1
|
Gupta N, Gupta M. Off-label psychopharmacological interventions for autism spectrum disorders: strategic pathways for clinicians. CNS Spectr 2024; 29:10-25. [PMID: 37539695 DOI: 10.1017/s1092852923002389] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The prevalence of autism spectrum disorder (ASD) continues to see a trend upward with a noticeable increase to 1 in 36 children less than 8 years of age in the recent MMWR. There are many factors linked to the substantially increased burden of seeking mental health services, and clinically these individuals are likely to present for impairments associated with co-occurring conditions. The advances in cutting-edge research and the understanding of co-occurring conditions in addition to psychosocial interventions have provided a window of opportunity for psychopharmacological interventions given the limited availability of therapeutics for core symptomatology. The off-label psychopharmacological treatments for these co-occurring conditions are central to clinical practice. However, the scattered evidence remains an impediment for practitioners to systematically utilize these options. The review collates the crucial scientific literature to provide stepwise treatment alternatives for individuals with ASD; with an aim to lead practitioners in making informed and shared decisions. There are many questions about the safety and tolerability of off-label medications; however, it is considered the best practice to utilize the available empirical data in providing psychoeducation for patients, families, and caregivers. The review also covers experimental medications and theoretical underpinnings to enhance further experimental studies. In summary, amidst the growing clinical needs for individuals with ASD and the lack of approved clinical treatments, the review addresses these gaps with a practical guide to appraise the risk and benefits of off-label medications.
Collapse
Affiliation(s)
| | - Mayank Gupta
- Southwood Psychiatric Hospital, Pittsburgh, PA, USA
| |
Collapse
|
2
|
Stanford SC, Heal DJ. Adrenoceptors: A Focus on Psychiatric Disorders and Their Treatments. Handb Exp Pharmacol 2024; 285:507-554. [PMID: 37495853 DOI: 10.1007/164_2023_675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Research into the involvement of adrenoceptor subtypes in the cause(s) of psychiatric disorders is particularly challenging. This is partly because of difficulties in developing animal models that recapitulate the human condition but also because no evidence for any causal links has emerged from studies of patients. These, and other obstacles, are outlined in this chapter. Nevertheless, many drugs that are used to treat psychiatric disorders bind to adrenoceptors to some extent. Direct or indirect modulation of the function of specific adrenoceptor subtypes mediates all or part of the therapeutic actions of drugs in various psychiatric disorders. On the other hand, interactions with central or peripheral adrenoceptors can also explain their side effects. This chapter discusses both aspects of the field, focusing on disorders that are prevalent: depression, schizophrenia, anxiety, attention-deficit hyperactivity disorder, binge-eating disorder, and substance use disorder. In so doing, we highlight some unanswered questions that need to be resolved before it will be feasible to explain how changes in the function of any adrenoceptor subtype affect mood and behavior in humans and other animals.
Collapse
Affiliation(s)
- S Clare Stanford
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK.
| | - David J Heal
- DevelRx Ltd, BioCity, Nottingham, UK
- Department of Life Sciences, University of Bath, Bath, UK
| |
Collapse
|
3
|
Kasahara S, Kanda S, Takahashi M, Fujioka M, Morita T, Matsudaira K, Sato N, Hattori M, Momose T, Niwa SI, Uchida K. Case Report: Guanfacine and methylphenidate improved chronic lower back pain in autosomal dominant polycystic kidney disease with comorbid attention deficit hyperactivity disorder and autism spectrum disorder. Front Pediatr 2023; 11:1283823. [PMID: 38027301 PMCID: PMC10646415 DOI: 10.3389/fped.2023.1283823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is an inherited renal disease characterized by the bilateral development of multiple cysts in the kidneys. Pain management is a clinically important issue, especially because approximately 60% of patients with ADPKD experience chronic pain related to hemorrhage from renal cysts, which significantly reduces their daily life. The cystic fibrosis transmembrane conductance regulator, the molecule responsible for cyst formation in ADPKD, is also the cause of cystic fibrosis. Since attention deficit hyperactivity disorder (ADHD) is known to occur frequently in conjunction with cystic fibrosis, ADPKD may be associated with ADHD. However, to our knowledge, no study has investigated 1) ADHD or autism spectrum disorder (ASD) as comorbidities with ADPKD, 2) the effects of ADHD medications on chronic pain in ADPKD, or 3) cerebral blood flow corresponding to guanfacine (GF) or methylphenidate (MP) treatment for chronic pain. We report the case of a 15-year-old girl with ADPKD, who had chronic back pain associated with ADPKD and had to withdraw from high school because the pain interfered with her daily life. Although she took antihypertensive medications to prevent bleeding, they did not provide adequate blood pressure control. The patient was referred to a child psychiatrist and diagnosed with ASD; however, the pain did not improve. Subsequently, she was referred to our pain center. The diagnosis of ADHD was confirmed and treatment with ADHD medications was initiated. Monotherapy with MP, atomoxetine, and GF resulted in hypertension and hypotension as side effects; however, a combination of MP 18 mg and GF 4 mg provided pain relief and moderate blood pressure control, and the patient was able to go on to college. During the course of treatment, there was an improvement in the distribution of cerebral blood flow in the prefrontal and insular cortices. Confirmation of an ADHD diagnosis comorbid with ASD enabled the use of ADHD medications. The combination of MP and GF improved chronic back pain and high blood pressure due to ADPKD and cerebral blood flow. Screening for ADHD is important in the treatment of ADPKD.
Collapse
Affiliation(s)
- Satoshi Kasahara
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shoichiro Kanda
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Pediatric Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Miwako Takahashi
- Institute for Quantum Medical Science, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Mao Fujioka
- Department of Neuropsychiatry, The University of Tokyo Hospital, Tokyo, Japan
| | - Taito Morita
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Ko Matsudaira
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoko Sato
- Nursing Department, The University of Tokyo Hospital, Tokyo, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Toshimitsu Momose
- Institute of Engineering Innovation, School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Shin-Ichi Niwa
- Department of Psychiatry, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
4
|
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
|
5
|
O'Connor L, Carbone S, Gobbo A, Gamble H, Faraone SV. Pediatric attention deficit hyperactivity disorder (ADHD): 2022 updates on pharmacological management. Expert Rev Clin Pharmacol 2023; 16:799-812. [PMID: 37587841 DOI: 10.1080/17512433.2023.2249414] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Pediatric attention-deficit disorder (ADHD) impacts a significant percentage of the population world-wide. Pharmacologic treatments have been shown to be safe and effective for managing symptoms. Various medication formulations exist, and new medication agents are continually approved each year. AREAS COVERED This article offers an overview of ADHD, an overview of both stimulant and non-stimulant medication options as well as an overview of stimulant misuse. It explores the medication mechanisms of action and side effect profiles, as well as offering an in-depth summary of the novel agents recently approved and soon-to-be approved for use in youth. PubMed and Medline were utilized. Search terms included children, adolescents, ADHD, and medication. FDA package inserts were reviewed for all medications. EXPERT OPINION New formulations of medications include an evening administered, extended, and delayed-release form of methylphenidate (DR/ER MPH), a methylphenidate pro-drug (serdexmethylphenidate) and an amphetamine patch. The availability of a new SNRI (selective norepinephrine reuptake inhibitor), viloxazine extended-release (VER), and the pending approval of a triple reuptake inhibitor (centanafadine) provides welcome additions to the prescriber's toolbox.
Collapse
Affiliation(s)
- Lisa O'Connor
- Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, USA
| | - Stephanie Carbone
- Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, USA
| | - Anthony Gobbo
- Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, USA
| | - Hilary Gamble
- Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, USA
| | - Stephen V Faraone
- Department of Psychiatry, Norton College of Medicine at SUNY Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
6
|
Maurer JJ, Choi A, An I, Sathi N, Chung S. Sleep disturbances in autism spectrum disorder: Animal models, neural mechanisms, and therapeutics. Neurobiol Sleep Circadian Rhythms 2023; 14:100095. [PMID: 37188242 PMCID: PMC10176270 DOI: 10.1016/j.nbscr.2023.100095] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/16/2023] [Accepted: 04/08/2023] [Indexed: 05/17/2023] Open
Abstract
Sleep is crucial for brain development. Sleep disturbances are prevalent in children with autism spectrum disorder (ASD). Strikingly, these sleep problems are positively correlated with the severity of ASD core symptoms such as deficits in social skills and stereotypic behavior, indicating that sleep problems and the behavioral characteristics of ASD may be related. In this review, we will discuss sleep disturbances in children with ASD and highlight mouse models to study sleep disturbances and behavioral phenotypes in ASD. In addition, we will review neuromodulators controlling sleep and wakefulness and how these neuromodulatory systems are disrupted in animal models and patients with ASD. Lastly, we will address how the therapeutic interventions for patients with ASD improve various aspects of sleep. Together, gaining mechanistic insights into the neural mechanisms underlying sleep disturbances in children with ASD will help us to develop better therapeutic interventions.
Collapse
|
7
|
Michelini G, Lenartowicz A, Vera JD, Bilder RM, McGough JJ, McCracken JT, Loo SK. Electrophysiological and Clinical Predictors of Methylphenidate, Guanfacine, and Combined Treatment Outcomes in Children With Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2023; 62:415-426. [PMID: 35963559 PMCID: PMC9911553 DOI: 10.1016/j.jaac.2022.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 05/07/2022] [Accepted: 08/03/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE The combination of d-methylphenidate and guanfacine (an α-2A agonist) has emerged as a potential alternative to either monotherapy in children with attention-deficit/hyperactivity disorder (ADHD), but it is unclear what predicts response to these treatments. This study is the first to investigate pretreatment clinical and electroencephalography (EEG) profiles as predictors of treatment outcome in children randomized to these different medications. METHOD A total of 181 children with ADHD (aged 7-14 years; 123 boys) completed an 8-week randomized, double-blind, comparative study with d-methylphenidate, guanfacine, or combined treatments. Pretreatment assessments included ratings on ADHD, anxiety, and oppositional behavior. EEG activity from cortical sources localized within midfrontal and midoccipital regions was measured during a spatial working memory task with encoding, maintenance, and retrieval phases. Analyses tested whether pretreatment clinical and EEG measures predicted treatment-related change in ADHD severity. RESULTS Higher pretreatment hyperactivity-impulsivity and oppositional symptoms and lower anxiety predicted greater ADHD improvements across all medication groups. Pretreatment event-related midfrontal beta power predicted treatment outcome with combined and monotherapy treatments, albeit in different directions. Weaker beta modulations predicted improvements with combined treatment, whereas stronger modulation during encoding and retrieval predicted improvements with d-methylphenidate and guanfacine, respectively. A multivariate model including EEG and clinical measures explained twice as much variance in ADHD improvement with guanfacine and combined treatment (R2= 0.34-0.41) as clinical measures alone (R2 = 0.14-.21). CONCLUSION We identified treatment-specific and shared predictors of response to different pharmacotherapies in children with ADHD. If replicated, these findings would suggest that aggregating information from clinical and brain measures may aid personalized treatment decisions in ADHD. CLINICAL TRIAL REGISTRATION INFORMATION Single Versus Combination Medication Treatment for Children With Attention Deficit Hyperactivity Disorder; https://clinicaltrials.gov; NCT00429273.
Collapse
Affiliation(s)
- Giorgia Michelini
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, United Kingdom; School of Biological & Behavioural Sciences, Queen Mary University of London, United Kingdom.
| | - Agatha Lenartowicz
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, United Kingdom
| | - Juan Diego Vera
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, United Kingdom
| | - Robert M Bilder
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, United Kingdom
| | - James J McGough
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, United Kingdom
| | - James T McCracken
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, United Kingdom
| | - Sandra K Loo
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, United Kingdom.
| |
Collapse
|
8
|
Cortese S. Evidence-based prescribing of medications for ADHD: where are we in 2023? Expert Opin Pharmacother 2023; 24:425-434. [PMID: 36639953 DOI: 10.1080/14656566.2023.2169604] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION A large number of randomized controlled trials (RCTs) and observational studies on the pharmacotherapy of ADHD are available. AREAS COVERED Based on a search in PubMed and PsycInfo (up to 15 September 2022), this review addresses to which extent this body of research is currently able to inform routine prescribing practice, in terms of the choice of medication, titration strategy, augmentation treatments, and use of alternative, non-approved treatments. EXPERT OPINION A growing body of evidence is informing prescribers on some, but certainly not all, aspects related to the pharmacological treatment of ADHD in the daily clinical practice, with important weaknesses/gaps that need to be addressed. First, evidence synthesis of RCTs is not able to inform decision-making at the individual patient level. Second, the maximum safe and effective doses, possibly beyond those currently recommended, are not well understood. Third, evidence from RCTs on augmenting strategies is still limited. Fourth, no novel agents with the same or higher effect size of stimulants, in terms of efficacy, but with better tolerability and lower abuse potential, have been found. Implementation of precision psychiatry approaches and stratification of patients in future RCTs will be key to, respectively, individualize the treatment strategies and test etiopathophysiology-based agents.
Collapse
Affiliation(s)
- Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,Solent NHS Trust, Southampton, UK.,Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, New York, USA.,Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
9
|
Idrees I, Bellato A, Cortese S, Groom MJ. The effects of stimulant and non-stimulant medications on the autonomic nervous system (ANS) functioning in people with ADHD: A systematic review and meta-analysis. Neurosci Biobehav Rev 2023; 144:104968. [PMID: 36427764 DOI: 10.1016/j.neubiorev.2022.104968] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/12/2022] [Accepted: 11/19/2022] [Indexed: 11/25/2022]
Abstract
We carried out a systematic review and meta-analysis to investigate the effects of stimulant and non-stimulant medications on autonomic functioning in people with ADHD (PROSPERO: CRD42020212439). We searched (9th August 2021) PsycInfo, MEDLINE, EMBASE, Web of Science and The Cochrane Library, for randomised and non-randomised studies reporting indices of autonomic activity, (electrodermal, pupillometry and cardiac), pre- and post-medication exposure in people meeting DSM/ICD criteria for ADHD. In the narrative syntheses, we included 5 electrodermal studies, 1 pupillometry study and 57 studies investigating heart rate and blood pressure. In the meta-analyses, 29 studies were included on blood pressure and 32 on heart rate. Administration of stimulants, and to a lesser degree, non-stimulants increased heart rate and blood pressure in people with ADHD. Similarly, an upregulation of arousal, reflected in increased electrodermal activity and pupil diameter was observed following stimulant use. Yet, the methodological diversity of studies presented in this review reinforces the need for more standardised and rigorous research to fully understand the relationship between arousal, medication, and behaviour in ADHD.
Collapse
Affiliation(s)
- Iman Idrees
- Academic Unit of Mental Health & Clinical Neurosciences, School of Medicine, Institute of Mental Health, University of Nottingham, Nottingham, UK.
| | - Alessio Bellato
- School of Psychology, University of Nottingham Malaysia, Malaysia
| | - Samuele Cortese
- Academic Unit of Mental Health & Clinical Neurosciences, School of Medicine, Institute of Mental Health, University of Nottingham, Nottingham, UK; Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK; Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK; Solent NHS Trust, Southampton, UK; Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA
| | - Madeleine J Groom
- Academic Unit of Mental Health & Clinical Neurosciences, School of Medicine, Institute of Mental Health, University of Nottingham, Nottingham, UK
| |
Collapse
|
10
|
Robinson CL, Parker K, Kataria S, Downs E, Supra R, Kaye AD, Viswanath O, Urits I. Viloxazine for the Treatment of Attention Deficit Hyperactivity Disorder. Health Psychol Res 2022; 10:38360. [DOI: 10.52965/001c.38360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Purpose of Review Attention deficit hyperactivity disorder (ADHD) is a widely diagnosed neurodevelopmental disorder giving rise to symptoms of hyperactivity, impulsivity, and inattentiveness that can impair daily functioning. Stimulants, such as methylphenidate and amphetamines, are the mainstay of treatment for ADHD. However, nonstimulant drugs such as viloxazine, atomoxetine, guanfacine, and clonidine are becoming more popular due to minimal adverse effects when compared to stimulants. Recent Findings Viloxazine is a selective norepinephrine reuptake inhibitor (NRI) originally used to treat depression in adults with activity in both the noradrenergic as well as serotonergic pathways. Studies have demonstrated its efficacy for its use in the treatment of ADHD. Unlike stimulants, viloxazine has a decreased chance of substance abuse, drug dependance, and withdrawal symptoms upon the cessation of therapy. Additionally, dopamine levels in the nucleus accumbens after treatment with viloxazine are elevated considerably less in comparison with traditional stimulant ADHD treatments. Viloxazine provides an alternative, nonstimulant approach to treating ADHD. Summary Viloxazine is a recently approved, non-stimulant medication functions by inhibiting the uptake of norepinephrine which has been seen to be decreased in patients with ADHD. When patients do not respond to first-line stimulants, cannot tolerate the side effects, or have contraindications to stimulants, viloxazine may be a nonstimulant option offering patients an increasing arsenal of medications to treat ADHD.
Collapse
Affiliation(s)
| | - Katelyn Parker
- Louisiana State University Health New Orleans School of Medicine
| | - Saurabh Kataria
- Louisiana State University Health Science Center at Shreveport
| | - Evan Downs
- Louisiana State University Health New Orleans School of Medicine
| | | | - Alan D. Kaye
- Louisiana State University Health New Orleans School of Medicine
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Envision Physician Services
| | | |
Collapse
|
11
|
Pharmacotherapy of Disruptive Behaviors in Children with Intellectual Disabilities. Paediatr Drugs 2022; 24:465-482. [PMID: 35781194 DOI: 10.1007/s40272-022-00517-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 10/17/2022]
Abstract
Disruptive behaviors are a class of predominantly externalizing behaviors that include physical aggression, property destruction, temper outbursts, verbal aggression, and some forms of self-injurious behaviors. Externalizing behaviors are also major components of disruptive, impulse-control and conduct disorders, disruptive mood dysregulation disorder, trauma-related and stressor-related disorders, intermittent explosive disorder, personality disorders, and other neuropsychiatric and neurodevelopmental disorders. Disruptive behaviors and associated disorders are among the most frequent reasons for child behavioral health referrals and are the most common reason for referrals among children with intellectual disabilities. The focus of this paper is on the adjunctive role of integrated psychopharmacological treatment in the management of children with disruptive behaviors and co-occurring intellectual disabilities. The decision-making process for adding pharmacotherapy to a comprehensive treatment plan incorporates not only a working knowledge of basic behavioral neurobiology of disruptive behaviors but also an understanding of the strengths and weaknesses of various pharmacotherapies. Importantly, there is little evidence to support the use of psychopharmacologic agents in managing difficult behaviors in children with intellectual disabilities, but with that said, risperidone has the strongest evidence base for its use.
Collapse
|
12
|
Heal DJ, Gosden J, Smith SL. New Drugs to Treat ADHD: Opportunities and Challenges in Research and Development. Curr Top Behav Neurosci 2022; 57:79-126. [PMID: 35507283 DOI: 10.1007/7854_2022_332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Since the landmark MTA (Multimodal Treatment of ADHD) trial unequivocally demonstrated the efficacy of methylphenidate, catecholaminergic drugs, especially stimulants, have been the therapeutic mainstay in treatment of Attention-Deficit Hyperactivity Disorder (ADHD). We review the new drugs which have entered the ADHD formulary. The lessons learned from drug-candidates that have succeeded in clinical trials together with those that have not have also been considered. What emerges confirms and consolidates the hypothesis that clinically effective ADHD drugs indirectly or directly increase catecholaminergic neurotransmission in the prefrontal cortex (PFC). Attempts to enhance catecholaminergic signalling through modulatory neurotransmitter systems or cognitive-enhancing drugs have all failed. New drugs approved for ADHD are catecholaminergic reuptake inhibitors and releasing agents, or selective noradrenaline reuptake inhibitors. Triple reuptake inhibitors with preferential effects on dopamine have not been successful. The substantial number of failures probably accounts for a continued focus on developing novel catecholaminergic and noradrenergic drugs, and a dearth of drug-candidates with novel mechanisms entering clinical development. However, substantial improvements in ADHD pharmacotherapy have been achieved by the almost exclusive use of once-daily medications and prodrugs, e.g. lisdexamfetamine and Azstarys®, which improve compliance, deliver greater efficacy and reduce risks for diversion and abuse.
Collapse
Affiliation(s)
- David J Heal
- DevelRx Ltd, Nottingham, UK.
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.
| | | | | |
Collapse
|
13
|
Kannen K, Aslan B, Boetzel C, Herrmann CS, Lux S, Rosen H, Selaskowski B, Wiebe A, Philipsen A, Braun N. P300 Modulation via Transcranial Alternating Current Stimulation in Adult Attention-Deficit/Hyperactivity Disorder: A Crossover Study. Front Psychiatry 2022; 13:928145. [PMID: 35923453 PMCID: PMC9339709 DOI: 10.3389/fpsyt.2022.928145] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE A repeated finding regarding event-related potentials (ERPs) is that patients with ADHD show a reduced P300 amplitude. This raises the question of whether the attention of ADHD patients can be increased by stabilizing the P300. Assuming that the P300 is generated by event-related oscillations (EROs) in the low frequency range (0-8 Hz), one approach to increase the P300 could be to stimulate the patient's P300 underlying ERO by means of transcranial alternating current stimulation (tACS). The aim of this follow-up study was to investigate this hypothesized mechanism of action in adult ADHD patients. MATERIALS AND METHODS Undergoing a crossover design, 20 adult ADHD patients (10 female) received an actual stimulation via tACS on one day and a sham stimulation on another day. Before and after each intervention, EEG characteristics (P300 amplitudes, low frequency power) and attention performances (d2 attention test, visual oddball task (VOT)) were recorded. RESULTS Electrophysiological analyses revealed no evidence for an enhanced P300 amplitude or low frequency power increase after actual stimulation compared to sham stimulation. Instead, a significant effect was found for a stronger N700 amplitude increase after actual stimulation compared to sham stimulation. Consistent with the P300 null results, none of the examined neuropsychological performance measures indicated a tACS-induced improvement in attentional ability. CONCLUSION Contrary to a previous study using tACS to modulate the P300 in adult ADHD patients, the current study yields no evidence that tACS can increase the P300 amplitude in adult ADHD patients and that such P300 enhancement can directly improve neuropsychological parameters of attention.
Collapse
Affiliation(s)
- Kyra Kannen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Behrem Aslan
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Cindy Boetzel
- Experimental Psychology Lab, Department of Psychology, Carl von Ossietzky University, Oldenburg, Germany
| | - Christoph S Herrmann
- Experimental Psychology Lab, Department of Psychology, Carl von Ossietzky University, Oldenburg, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Rosen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Benjamin Selaskowski
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Annika Wiebe
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Niclas Braun
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
14
|
van Stralen J, Gill SK, Reaume CJ, Handelman K. A retrospective medical chart review of clinical outcomes in children and adolescents with attention-deficit/hyperactivity disorder treated with guanfacine extended-release in routine Canadian clinical practice. Child Adolesc Psychiatry Ment Health 2021; 15:55. [PMID: 34607580 PMCID: PMC8491395 DOI: 10.1186/s13034-021-00402-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 09/03/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study evaluated clinical outcomes in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) treated with the α2-adrenoceptor agonist guanfacine extended-release (GXR) in routine Canadian clinical practice. METHODS This retrospective chart review focused on patients with ADHD aged 6-17 years initiating treatment with GXR as monotherapy or adjunctive therapy. Patients were followed for up to 12 months after GXR initiation and, if they had received prior ADHD pharmacotherapy, for 12 months before GXR initiation. The primary outcome was change in ADHD symptoms and functionality based on physician assessments, classified as improvement, no change, or worsening relative to the time of GXR initiation. Treatment-emergent adverse events (TEAEs) were evaluated. Clinical outcomes were also analyzed post hoc according to whether GXR treatment was received as monotherapy or adjunctive therapy, and by select psychiatric comorbidities. Exploratory analyses were conducted in patients who had received prior ADHD pharmacotherapy to evaluate clinical outcomes after initiating GXR. RESULTS Improvements in ADHD symptoms were reported for 232/330 (70.3%) patients. Functional improvements in school performance and home life were reported for 213/330 (64.5%) and 209/330 (63.3%) patients, respectively. The most frequent TEAEs (≥ 5%) were somnolence, headache, insomnia, presyncope, and decreased appetite. Improvements in ADHD symptoms were observed when GXR was received as either monotherapy (35/60 [58.3%]) or adjunctive therapy (197/270 [73.0%]). Improvements in ADHD symptoms and functionality were observed in the majority of patients with select psychiatric comorbidities. Among patients who had experienced worsening of symptoms with prior ADHD pharmacotherapy, 44/54 (81.5%) experienced symptom improvement, 33/44 (75.0%) who had previously experienced worsening of school performance improved, and 34/48 (70.8%) who had previously experienced worsening of home life improved. CONCLUSION In Canadian routine clinical practice, most children and adolescents with ADHD treated with GXR experienced improvements in ADHD symptoms and in functionality both at school and at home.
Collapse
Affiliation(s)
- Judy van Stralen
- Center for Pediatric Excellence, 206-1637 Woodroffe Avenue, Ottawa, ON, K2G 1W2, Canada.
| | - Simerpal K. Gill
- grid.507459.a0000 0004 0436 0978Takeda Canada Inc., Toronto, ON Canada
| | - Christopher J. Reaume
- grid.507459.a0000 0004 0436 0978Shire Pharma Canada ULC, A Takeda Company (Now Takeda Canada Inc.), Toronto, ON Canada
| | | |
Collapse
|
15
|
Cortese S, Newcorn JH, Coghill D. A Practical, Evidence-informed Approach to Managing Stimulant-Refractory Attention Deficit Hyperactivity Disorder (ADHD). CNS Drugs 2021; 35:1035-1051. [PMID: 34403134 DOI: 10.1007/s40263-021-00848-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Stimulants (methylphenidate or amphetamines) are the recommended first-line option for the pharmacological treatment of individuals with attention deficit hyperactivity disorder (ADHD). However, some patients with ADHD will not respond optimally to stimulants. Here, we discuss strategies to manage stimulant-refractory ADHD, based on the recommendations advanced in clinical guidelines, knowledge of expert practice in the field, and our own clinical recommendations, informed by a comprehensive literature search in PubMed, PsycInfo, EMBASE + EMBASE classic, OVID Medline, and Web of Science (up to 30 March 2021). We first highlight the importance of stimulant optimization as an effective strategy to increase response. We then discuss a series of factors that should be considered before using alternative pharmacological strategies for ADHD, including poor adherence, time action properties of stimulants (and wearing-off of effects), poor tolerability (that prevents the use of higher, more effective doses), excessive focus on or confounding from presence of comorbid non-ADHD symptoms, and tolerance. Finally, we consider the role of non-stimulants and combined pharmacological approaches. While the choice of medication for ADHD is still to a large extent based on a trial-and-error process, there are reasonably accepted data and guidelines to aid in clinical decision-making. It is hoped that advances in precision psychiatry in the years ahead will further guide prescribers to tailor medication choice to the specific characteristics of the patient.
Collapse
Affiliation(s)
- Samuele Cortese
- School of Psychology, Centre for Innovation in Mental Health (CIMH), Faculty of Environmental and Life Sciences, University of Southampton, Highfield Campus, Building 44, Southampton, SO17 1BJ, UK. .,Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK. .,Solent NHS Trust, Southampton, UK. .,Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA. .,Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Jeffrey H Newcorn
- Division of ADHD and Learning Disorders, Departments of Psychiatry and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Coghill
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,The Royal Children's Hospital, Melbourne, VIC, Australia
| |
Collapse
|
16
|
Baweja R, Hale DE, Waxmonsky JG. Impact of CNS Stimulants for Attention-Deficit/Hyperactivity Disorder on Growth: Epidemiology and Approaches to Management in Children and Adolescents. CNS Drugs 2021; 35:839-859. [PMID: 34297331 DOI: 10.1007/s40263-021-00841-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 12/30/2022]
Abstract
Central nervous system stimulants are established treatments for pediatric attention-deficit/hyperactivity disorder with robust efficacy data. Reductions in appetite, weight, and growth velocity are some of the most common concerns regarding the long-term use of central nervous system stimulants in developing children. They are associated with suppression of weight and body mass index in childhood. However, both weight and body mass index often progressively increase over adolescence at rates faster than those seen in non-attention-deficit/hyperactivity disorder youth to the degree that attention-deficit/hyperactivity disorder is associated with elevated body mass index by the end of adolescence regardless of medication use. The capacity of central nervous system stimulants to slow growth was identified 50 years ago. Recent work has established that the growth deficits accumulate during the first 2 years of use and may persist provided medication is used. Early initiation coupled with persistent use through adolescence is most likely to be associated with clinical impactful growth suppression. There has been limited formal investigation of treatments for stimulant-associated reductions in weight and height. The most robust evidence exists for drug holidays improving weight gain. Observational studies suggest that limiting lifetime exposure or discontinuing medication is associated with greater adult height. Additional research is needed to identify the causal mechanisms driving the observed slowing in growth as well as the identification of predictors of clinically impactful growth suppression.
Collapse
Affiliation(s)
- Raman Baweja
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA.
| | - Daniel E Hale
- Division of Pediatric Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - James G Waxmonsky
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA, 17033-0850, USA
| |
Collapse
|
17
|
Baker M, Huefner JC, Bellonci C, Hilt R, Carlson GA. Polypharmacy in the Management of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Review and Update. J Child Adolesc Psychopharmacol 2021; 31:148-163. [PMID: 33600217 DOI: 10.1089/cap.2020.0162] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective: Prescription of multiple medications concurrently for children and adolescents has increased in recent years. Examination of this practice has been undervalued relative to its incidence. This article reviews studies investigating effectiveness of medication combinations for youth with attention-deficit/hyperactivity disorder (ADHD). Methods: A literature search identified studies that combined two or more prescribed medications for the treatment of ADHD. Included studies focused on youth; had study design of randomized controlled trial (RCT), nonrandomized trial, or case review (n > 10); and included an outcome measure of treatment effectiveness. Results: Thirty-nine pertinent studies were identified. All studies combined two medications, with the vast majority including a stimulant (n = 37). The largest group (n = 16) combined stimulant and alpha-agonist, finding greater efficacy than alpha-agonist alone but not stimulant alone in all cases. A few RCTs found benefit from the addition of risperidone or divalproex to stimulant for comorbid aggression. Four studies adding atomoxetine found mixed reports of benefit, including the only small RCT showing no benefit. RCTs with selective serotonin reuptake inhibitors found minimal evidence of benefit for mood or anxiety comorbidities. Conclusion: The best studied combination is stimulant and alpha-agonist; addition of alpha-agonist to stimulant seems effective for residual symptoms of ADHD. Stimulant plus risperidone has the most evidence of efficacy for comorbid aggression or disruptive behavior. Limited support exists for the effectiveness of other medication combinations, including no trials studying three or more medications concurrently. Combinations frequently yielded more side effects, leaving monotherapy preferable if a sufficient treatment response can be achieved.
Collapse
Affiliation(s)
- Megan Baker
- Momentum for Health, San Jose, California, USA
| | - Jonathan C Huefner
- Boys Town Child and Family Translational Research Center, Boys Town, Nebraska, USA
| | - Christopher Bellonci
- Judge Baker Children's Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Hilt
- Seattle Children's Hospital, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Gabrielle A Carlson
- Division of Child and Adolescent Psychiatry, Renaissance School of Medicine at Stony Brook, Stony Brook, New York, USA
| |
Collapse
|
18
|
Pharmacotherapy of attention-deficit hyperactivity disorder: common quandaries, dilemmas and challenges. Int Clin Psychopharmacol 2020; 35:300-304. [PMID: 32694317 DOI: 10.1097/yic.0000000000000323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Multiple studies have shown that pharmacologic treatments for attention-deficit hyperactivity disorder (ADHD), especially stimulants, are generally effective. There is yet a paucity of empirical data, however, for some common clinical conditions overlooked in the ADHD treatment guidelines. Some examples include: in cases of first line treatment failure, it is unclear whether switching from one type of stimulant to another is beneficial. In cases of comorbid ADHD and severe aggressive/disruptive behavior in children, it is unclear whether the best first-line treatment is stimulants or atypical antipsychotics like risperidone. In cases of ADHD with comorbid anxiety disorders, there is no clear evidence regarding optimal treatment. The objectives of this article are to review these issues and propose possible answers for such clinical dilemmas.
Collapse
|
19
|
Solmi M, Fornaro M, Ostinelli EG, Zangani C, Croatto G, Monaco F, Krinitski D, Fusar‐Poli P, Correll CU. Safety of 80 antidepressants, antipsychotics, anti-attention-deficit/hyperactivity medications and mood stabilizers in children and adolescents with psychiatric disorders: a large scale systematic meta-review of 78 adverse effects. World Psychiatry 2020; 19:214-232. [PMID: 32394557 PMCID: PMC7215080 DOI: 10.1002/wps.20765] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Mental disorders frequently begin in childhood or adolescence. Psychotropic medications have various indications for the treatment of mental dis-orders in this age group and are used not infrequently off-label. However, the adverse effects of these medications require special attention during developmentally sensitive periods of life. For this meta-review, we systematically searched network meta-analyses and meta-analyses of randomized controlled trials (RCTs), individual RCTs, and cohort studies reporting on 78 a priori selected adverse events across 19 categories of 80 psychotropic medications - including antidepressants, antipsychotics, anti-attention-deficit/hyperactivity disorder (ADHD) medications and mood stabilizers - in children and adolescents with mental disorders. We included data from nine network meta-analyses, 39 meta-analyses, 90 individual RCTs, and eight cohort studies, including 337,686 children and adolescents. Data on ≥20% of the 78 adverse events were available for six antidepressants (sertraline, escitalopram, paroxetine, fluoxetine, venlafaxine and vilazodone), eight antipsychotics (risperidone, quetiapine, aripiprazole, lurasidone, paliperidone, ziprasidone, olanzapine and asenapine), three anti-ADHD medications (methylphenidate, atomoxetine and guanfacine), and two mood stabilizers (valproate and lithium). Among these medications with data on ≥20% of the 78 adverse events, a safer profile emerged for escitalopram and fluoxetine among antidepressants, lurasidone for antipsychotics, methylphenidate among anti-ADHD medications, and lithium among mood stabilizers. The available literature raised most concerns about the safety of venlafaxine, olanzapine, atomoxetine, guanfacine and valproate. Nausea/vomiting and discontinuation due to adverse event were most frequently associated with antidepressants; sedation, extrapyramidal side effects, and weight gain with antipsychotics; anorexia and insomnia with anti-ADHD medications; sedation and weight gain with mood stabilizers. The results of this comprehensive and updated quantitative systematic meta-review of top-tier evidence regarding the safety of antidepressants, antipsychotics, anti-ADHD medications and mood stabilizers in children and adolescents can inform clinical practice, research and treatment guidelines.
Collapse
Affiliation(s)
- Marco Solmi
- Neurosciences DepartmentUniversity of PaduaPaduaItaly,Padua Neuroscience CenterUniversity of PaduaPaduaItaly,Early Psychosis: Interventions and Clinical‐detection (EPIC) lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | | | - Edoardo G. Ostinelli
- Oxford Health NHS Foundation TrustWarneford Hospital, and Department of Psychiatry, University of OxfordOxfordUK,Department of Health SciencesUniversity of MilanMilanItaly
| | | | | | | | | | - Paolo Fusar‐Poli
- Early Psychosis: Interventions and Clinical‐detection (EPIC) lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,OASIS ServiceSouth London & Maudsley NHS Foundation TrustLondonUK,Department of Brain and Behavioral SciencesUniversity of PaviaPaviaItaly,National Institute for Health Research, Maudsley Biomedical Research CentreSouth London & Maudsley NHS Foundation TrustLondonUK
| | - Christoph U. Correll
- Department of Psychiatry, Zucker Hillside HospitalNorthwell HealthGlen OaksNew YorkNYUSA,Department of Psychiatry and Molecular MedicineZucker School of Medicine at Hofstra/NorthwellHempsteadNYUSA,Center for Psychiatric NeuroscienceFeinstein Institute for Medical ResearchManhassetNYUSA,Department of Child and Adolescent PsychiatryCharité Universitätsmedizin BerlinBerlinGermany
| |
Collapse
|
20
|
Elbe D. Switching from Clonidine Immediate-Release to Guanfacine Extended-Release. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2020; 29:121-123. [PMID: 32405313 PMCID: PMC7213916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Dean Elbe
- Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia
- Child and Adolescent Mental Health Programs, BC Children's Hospital, Vancouver, British Columbia
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
21
|
Childress A, Hoo-Cardiel A, Lang P. Evaluation of the current data on guanfacine extended release for the treatment of ADHD in children and adolescents. Expert Opin Pharmacother 2020; 21:417-426. [DOI: 10.1080/14656566.2019.1706480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Ann Childress
- Center for Psychiatry and Behavioral Medicine, Las Vegas, NV, USA
| | - Asmara Hoo-Cardiel
- Touro University Nevada, College of Osteopathic Medicine, Henderson, NV, USA
| | - Peter Lang
- Touro University Nevada, College of Osteopathic Medicine, Henderson, NV, USA
| |
Collapse
|
22
|
Dallmer-Zerbe I, Popp F, Lam AP, Philipsen A, Herrmann CS. Transcranial Alternating Current Stimulation (tACS) as a Tool to Modulate P300 Amplitude in Attention Deficit Hyperactivity Disorder (ADHD): Preliminary Findings. Brain Topogr 2020; 33:191-207. [PMID: 31974733 PMCID: PMC7066286 DOI: 10.1007/s10548-020-00752-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/04/2020] [Indexed: 12/22/2022]
Abstract
Studies examining event-related potentials (ERP) in patients affected by attention deficit/hyperactivity disorder (ADHD) have found considerable evidence of reduced target P300 amplitude across different perceptual modalities. P300 amplitude has been related to attention-driven context comparison and resource allocation processes. Altered P300 amplitude in ADHD can be reasonably assumed to be related to ADHD typical cognitive performance deficits. Transcranial alternating current stimulation (tACS) can increase the amplitude of endogenous brain oscillations. Because ERP components can be viewed as event-related oscillations (EROs), with P300 translating into the delta (0–4 Hz) and theta (4–8 Hz) frequency range, an increase of delta and theta ERO amplitudes by tACS should result in an increase of P300 amplitudes in ADHD patients. In this pilot study, 18 adult ADHD patients (7 female) performed three consecutive blocks of a visual oddball task while the electroencephalogram (EEG) was recorded. Patients received either 20 min of tACS or sham stimulation at a stimulation intensity of 1 mA. Individual stimulation frequency was determined using a time–frequency decomposition of the P300. Our preliminary results demonstrate a significant increase in P300 amplitude in the stimulation group which was accompanied by a decrease in omission errors pre-to-post tACS. However, studies including larger sample sizes are advised.
Collapse
Affiliation(s)
- Isa Dallmer-Zerbe
- Department of Complex Systems, Institute of Computer Science, Czech Academy of Sciences, Prague, Czech Republic.,Department of Physiology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,Experimental Psychology Lab, Department of Psychology, European Medical School, Cluster for Excellence "Hearing for All", Carl Von Ossietzky University Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany
| | - Fabian Popp
- Experimental Psychology Lab, Department of Psychology, European Medical School, Cluster for Excellence "Hearing for All", Carl Von Ossietzky University Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany
| | - Alexandra Philomena Lam
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany.,Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy - University Hospital, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany.,Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy - University Hospital, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany
| | - Christoph Siegfried Herrmann
- Experimental Psychology Lab, Department of Psychology, European Medical School, Cluster for Excellence "Hearing for All", Carl Von Ossietzky University Oldenburg, Ammerländer Heerstr. 114-118, 26129, Oldenburg, Germany. .,Research Center Neurosensory Science, Carl Von Ossietzky University, Oldenburg, Germany.
| |
Collapse
|
23
|
van Stralen JPM. A Controlled Trial of Extended-Release Guanfacine and Psychostimulants on Executive Function and ADHD. J Atten Disord 2020; 24:318-325. [PMID: 29313415 DOI: 10.1177/1087054717751197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To evaluate the effectiveness of guanfacine extended-release (GXR) versus placebo as adjunct therapy to usual care stimulant therapy in improving executive function in children aged 6 to 12 years diagnosed with ADHD. Method: In this single center, double-blind placebo-controlled crossover trial, subjects continued to take their psychostimulant and were randomly assigned at baseline to receive active treatment or placebo first. Efficacy measures included Behavioural Rating Inventory of Executive Function (BRIEF-P), ADHD Rating Scale IV (ADHD-RS IV), and Clinical Global Impressions of Severity of Illness (CGI-S) and Improvement (CGI-I) scales. Safety measures included adverse events and vital signs. Results: Significant benefits of GXR plus psychostimulant were observed on BRIEF-P (p value = .0392), ADHD-RS-IV (p < .0001), CGI-S (p = .0007), and CGI-I (p = .003). There were no serious adverse events and no new safety signals. Conclusion: Use of GXR as adjunctive therapy to stimulant therapy significantly improves executive function in children with ADHD.
Collapse
|
24
|
Lachaine J, Ben Amor L, Pringsheim T, Burns J, van Stralen J. Treatment Patterns, Health Care Resource Utilization, and Health Care Cost Associated with Atypical Antipsychotics or Guanfacine Extended Release in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder in Quebec, Canada. J Child Adolesc Psychopharmacol 2019; 29:730-739. [PMID: 31433205 PMCID: PMC6885769 DOI: 10.1089/cap.2019.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective: To assess treatment patterns, health care resource utilization, and health care costs associated with use of atypical antipsychotics (AAPs) or the nonstimulant guanfacine extended release (GXR) after stimulant therapy for attention-deficit/hyperactivity disorder (ADHD). In Canada, GXR is approved as a monotherapy for children and adolescents with ADHD or as an adjunct to stimulants, and AAPs are commonly used off-label as an adjunct to stimulants. Methods: Health care claims data (January 1, 2007 to March 31, 2016) from Quebec's provincial health plan were assessed for individuals with ADHD, 6-17 years of age, who received ≥1 stimulant followed by a first AAP or GXR prescription (index medication), without a diagnosis for which AAPs are indicated. Results: Overall, 1327 individuals were included (AAPs, 1098; GXR, 229). Rates of discontinuation, augmentation, or switching of the index medication did not differ between AAPs and GXR during the first follow-up year. Discontinuation rates were significantly lower with GXR than with AAPs during the second year (22.0% vs. 35.9%; p = 0.03). GXR and AAPs resulted in similar increases in total health care cost. In GXR users, the increase in prescription drug cost after 6 months was higher than in AAP users, whereas the increase in overall medical cost was higher with AAPs than GXR, owing to more psychiatric department visits. Conclusions: In children and adolescents with ADHD who used AAPs or GXR after stimulants, secondary treatment changes were similar with both treatments after 1 year, but discontinuation rates were significantly lower with GXR than with AAPs in the second year. The greater increase in prescription cost with GXR was balanced by a greater increase in overall medical costs with AAPs, resulting in no overall difference in total health care cost between the two treatments.
Collapse
Affiliation(s)
- Jean Lachaine
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada.,Address correspondence to: Jean Lachaine, PhD, Faculty of Pharmacy, University of Montreal, C.P. 6128, Succursale Centre-Ville, Montreal, QC H3C 3J7, Canada
| | - Leila Ben Amor
- Department of Psychiatry, University of Montreal, Montreal, Quebec, Canada
| | - Tamara Pringsheim
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - James Burns
- Shire, a Takeda company, Toronto, Ontario, Canada
| | - Judy van Stralen
- Center for Pediatric Excellence, Ottawa, Ontario, Canada.,Department of Paediatrics, Queen's University, Ottawa, Ontario, Canada
| |
Collapse
|
25
|
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
|
26
|
Feldman ME, Charach A, Bélanger SA. Le TDAH chez les enfants et les adolescents, partie 2 : le traitement. Paediatr Child Health 2018; 23:473-484. [PMCID: PMC6199638 DOI: 10.1093/pch/pxy114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Le trouble de déficit de l’attention/hyperactivité (TDAH) est un trouble neurodéveloppemental chronique. La Société canadienne de pédiatrie a préparé trois documents de principes après avoir effectué des analyses bibliographiques systématiques. Leurs objectifs s’établissent comme suit : 1) Résumer les données probantes cliniques à jour sur le TDAH. 2) Établir une norme pour les soins du TDAH. 3) Aider les cliniciens canadiens à prendre des décisions éclairées et fondées sur des données probantes pour rehausser la qualité des soins aux enfants et aux adolescents qui présentent cette affection. La partie 2, axée sur le traitement, porte sur les données probantes et le contexte entourant diverses approches cliniques, la combinaison des interventions comportementales et pharmacologiques pour assurer un traitement plus efficace, le rôle de la formation des parents et des enseignants (ou des autres personnes qui s’occupent de l’enfant), le recours aux stimulants et aux non-stimulants, leurs effets et leurs risques, leur posologie et les protocoles de surveillance. Les recommandations thérapeutiques reposent sur les lignes directrices à jour, les données probantes tirées de publications scientifiques et le consensus d’experts.
Collapse
Affiliation(s)
- Mark E Feldman
- Société canadienne de pédiatrie, comité de la santé mentale et des troubles du développement, Ottawa (Ontario)
| | - Alice Charach
- Société canadienne de pédiatrie, comité de la santé mentale et des troubles du développement, Ottawa (Ontario)
| | - Stacey A Bélanger
- Société canadienne de pédiatrie, comité de la santé mentale et des troubles du développement, Ottawa (Ontario)
| |
Collapse
|
27
|
Cardiovascular Effects of Drugs Used to Treat Attention-Deficit/Hyperactivity Disorder: Part 1: Epidemiology, Pharmacology, and Impact on Hemodynamics and Ventricular Repolarization. Cardiol Rev 2018; 27:113-121. [PMID: 30365404 DOI: 10.1097/crd.0000000000000233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a clinical syndrome characterized by persistent inattention, impulsivity, and hyperactivity. It is most commonly encountered in children and adolescents but may persist into adulthood. A variety of psychostimulant and nonpsychostimulant medications have proven to be successful in reducing inattention, impulsivity, and hyperactivity in those with ADHD. Psychostimulants used to treat ADHD include methylphenidate and related drugs and various amphetamine preparations. Non-psychostimulant medications used to treat ADHD include atomoxetine and two alpha-2 adrenergic agonists: guanfacine extended-release and clonidine extended-release. The psychostimulants and atomoxetine have been shown, on average, to increase heart rate by 3-10 beats/min, systolic blood pressure by 3-8 mm Hg, and diastolic blood pressure by 2-14 mm Hg. These drugs may also delay ventricular repolarization. The alpha-2 adrenergic agonists may reduce heart rate and blood pressure. For these reasons, there is concern about the safety of psychostimulant and nonpsychostimulant medications in patients with ADHD. In part 1 of this review, we discuss the epidemiology and natural history of ADHD, describe the pharmacology of drugs used to treat ADHD, and discuss in detail studies assessing the effects of ADHD drugs on blood pressure, heart or pulse rate, and electrocardiographic indices of ventricular repolarization.
Collapse
|
28
|
Feldman ME, Charach A, Bélanger SA. ADHD in children and youth: Part 2-Treatment. Paediatr Child Health 2018; 23:462-472. [PMID: 30681665 DOI: 10.1093/pch/pxy113] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Three position statements have been developed by the Canadian Paediatric Society, following systematic literature reviews. Statement objectives are to: 1) Summarize the current clinical evidence regarding ADHD,2) Establish a standard for ADHD care, and3) Assist Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. Specific topics reviewed in Part 2, which focuses on treatment, include: evidence and context for a range of clinical approaches, combining behavioural and pharmacological interventions to address impairment more effectively, the role of parent and teacher (or other caregiver) training, the use of stimulant and nonstimulant medications, with effects and risks, and dosing and monitoring protocols. Treatment recommendations are based on current guidelines, evidence from the literature, and expert consensus.
Collapse
Affiliation(s)
- Mark E Feldman
- Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee, Ottawa, Ontario
| | - Alice Charach
- Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee, Ottawa, Ontario
| | - Stacey A Bélanger
- Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee, Ottawa, Ontario
| |
Collapse
|
29
|
Affiliation(s)
- Lukas Propper
- From the IWK Health Centre, Department of Psychiatry and Dalhousie University, Department of Psychiatry, Halifax, NS, Canada
| |
Collapse
|
30
|
Coghill DR, Banaschewski T, Soutullo C, Cottingham MG, Zuddas A. Systematic review of quality of life and functional outcomes in randomized placebo-controlled studies of medications for attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry 2017; 26:1283-1307. [PMID: 28429134 PMCID: PMC5656703 DOI: 10.1007/s00787-017-0986-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 04/03/2017] [Indexed: 10/31/2022]
Abstract
Children, adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) experience functional impairment and poor health-related quality of life (HRQoL) in addition to symptoms of inattention/hyperactivity-impulsivity. To synthesize qualitatively the published evidence from randomized, double-blind, placebo-controlled trials of the effectiveness of pharmacotherapy on functional impairment or HRQoL in patients with ADHD, a systematic PubMed searching and screening strategy was designed to identify journal articles meeting pre-specified criteria. Post hoc analyses and meta-analyses were excluded. HRQoL outcomes, functional outcomes and the principal ADHD symptom-based outcome were extracted from included studies. An effect size of 0.5 versus placebo was used as a threshold for potential clinical relevance (unreported effect sizes were calculated when possible). Of 291 records screened, 35 articles describing 34 studies were included. HRQoL/functioning was usually self-rated in adults and proxy-rated in children/adolescents. Baseline data indicated substantial HRQoL deficits in children/adolescents. Placebo-adjusted effects of medication on ADHD symptoms, HRQoL and functioning, respectively, were statistically or nominally significant in 18/18, 10/12 and 7/9 studies in children/adolescents and 14/16, 9/11 and 9/10 studies in adults. Effect sizes were ≥0.5 versus placebo for symptoms, HRQoL and functioning, respectively, in 14/16, 7/9 and 4/8 studies in children/adolescents; and 6/12, 1/6 and 1/8 studies in adults. Effect sizes were typically larger for stimulants than for non-stimulants, for symptoms than for HRQoL/functioning, and for children/adolescents than for adults. The efficacy of ADHD medication extends beyond symptom control and may help reduce the related but distinct functional impairments and HRQoL deficits in patients with ADHD.
Collapse
Affiliation(s)
- David R Coghill
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia.
- Department of Psychiatry, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia.
- Division of Neuroscience, University of Dundee, Dundee, UK.
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - César Soutullo
- Child and Adolescent Psychiatry Unit, Department of Psychiatry and Medical Psychology, University of Navarra Clinic, Pamplona, Spain
| | | | - Alessandro Zuddas
- Child and Adolescent Psychiatry Unit, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| |
Collapse
|
31
|
Catalá-López F, Hutton B, Núñez-Beltrán A, Page MJ, Ridao M, Macías Saint-Gerons D, Catalá MA, Tabarés-Seisdedos R, Moher D. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: A systematic review with network meta-analyses of randomised trials. PLoS One 2017; 12:e0180355. [PMID: 28700715 PMCID: PMC5507500 DOI: 10.1371/journal.pone.0180355] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 06/14/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed psychiatric disorders in childhood. A wide variety of treatments have been used for the management of ADHD. We aimed to compare the efficacy and safety of pharmacological, psychological and complementary and alternative medicine interventions for the treatment of ADHD in children and adolescents. METHODS AND FINDINGS We performed a systematic review with network meta-analyses. Randomised controlled trials (≥ 3 weeks follow-up) were identified from published and unpublished sources through searches in PubMed and the Cochrane Library (up to April 7, 2016). Interventions of interest were pharmacological (stimulants, non-stimulants, antidepressants, antipsychotics, and other unlicensed drugs), psychological (behavioural, cognitive training and neurofeedback) and complementary and alternative medicine (dietary therapy, fatty acids, amino acids, minerals, herbal therapy, homeopathy, and physical activity). The primary outcomes were efficacy (treatment response) and acceptability (all-cause discontinuation). Secondary outcomes included discontinuation due to adverse events (tolerability), as well as serious adverse events and specific adverse events. Random-effects Bayesian network meta-analyses were conducted to obtain estimates as odds ratios (ORs) with 95% credibility intervals. We analysed interventions by class and individually. 190 randomised trials (52 different interventions grouped in 32 therapeutic classes) that enrolled 26114 participants with ADHD were included in complex networks. At the class level, behavioural therapy (alone or in combination with stimulants), stimulants, and non-stimulant seemed significantly more efficacious than placebo. Behavioural therapy in combination with stimulants seemed superior to stimulants or non-stimulants. Stimulants seemed superior to behavioural therapy, cognitive training and non-stimulants. Behavioural therapy, stimulants and their combination showed the best profile of acceptability. Stimulants and non-stimulants seemed well tolerated. Among medications, methylphenidate, amphetamine, atomoxetine, guanfacine and clonidine seemed significantly more efficacious than placebo. Methylphenidate and amphetamine seemed more efficacious than atomoxetine and guanfacine. Methylphenidate and clonidine seemed better accepted than placebo and atomoxetine. Most of the efficacious pharmacological treatments were associated with harms (anorexia, weight loss and insomnia), but an increased risk of serious adverse events was not observed. There is lack of evidence for cognitive training, neurofeedback, antidepressants, antipsychotics, dietary therapy, fatty acids, and other complementary and alternative medicine. Overall findings were limited by the clinical and methodological heterogeneity, small sample sizes of trials, short-term follow-up, and the absence of high-quality evidence; consequently, results should be interpreted with caution. CONCLUSIONS Clinical differences may exist between the pharmacological and non-pharmacological treatment used for the management of ADHD. Uncertainties about therapies and the balance between benefits, costs and potential harms should be considered before starting treatment. There is an urgent need for high-quality randomised trials of the multiple treatments for ADHD in children and adolescents. PROSPERO, number CRD42014015008.
Collapse
Affiliation(s)
- Ferrán Catalá-López
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Fundación Instituto de Investigación en Servicios de Salud, Valencia, Spain
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain
- * E-mail:
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amparo Núñez-Beltrán
- Centro de Atención Integral a Drogodependientes (CAID) Norte, Regional Health Council, Madrid, Spain
| | - Matthew J. Page
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Manuel Ridao
- Fundación Instituto de Investigación en Servicios de Salud, Valencia, Spain
- Instituto Aragonés de Ciencias de la Salud (IACS), Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Zaragoza, Spain
| | - Diego Macías Saint-Gerons
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Medicines and Healthcare Products Agency (AEMPS), Madrid, Spain
| | | | - Rafael Tabarés-Seisdedos
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
32
|
Meyers J, Gajria K, Candrilli SD, Fridman M, Sikirica V. The impact of adjunctive guanfacine extended release on stimulant adherence in children/adolescents with attention-deficit/hyperactivity disorder. J Comp Eff Res 2017; 6:109-125. [DOI: 10.2217/cer-2016-0039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Aim: To assess stimulant adherence among children/adolescents with attention-deficit/hyperactivity disorder (ADHD) augmenting stimulants with guanfacine extended-release (GXR). Patients & methods: Inclusion criteria: 6–17 years, ≥1 ADHD diagnosis, ≥1 long-acting and/or short-acting stimulant with GXR augmentation. Modified medication possession ratio (mMPR; days medication available/days in period, excluding medication holidays) was assessed; mMPR <0.80 nonadherent. Regression models assessed change in mMPR adjusting for demographic and clinical characteristics. Results: Among patients nonadherent to stimulants pre-augmentation (n = 165), unadjusted mean (SD) pre- and post-stimulant mMPRs were 0.68 (0.11) and 0.87 (0.16). Adjusted mean change in mMPR was 0.20 for long-acting versus 0.18 for short-acting stimulants (p = 0.34). Conclusion: Among patients nonadherent to stimulants, GXR augmentation was associated with increased stimulant adherence.
Collapse
Affiliation(s)
- Juliana Meyers
- RTI Health Solutions, 3040 Cornwallis Road, Post Office Box 12194, Research Triangle Park, NC 27709, USA
| | - Kavita Gajria
- Shire, 725 Chesterbrook Boulevard, Wayne, PA 19087, USA
| | - Sean D Candrilli
- RTI Health Solutions, 3040 Cornwallis Road, Post Office Box 12194, Research Triangle Park, NC 27709, USA
| | - Moshe Fridman
- AMF Consulting, 846 S Citrus Avenue, Los Angeles, CA 90036, USA
| | | |
Collapse
|
33
|
Strawn JR, Compton SN, Robertson B, Albano AM, Hamdani M, Rynn MA. Extended Release Guanfacine in Pediatric Anxiety Disorders: A Pilot, Randomized, Placebo-Controlled Trial. J Child Adolesc Psychopharmacol 2017; 27:29-37. [PMID: 28165762 PMCID: PMC5695796 DOI: 10.1089/cap.2016.0132] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE This is a feasibility study evaluating the safety, tolerability, and potential anxiolytic efficacy of the α2 agonist guanfacine extended-release (GXR) in children and adolescents with generalized anxiety disorder (GAD), separation anxiety disorder (SAD), or social phobia/social anxiety disorder. METHODS Youth aged 6-17 years with a primary diagnosis of GAD, SAD, and/or social anxiety disorder were treated with flexibly dosed GXR (1-6 mg daily, n = 62) or placebo (n = 21) for 12 weeks. The primary aim of this study was to determine the safety and tolerability of GXR in youth with anxiety disorders, which involved the analysis of treatment-emergent adverse events (TEAEs), the emergence of suicidal ideation and behaviors, vital signs, and electrocardiographic/laboratory parameters. Exploratory efficacy measures included dimensional anxiety scales (Pediatric Anxiety Rating Scale [PARS] and Screen for Child Anxiety Related Emotional Disorders [SCARED]), as well as the Clinical Global Impression-Improvement (CGI-I) scale. As this was an exploratory study, no inferential statistical analyses were performed. RESULTS GXR was safe and well tolerated. Treatment-related mean ± standard deviation changes in heart rate (GXR: 1.8 ± 12 beats per minute [bpm] decrease; placebo: 0.5 ± 11 bpm decrease), systolic blood pressure (GXR: 2.3 ± 11 mm Hg decrease; placebo: 1.7 ± 11 mm Hg decrease), or diastolic blood pressure (GXR: 1.3 ± 9 mm Hg decrease; placebo: 0.9 ± 7 mm Hg increase) were similar between treatment groups. TEAEs, including headache, somnolence/fatigue, abdominal pain, and dizziness, were consistent with the known safety profile of GXR. No differences were observed between treatment groups for PARS and SCARED scores, although at endpoint, a higher proportion of subjects receiving GXR versus placebo demonstrated CGI-I scores ≤2 (54.2% vs. 31.6%), as rated by the clinician investigator. CONCLUSIONS GXR was well tolerated in pediatric subjects with GAD, SAD, and/or social anxiety disorder. ClinicalTrials.gov Identifier: NCT01470469.
Collapse
Affiliation(s)
- Jeffrey R. Strawn
- Anxiety Disorders Research Program, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Scott N. Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Anne Marie Albano
- New York State Psychiatric Institute, Columbia University, New York, New York
| | | | - Moira A. Rynn
- New York Presbyterian Morgan Stanley Children's Hospital, Columbia University/New York State Psychiatric Institute, New York, New York
| |
Collapse
|
34
|
Wilens TE, McBurnett K, Turnbow J, Rugino T, White C, Youcha S. Morning and Evening Effects of Guanfacine Extended Release Adjunctive to Psychostimulants in Pediatric ADHD. J Atten Disord 2017; 21:110-119. [PMID: 24071772 DOI: 10.1177/1087054713500144] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine efficacy and safety of adjunctive guanfacine extended release (GXR) on morning and evening ADHD symptoms using the Conners' Global Index-Parent (CGI-P) and Before-School Functioning Questionnaire (BSFQ). METHOD Participants 6 to 17 years with ADHD ( N = 461) and suboptimal psychostimulant response were maintained on current psychostimulants and randomized to dose-optimized GXR (≤4 mg/d) in the morning (GXR AM) or evening (GXR PM), or placebo. RESULTS CGI-P scores improved with GXR (morning assessment, GXR AM, placebo-adjusted least squares [LS] mean = -1.7, GXR PM = -2.6; evening assessment, GXR AM = -2.4, GXR PM = -3.0; all ps < .01). Parent-rated BSFQ scores reflected improved morning functioning with GXR (GXR AM, placebo-adjusted LS mean = -5.1; GXR PM = -4.7; both ps < .01). Most adverse events were mild or moderate. CONCLUSION Adjunctive GXR AM or GXR PM was associated with improvements in morning and evening ADHD symptoms in children and adolescents.
Collapse
Affiliation(s)
- Timothy E Wilens
- 1 Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Keith McBurnett
- 2 University of California, San Francisco, San Francisco, CA, USA
| | - John Turnbow
- 3 Westex Clinical Investigations, Lubbock, TX, USA
| | - Thomas Rugino
- 4 Children's Specialized Hospital, Toms River, NJ, USA
| | - Carla White
- 5 Shire Pharmaceutical Development Ltd., Basingstoke, UK
| | - Sharon Youcha
- 6 Drexel University College of Medicine, Philadelphia, PA, USA; formerly of Shire Development, LLC, Wayne, PA, USA
| |
Collapse
|
35
|
Luan R, Mu Z, Yue F, He S. Efficacy and Tolerability of Different Interventions in Children and Adolescents with Attention Deficit Hyperactivity Disorder. Front Psychiatry 2017; 8:229. [PMID: 29180967 PMCID: PMC5694170 DOI: 10.3389/fpsyt.2017.00229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 10/25/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Our study is an analysis of multiple publications involving assessing the comparable efficacy and tolerability of six interventions, which are lisdexamfetamine dimesylate (LDX), atomoxetine (ATX), methylphenidate (MPH), clonidine hydrochloride (CLON), guanfacine extended release (GXR), and bupropion, for young patients (6-18 years old) suffering from attention deficit hyperactivity disorder (ADHD). METHODS A conventional meta-analysis (MA) was performed to give direct comparisons and a network meta-analysis (NMA) was used to show the combination of direct and indirect evidence. Ranking preference for all the interventions under a certain outcome was given by the surface of cumulative ranking curve area (SUCRA). RESULTS Overall, 15,025 participants from 73 studies were involved in our analysis. In the pairwise MA, LDX was associated with less withdrawal than ATX for lack of efficacy. MPH showed less effectiveness than LDX according to ADHD Rating Scale score. Based on the analysis of our NMA, significant results of efficacy that LDX is a competitive drug were observed when evaluating LDX in comparison with other drugs except for CLON. ATX and GXR presented higher rates of abdominal pain morbidity versus inactive treatment. CONCLUSION The stimulants LDX and MPH are still highly recommended because they are highly effective and are tolerated well by patients. Among the non-stimulants, CLON can be taken into consideration for its appreciable effectiveness and tolerability. ATX and GXR can be seen as moderate choices.
Collapse
Affiliation(s)
- Ruiling Luan
- Department of Pharmacy, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Zhiling Mu
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Fang Yue
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shaoying He
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| |
Collapse
|
36
|
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
|
37
|
Martinez-Raga J, Ferreros A, Knecht C, de Alvaro R, Carabal E. Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects and outcomes. Ther Adv Drug Saf 2016; 8:87-99. [PMID: 28382197 DOI: 10.1177/2042098616679636] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
While treatment of patients with attention-deficit hyperactivity disorder (ADHD) is based on a multimodal approach that combines medication with specific psychological interventions, pharmacotherapy alone is generally considered an essential and cost-effective element. This paper aims to comprehensively and critically review factors involved in prescribing and medication use in individuals diagnosed with ADHD, focusing on the difficulties facing patients with ADHD seeking treatment, as well as the safety and tolerability aspects of ADHD pharmacotherapies, with particular attention on the cardiovascular adverse events and the potential risk of misuse or diversion of ADHD medications. A comprehensive and systematic literature search of PubMed/MEDLINE database was conducted to identify studies published in peer-reviewed journals until 1 August 2016. Children, adolescents and adults often encounter significant difficulties in the process of accessing specialist assessment and treatment for ADHD as a consequence of disparities in service organization and available treatment provision. Despite the well-established efficacy and overall safety profile, ADHD medications are not exempt from adverse events. The cardiovascular safety of pharmacotherapies used for treating individuals with ADHD has raised particular concerns; however there is little evidence of serious cardiovascular adverse events, including no serious corrected QT (QTc) abnormalities associated with stimulants, atomoxetine or α2-adrenergic receptor agonists. Although the abuse of prescription stimulant drugs, particularly, short-acting stimulants is a prevalent and growing problem, nonmedical use of prescription stimulants within the clinical context is very limited. In addition, nonstimulant ADHD medications lack any reinforcing effects and consequently any abuse potential.
Collapse
Affiliation(s)
- Jose Martinez-Raga
- Teaching Unit of Psychiatry and Clinical Psychology, University of Valencia, University Cardenal Herrera CEU and Hospital Universitario Doctor Peset, Avda. Gaspar Aguilar, 90, 46017 Valencia, Spain
| | | | - Carlos Knecht
- Mental Health Area, Hospital Padre Jofré, Valencia, Spain
| | - Raquel de Alvaro
- Hospital General de Castellón, Consorcio Hospitalario Provincial, Castellón, Spain
| | - Eloisa Carabal
- Teaching Unit of Psychiatry and Clinical Psychology, University Hospital Doctor Peset, Valencia, Spain University Cardenal Herrera CEU, Valencia, Spain
| |
Collapse
|
38
|
Li Y, Gao J, He S, Zhang Y, Wang Q. An Evaluation on the Efficacy and Safety of Treatments for Attention Deficit Hyperactivity Disorder in Children and Adolescents: a Comparison of Multiple Treatments. Mol Neurobiol 2016; 54:6655-6669. [DOI: 10.1007/s12035-016-0179-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/28/2016] [Indexed: 11/25/2022]
|
39
|
Abstract
Children/adolescents with attention-deficit/hyperactivity disorder (ADHD) may have a poor or inadequate response to psychostimulants or be unable to tolerate their side-effects; furthermore, stimulants may be inappropriate because of co-existing conditions. Only one non-stimulant ADHD pharmacotherapy, the noradrenaline transporter inhibitor atomoxetine, is currently approved for use in Europe. We review recent advances in understanding of the pathophysiology of ADHD with a focus on the roles of catecholamine receptors in context of the α2A-adrenergic receptor agonist guanfacine extended release (GXR), a new non-stimulant treatment option in Europe. Neuroimaging studies of children/adolescents with ADHD show impaired brain maturation, and structural and functional anomalies in brain regions and networks. Neurobiological studies in ADHD and medication response patterns support involvement of monoaminergic neurotransmitters (primarily dopamine and noradrenaline). Guanfacine is a selective α2A-adrenergic receptor agonist that has been shown to improve prefrontal cortical cognitive function, including working memory. The hypothesized mode of action of guanfacine centres on direct stimulation of post-synaptic α2A-adrenergic receptors to enhance noradrenaline neurotransmission. Preclinical data suggest that guanfacine also influences dendritic spine growth and maturation. Clinical trials have demonstrated the efficacy of GXR in ADHD, and it is approved as monotherapy or adjunctive therapy to stimulants in Canada and the USA (for children and adolescents). GXR was approved recently in Europe for the treatment of ADHD in children and adolescents for whom stimulants are not suitable, not tolerated or have been shown to be ineffective. GXR may provide particular benefit for children/adolescents who have specific co-morbidities such as chronic tic disorders or oppositional defiant disorder (or oppositional symptoms) that have failed to respond to first-line treatment options.
Collapse
|
40
|
Loo SK, Bilder RM, Cho AL, Sturm A, Cowen J, Walshaw P, Levitt J, Del'Homme M, Piacentini J, McGough JJ, McCracken JT. Effects of d-Methylphenidate, Guanfacine, and Their Combination on Electroencephalogram Resting State Spectral Power in Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2016; 55:674-682.e1. [PMID: 27453081 PMCID: PMC5003618 DOI: 10.1016/j.jaac.2016.04.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/25/2016] [Accepted: 05/16/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Psychostimulant medications are the gold standard of treatment for attention-deficit/hyperactivity disorder (ADHD); however, a significant minority (∼30%) of individuals with ADHD fail to respond favorably. Noradrenergic agents are increasingly used as ADHD monotherapies or adjuncts for suboptimal stimulant response, yet knowledge of their cortical effects is limited. This study is the first to examine comparative effects of guanfacine (an α adrenergic 2A agonist), psychostimulant, and their combination on resting state cortical activity in ADHD. METHOD The sample comprised 179 participants aged 7 to 14 years old with ADHD (113 boys, 55 girls). Participants were randomized to 1 of 3 blinded conditions: guanfacine (GUAN), d-methylphenidate (DMPH), or the combination (COMB). Electroencephalography (EEG) was performed pre-, mid-, and post-medication titration, with concomitant assessment of behavioral and cognitive functioning. RESULTS Analyses of spectral power measures during resting EEG suggested that each medication condition displayed a distinct profile of effects on cortical activity. Significant time effects suggested that GUAN decreased global alpha band (8-12 hertz [Hz]) power, DMPH and COMB increased centro-parietal beta band (13-21 Hz) power, and COMB resulted in decreased theta band (4-7 Hz) power. Relative to other medication groups, COMB was associated with significantly lower theta band power and DMPH with higher beta band power compared with those in the GUAN group. Medication-related changes in theta power were correlated with improvements in behavioral and cognitive functioning. CONCLUSION These data reveal distinct underlying medication-related effects on neural mechanisms. The COMB condition uniquely exhibited an EEG profile that was associated with improved behavioral and cognitive functioning. Clinical trial registration information-Single Versus Combination Medication Treatment for Children With Attention Deficit Hyperactivity Disorder; http://clinicaltrials.gov/; NCT00429273.
Collapse
Affiliation(s)
- Sandra K Loo
- University of California, Los Angeles Semel Institute, Los Angeles.
| | - Robert M Bilder
- University of California, Los Angeles Semel Institute, Los Angeles
| | - Alexander L Cho
- University of California, Los Angeles Semel Institute, Los Angeles
| | - Alexandra Sturm
- University of California, Los Angeles Semel Institute, Los Angeles
| | - Jennifer Cowen
- University of California, Los Angeles Semel Institute, Los Angeles
| | - Patricia Walshaw
- University of California, Los Angeles Semel Institute, Los Angeles
| | - Jennifer Levitt
- University of California, Los Angeles Semel Institute, Los Angeles
| | | | - John Piacentini
- University of California, Los Angeles Semel Institute, Los Angeles
| | - James J McGough
- University of California, Los Angeles Semel Institute, Los Angeles
| | | |
Collapse
|
41
|
McCracken JT, McGough JJ, Loo SK, Levitt J, Del'Homme M, Cowen J, Sturm A, Whelan F, Hellemann G, Sugar C, Bilder RM. Combined Stimulant and Guanfacine Administration in Attention-Deficit/Hyperactivity Disorder: A Controlled, Comparative Study. J Am Acad Child Adolesc Psychiatry 2016; 55:657-666.e1. [PMID: 27453079 PMCID: PMC4976782 DOI: 10.1016/j.jaac.2016.05.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 05/14/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Because models of attention-deficit/hyperactivity disorder (ADHD) therapeutics emphasize benefits of both enhanced dopaminergic and noradrenergic signaling, strategies to enhance D1 and α2A agonism may yield enhanced clinical and cognitive responses. This study tested the hypothesis that combined effects of a dopamine and noradrenergic agonist, d-methylphenidate extended-release (DMPH) with guanfacine (GUAN), an α2A receptor agonist, would be clinically superior to either monotherapy and would have equal tolerability. METHOD An 8-week, double-blind, 3-arm, comparative trial randomized 7- to 14-year-olds with DSM-IV ADHD to GUAN (1-3 mg/day), DMPH (5-20 mg/day), or a combination (COMB) with fixed-flexible dosing. Outcome measures were the ADHD Rating Scale IV (ADHD-RS-IV) and the Clinical Global Impression-Improvement (CGI-I) scale. Data on adverse events and safety measures were obtained. RESULTS A total of 207 participants were randomized and received drug. Analyses showed significant treatment group main effects for ADHD-RS-IV ADHD total (p = .0001) and inattentive symptoms (p = .0001). COMB demonstrated small but consistently greater reductions in ADHD-RS-IV Inattentive subscale scores versus monotherapies (DMPH: p = .05; f(2) = .02; and GUAN: p = .02; f(2) = .02), and was associated with a greater positive response rate by CGI-I (p = .01). No serious cardiovascular events occurred. Sedation, somnolence, lethargy, and fatigue were greater in both guanfacine groups. All treatments were well tolerated. CONCLUSION COMB showed consistent evidence of clinical benefits over monotherapies, possibly reflecting advantages of greater combined dopaminergic and α2A agonism. Adverse events were generally mild to moderate, and COMB treatment showed no differences in safety or tolerability. CLINICAL TRIAL REGISTRATION INFORMATION Single Versus Combination Medication Treatment for Children With Attention Deficit Hyperactivity Disorder (Project1); http://clinicaltrials.gov/; NCT00429273.
Collapse
Affiliation(s)
- James T. McCracken
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA
| | - James J. McGough
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA
| | - Sandra K. Loo
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA
| | - Jennifer Levitt
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA
| | - Melissa Del'Homme
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA
| | - Jennifer Cowen
- Semel Institute for Neuroscience and Human Behavior at UCLA
| | | | - Fiona Whelan
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA
| | - Gerhard Hellemann
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA
| | - Catherine Sugar
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA.,UCLA School of Public Health
| | - Robert M. Bilder
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA.,UCLA College of Letters and Science
| |
Collapse
|
42
|
Sleep Problems in Children with Attention Deficit/Hyperactivity Disorder: Current Status of Knowledge and Appropriate Management. Curr Psychiatry Rep 2016; 18:76. [PMID: 27357497 DOI: 10.1007/s11920-016-0711-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Attention deficit hyperactivity disorder (ADHD) affects approximately 5 % of children and adolescents, and sleep problems are common in these patients. There is growing evidence informing the significant importance of sleep problems in youth with ADHD. The sleep problems in children with ADHD include specific sleep disorders and sleep disturbances due to comorbid psychiatric disorders or ADHD medications. The specific sleep disorders of ADHD children include behaviorally based insomnia, sleep-disordered breathing, and restless legs syndrome/periodic limb movement disorder. Current practices on the management of sleep problems for ADHD children are based mostly on expert consensus, whereas more evidence-based literature can be found only recently. Assessment of the sleep conditions in ADHD children before initiation of pharmacotherapy is the currently recommended guideline, and good sleep hygiene can be considered as the first-line treatment option. In addition to modifying the dose regimens, formulation, or alternative stimulants when sleep problems are encountered in ADHD children, atomoxetine, once daily guanfacine extended release, and melatonin are potential choices for ADHD children with more severe sleep problems. In this review, we aimed to provide the most updated information, preferably based on meta-analyses, systemic review, and randomized controlled trials published in the latest 3 years, in order to be clinically useful for practitioners and clinicians.
Collapse
|
43
|
Bilder RM, Loo S, McGough JJ, Whelan F, Hellemann G, Sugar C, Del’Homme M, Sturm A, Cowen J, Hanada G, McCracken JT. Cognitive Effects of Stimulant, Guanfacine, and Combined Treatment in Child and Adolescent Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2016; 55:667-73. [PMID: 27453080 PMCID: PMC4964604 DOI: 10.1016/j.jaac.2016.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 05/03/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Psychostimulants are partially effective in reducing cognitive dysfunction associated with attention-deficit/hyperactivity disorder (ADHD). Cognitive effects of guanfacine, an alternative treatment, are poorly understood. Given its distinct action on α2A receptors, guanfacine may have different or complementary effects relative to stimulants. This study tested stimulant and guanfacine monotherapies relative to combined treatment on cognitive functions important in ADHD. METHOD Children with ADHD (n = 182; aged 7-14 years) completed an 8-week, double blind, randomized, controlled trial with 3 arms: d-methylphenidate (DMPH), guanfacine (GUAN), or combination treatment with DMPH and GUAN (COMB). A nonclinical comparison group (n = 93) had baseline testing, and a subset was retested 8 weeks later (n = 38). Analyses examined treatment effects in 4 cognitive domains (working memory, response inhibition, reaction time, and reaction time variability) constructed from 20 variables. RESULTS The ADHD group showed impaired working memory relative to the nonclinical comparison group (effect size = -0.53 SD unit). The treatments differed in effects on working memory but not other cognitive domains. Combination treatment improved working memory more than GUAN but was not significantly better than DMPH alone. Treatment did not fully normalize the initial deficit in ADHD relative to the comparison group. CONCLUSION Combined treatment with DMPH and GUAN yielded greater improvements in working memory than placebo or GUAN alone, but the combined treatment was not superior to DMPH alone and did not extend to other cognitive domains. Although GUAN may be a useful add-on treatment to psychostimulants, additional strategies appear to be necessary to achieve normalization of cognitive function in ADHD. CLINICAL TRIAL REGISTRATION INFORMATION Single Versus Combination Medication Treatment for Children With Attention Deficit Hyperactivity Disorder; http://clinicaltrials.gov/; NCT00429273.
Collapse
|
44
|
Hong SS, Cho SH. Treating attention deficit hyperactivity disorder with acupuncture: A randomized controlled trial. Eur J Integr Med 2016. [DOI: 10.1016/j.eujim.2015.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
45
|
Abstract
Prolonged-action ▼guanfacine (Intuniv-Shire Pharmaceuticals Ltd) is a non-stimulant drug that has recently been licensed in Europe for the management of attention deficit hyperactivity disorder (ADHD) in children and adolescents aged 6-17 years for whom stimulants are unsuitable.(1) The company suggests that it has a unique mechanism of action in ADHD, providing improvement in core symptoms within 3 weeks with once-daily flexible dosing.(2) Here we review the evidence on the efficacy and safety of guanfacine in ADHD and consider whether it offers any advantages over other therapeutic options.
Collapse
|
46
|
Gurnani T, Ivanov I, Newcorn JH. Pharmacotherapy of Aggression in Child and Adolescent Psychiatric Disorders. J Child Adolesc Psychopharmacol 2016; 26:65-73. [PMID: 26881859 DOI: 10.1089/cap.2015.0167] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Aggression is a common, yet complex, behavioral complaint, and a frequent indication for referral to child and adolescent psychiatrist treatment. This article reviews the evidence supporting pharmacotherapy of aggression in youth, with a primary focus on impulsive aggression (the primary indication for this intervention). Relevant diagnostic considerations and consensus guidelines are discussed. METHODS Articles examining the role of medications in the treatment of aggression in youth with pathological aggression were identified using PubMed and MEDLINE® databases over the past 15 years (2000-2015); selected articles published prior to 2000 and deemed to be of high relevance were searched and also included. Search terms included: Aggression, aggressive, disruptive behavior, conduct, youth, children, and adolescents. Cited references were also searched for relevant articles. RESULTS There are a number of evidence-based medication treatments for aggression, which are generally best considered in the context of differential diagnosis and ongoing evidence-based psychosocial interventions. Impulsive aggression is generally considered the type of aggression most amenable to medication, but other aggression subtypes may also possibly respond to treatment. Medication classes with positive evidence include the psychostimulants and α-2 agonists (in the presence of attention-deficit/hyperactivity disorder [ADHD] and/or disruptive behavior disorders), mood stabilizing agents, and atypical antipsychotics. Published guidelines recommend systematic and adequate trials of medications in sequential order, to optimize response and minimize polypharmacy. Guidelines for safety monitoring are available for many of the medications used for aggression in youth, and are also discussed. CONCLUSIONS Aggression in children carries a high risk of poor outcomes, and, therefore, a better understanding of treatment options is a high priority. The available literature points to the importance of identifying the underlying disorder, when possible, and using this information to guide treatment selection. Future studies are needed to better inform the treatment of aggression across disorders, and the treatment of different aggression subtypes.
Collapse
Affiliation(s)
- Tina Gurnani
- 1 Department of Psychiatry, Mount Sinai-St. Luke's Hospital Center , New York, New York
| | - Iliyan Ivanov
- 1 Department of Psychiatry, Mount Sinai-St. Luke's Hospital Center , New York, New York.,2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Jeffrey H Newcorn
- 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, New York
| |
Collapse
|
47
|
Lachaine J, Sikirica V, Mathurin K. Is adjunctive pharmacotherapy in attention-deficit/hyperactivity disorder cost-effective in Canada: a cost-effectiveness assessment of guanfacine extended-release as an adjunctive therapy to a long-acting stimulant for the treatment of ADHD. BMC Psychiatry 2016; 16:11. [PMID: 26774811 PMCID: PMC4715876 DOI: 10.1186/s12888-016-0708-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 01/05/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder in children, with worldwide prevalence of ADHD varying from 5.9 to 7.1 %, depending on the reporter. In case of inadequate response to stimulants, combination therapy of stimulants and an adjunctive medication may improve the control of ADHD symptoms, reduce the dose-limiting adverse events, and help control comorbidities. To date, the only medication to be used for adjunctive therapy to psychostimulants is guanfacine extended release (GXR). The aim of this study was to assess the economic impact of GXR as an adjunct therapy with long-acting stimulants (GXR + stimulant) compared to long-acting stimulant monotherapy (stimulant alone) in the treatment of children and adolescents with ADHD in Canada. METHOD A Markov model was developed using health states defined based on the clinician-reported Clinical Global Impression-Severity (CGI-S) score (normal, mild, moderate, severe). Transition probabilities were calculated based on patient-level data from a published study. Long-acting stimulants available in Canada were considered in the base-case model: amphetamine mixed salts, methylphenidate HCl formulations, and lisdexamfetamine dimesylate. Analyses were conducted from a Canadian Ministry of Health (MoH; Ontario) and a societal perspective over a 1-year time horizon with weekly cycles. RESULTS Over a 1-year time horizon, GXR + stimulant was associated with 0.655 quality-adjusted life year (QALY), compared to 0.627 QALY with stimulant alone, for a gain of 0.028 QALY. From a MoH perspective, GXR+ stimulant and stimulant alone were associated with total costs of $CA1,617 and $CA949, respectively (difference of $CA668), which resulted in an incremental cost-effectiveness ratio (ICER) of $CA23,720/QALY. From a societal perspective, GXR + stimulant and stimulant alone were associated with total costs of $CA3,915 and $CA3,582, respectively (difference of $CA334), which resulted in an ICER of $CA11,845/QALY. Probabilistic sensitivity analysis (PSA) of GXR + stimulant showed that it remains a cost-effective strategy in 100 % of the simulations from both perspectives in numerous PSA and one-way sensitivity analyses, relative to a willingness to pay threshold of $50,000/QALY. CONCLUSIONS This economic evaluation demonstrates that GXR + stimulant is cost-effective compared to stimulant alone in the treatment of children and adolescents with ADHD in Canada.
Collapse
Affiliation(s)
- Jean Lachaine
- Faculty of Pharmacy, University of Montreal, P.O. Box 6128, Station Centre-ville, Montreal, Quebec, H3C 3J7, Canada.
| | - Vanja Sikirica
- Shire, 725 Chesterbrook Boulevard, Wayne, PA, 19087, USA.
| | - Karine Mathurin
- Faculty of Pharmacy, University of Montreal, P.O. Box 6128, Station Centre-ville, Montreal, Quebec, H3C 3J7, Canada.
| |
Collapse
|
48
|
Huss M, Sikirica V, Hervas A, Newcorn JH, Harpin V, Robertson B. Guanfacine extended release for children and adolescents with attention-deficit/hyperactivity disorder: efficacy following prior methylphenidate treatment. Neuropsychiatr Dis Treat 2016; 112:1085-101. [PMID: 27226715 PMCID: PMC4863687 DOI: 10.2147/ndt.s94158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Guanfacine extended release (GXR) and atomoxetine (ATX) are nonstimulant treatments for attention-deficit/hyperactivity disorder (ADHD). As nonstimulant treatments are often used after stimulants in ADHD, GXR was assessed relative to prior stimulant treatment in a randomized controlled trial (RCT), in which ATX was included as a reference arm, and in the open-label phase of a randomized-withdrawal study (RWS). Participants were 6-17 years old with ADHD Rating Scale version IV (ADHD-RS-IV) scores ≥32 and Clinical Global Impressions - Severity scores ≥4. RCT participants received dose-optimized GXR (1-7 mg/day), ATX (10-100 mg/day), or placebo for 10-13 weeks. RWS participants received dose-optimized GXR (1-7 mg/day) for 13 weeks. Participants' last stimulant medication prior to enrolment, and reasons for stopping this medication, were collected at baseline. Change from baseline ADHD-RS-IV score and the proportion of responders were assessed by prior stimulant exposure. Of 163 RCT and 296 RWS participants who had previously received stimulant treatment, 142 and 224, respectively, had received methylphenidate (MPH); due to the low number of participants and the heterogeneity of non-MPH treatments, we only report data for prior MPH treatment. The most frequent reasons for stopping MPH were lack of effectiveness or side effects. Placebo-adjusted ADHD-RS-IV changes from baseline were significant in participants receiving GXR (prior MPH, -9.8, P<0.001, effect size [ES] 0.85; stimulant-naïve, -7.6, P<0.001, ES 0.65). In ATX-treated participants, significant placebo-adjusted differences were seen in stimulant-naïve (-5.0, P=0.022, ES 0.43) but not prior MPH-treated (-1.8, P>0.05, ES 0.15) participants. More participants met responder criteria with GXR versus placebo, regardless of prior treatment. GXR response was unaffected by prior stimulant treatment; ATX produced improvement only in stimulant-naïve participants relative to placebo. These findings may be relevant to clinical decision-making regarding sequencing of ADHD treatments.
Collapse
Affiliation(s)
- Michael Huss
- Child and Adolescent Psychiatry, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Vanja Sikirica
- Global Health Economics, Outcomes Research and Epidemiology, Shire, Wayne, PA, USA
| | - Amaia Hervas
- Child and Adolescent Mental Health Unit, University Hospital Mútua de Terressa, Barcelona, Spain; Developmental Disorders Unit (UETD), Hospital San Juan de Dios, Barcelona, Spain
| | - Jeffrey H Newcorn
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Valerie Harpin
- Ryegate Children's Centre, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | | |
Collapse
|
49
|
Gajria K, Kosinski M, Sikirica V, Huss M, Livote E, Reilly K, Dittmann RW, Erder MH. Psychometric validation of the Weiss Functional Impairment Rating Scale-Parent Report Form in children and adolescents with attention-deficit/hyperactivity disorder. Health Qual Life Outcomes 2015; 13:184. [PMID: 26577642 PMCID: PMC4650258 DOI: 10.1186/s12955-015-0379-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 11/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Measurement properties of the Weiss Functional Impairment Rating Scale-Parent Report Form (WFIRS-P), which assesses attention-deficit/hyperactivity disorder (ADHD)-related functional impairment in children/adolescents (6-17 years), were examined. METHODS Data from seven randomized, controlled trials were pooled. Analyses were conducted in two random half-samples. WFIRS-P conceptual framework was evaluated using confirmatory factor analyses (CFA). Reliability was estimated using internal consistency (Cronbach's alpha) and test-retest reliability methods. Convergent validity was assessed using correlations between WFIRS-P domain scores and the ADHD-RS-IV and Clinical Global Impression-Severity (CGI-S) scales. Responsiveness was tested by comparing mean changes in WFIRS-P domain scores between responders and non-responders based on clinical criteria. RESULTS CFA adequately confirmed the item-to-scale relationships defined in the WFIRS-P conceptual framework. Cronbach's alpha coefficient exceeded 0.7 for all domains and test-retest reliability exceeded 0.7 for all but Risky Activities. With few exceptions, WFIRS-P domains correlated significantly (p < 0.05) with ADHD-RS-IV Total, Inattention and Hyperactivity-Impulsivity scores and CGI-S at baseline and follow-up in both random half-samples. Mean changes in WFIRS-P domain scores differed significantly between responder and non-responder groups in the expected direction (p < 0.001). CONCLUSIONS Study results support the reliability, validity and responsiveness of the WFIRS-P. Findings were replicated between two random samples, further demonstrating the robustness of results.
Collapse
Affiliation(s)
- Kavita Gajria
- Shire, 725 Chesterbrook Boulevard, Wayne, PA, 19087, USA.
| | - Mark Kosinski
- QualityMetric Incorporated, 24 Albion Road, Building 400, Lincoln, RI, 02865, USA.
| | - Vanja Sikirica
- Shire, 725 Chesterbrook Boulevard, Wayne, PA, 19087, USA.
| | - Michael Huss
- Klinik für Kinder- und Jugendpsychiatrie und -psychotherapie, Universitätsmedizin der Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Elayne Livote
- QualityMetric Incorporated, 24 Albion Road, Building 400, Lincoln, RI, 02865, USA.
| | - Kathleen Reilly
- QualityMetric Incorporated, 24 Albion Road, Building 400, Lincoln, RI, 02865, USA.
| | - Ralf W Dittmann
- Paediatric Psychopharmacology, Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, D-68072, Mannheim, Germany.
| | - M Haim Erder
- Shire, 725 Chesterbrook Boulevard, Wayne, PA, 19087, USA.
| |
Collapse
|
50
|
Pillidge K, Porter AJ, Dudley JA, Tsai YC, Heal DJ, Stanford SC. The behavioural response of mice lacking NK₁ receptors to guanfacine resembles its clinical profile in treatment of ADHD. Br J Pharmacol 2015; 171:4785-96. [PMID: 25074741 PMCID: PMC4209942 DOI: 10.1111/bph.12860] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 07/16/2014] [Accepted: 07/23/2014] [Indexed: 01/15/2023] Open
Abstract
Background and Purpose Mice with functional ablation of substance P-preferring neurokinin-1 receptors (NK1R−/− mice) display behavioural abnormalities resembling those in attention deficit hyperactivity disorder (ADHD). Here, we investigated whether the ADHD treatment, guanfacine, alleviated the hyperactivity and impulsivity/inattention displayed by NK1R−/− mice in the light/dark exploration box (LDEB) and 5-choice serial reaction–time task (5-CSRTT), respectively. Following reports of co-morbid anxiety in ADHD, we also investigated effects of guanfacine on anxiety-like behaviour displayed by NK1R−/− and wild-type (WT) mice in the elevated plus maze (EPM). Experimental Approach Mice were treated with guanfacine (0.1, 0.3 or 1.0 mg·kg−1, i.p.), vehicle or no injection and tested in the 5-CSRTT or the LDEB. Only the lowest dose of guanfacine was used in the EPM assays. Key Results In the 5-CSRTT, a low dose of guanfacine (0.1 mg·kg−1) increased attention in NK1R−/− mice, but not in WT mice. This dose did not affect the total number of trials completed, latencies to respond or locomotor activity in the LDEB. Impulsivity was decreased by the high dose (1.0 mg·kg−1) of guanfacine, but this was evident in both genotypes and is likely to be secondary to a generalized blunting of behaviour. Although the NK1R−/− mice displayed marked anxiety-like behaviour, guanfacine did not affect the behaviour of either genotype in the EPM. Conclusions and Implications This evidence that guanfacine improves attention at a dose that did not affect arousal or emotionality supports our proposal that NK1R−/− mice express an attention deficit resembling that of ADHD patients. Linked Articles This article is part of a themed section on Animal Models in Psychiatry Research. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2014.171.issue-20
Collapse
Affiliation(s)
- Katharine Pillidge
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | | | | | | | | | | |
Collapse
|