be advised to systematically screen for and effectively treat Restless Legs Syndrome/Periodic Limb Movements during Sleep even before starting treatment with Attention-Deficit/Hyperactivity Disorder drugs. The management of Restless Legs Syndrome/Periodic Limb Movements during Sleep might reduce cardiovascular risk during pharmacological treatment of Attention-Deficit/Hyperactivity Disorder.
Collapse
Affiliation(s)
- Marco Angriman
- Child Neurology and Neurorehabilitation Unit, Department of Pediatrics, Central Hospital of Bolzano, Italy.
| | | | | |
Collapse
|
48
|
Abstract
This article is a review of several of the most concerning side effects of psychotropic medications in children and adolescents. An emphasis is placed on review of the prevalence, presentation, monitoring, and evidence-based management of these side effects.
Collapse
|
49
|
Abstract
PURPOSE OF REVIEW Sudden death is a leading cause of death in industrialized nations. Sudden death in children represents a relatively small proportion of sudden death in the population, but has devastating effects on families and communities, and often attracts significant attention. RECENT FINDINGS Several recent studies show that a portion of previously unexplained sudden death in children is due to cardiac conditions which are potentially identifiable by 'molecular autopsy' or investigation of family members. As some of these conditions that may present with sudden death can be detected by ECG, the controversial role of screening asymptomatic children will be discussed, as will the question of increased risk associated with stimulant medications. Recent pharmacologic and nonpharmacologic advancements for those with identifiable conditions at increased risk of sudden death will be reviewed. SUMMARY Recent developments have refined our understanding of the various causes of sudden death in children. Post-mortem genetic testing and/or investigation of family members can be fruitful in determining a cause and identifying at-risk relatives. Given the available and potential treatments for specific disorders with increased risk of sudden death, the benefit of identifying such disorders early is clear. The debate regarding universal ECG screening is social and political, as well as scientific.
Collapse
|
50
|
Imeraj L, Sonuga-Barke E, Antrop I, Roeyers H, Wiersema R, Bal S, Deboutte D. Altered circadian profiles in attention-deficit/hyperactivity disorder: An integrative review and theoretical framework for future studies. Neurosci Biobehav Rev 2012; 36:1897-919. [DOI: 10.1016/j.neubiorev.2012.04.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 04/20/2012] [Accepted: 04/23/2012] [Indexed: 12/26/2022]
|