An interim analysis of the Quality of Life, Effectiveness, Safety, and Tolerability (QU.E.S.T.) evaluation of mixed amphetamine salts extended release in adults with ADHD

A review of amphetamine extended release once-daily options for the management of attention-deficit hyperactivity disorder

INTRODUCTION

Amphetamine preparations are one of the two categories of stimulant medications approved for the treatment of attention deficit hyperactivity disorder (ADHD). Optimal treatment of ADHD aims to reduce core symptoms for as much of the waking hours as possible, leading to longer-acting delivery formats. In addition, the pediatric population commonly has difficulty swallowing pills and manufacturers have developed a variety of options to facilitate this concern. These include chewable tablets, capsules that may be sprinkled on soft food, liquids and transdermal patches.

AREAS COVERED

This article reviews the once-daily extended-release preparations currently available for amphetamine compounds, their pharmacodynamics, and common adverse effects.

EXPERT OPINION

There is an extensive evidence base supporting use of amphetamine preparations in the treatment of ADHD. Rapid onset of action and a favorable side effect profile make these widely used. The availability of once-daily extended-release chewable tablets, capsules that can be opened and sprinkled, and liquid formulations provides clinicians with multiple options to meet the specific needs of patients with difficulty swallowing whole pills.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.

Effects of chronic methamphetamine exposure on rewarding behavior and neurodegeneration markers in adult mice

Recreational and medical use of stimulants among young adults have gained popularity in the United States over the last decade and their use may increase vulnerability to brain biochemical changes and addictive behaviors. The long-term effects of chronic stimulant exposure in later adulthood have not been fully elucidated.Our study investigated whether chronic exposure to methamphetamine (METH), at a dose designed to emulate human therapeutic dosing for ADHD, would promote biochemical alterations and affect sensitivity to the rewarding effects of subsequent METH dosing.Groups of 3.5-month-old male and female C57BL/6J mice were administered non-contingent intraperitoneal injections of either saline or METH (1.4 mg/kg) twice a day for 1 month (5 days/week). METH (0.5 mg/kg)-induced conditioned place preference (CPP) was tested in mice to determine the effects of previous METH exposure on reward-related behavior. Mice were randomly assigned to Experiment I (males and females) or Experiment II (females only) in which CPP testing was respectively performed either 0.5 or 5 months after the end of METH injections, at ~5 or 10 months old respectively. The midbrain and striatum, regions involved in reward circuit, were assessed for markers associated with neurotoxicity, dopaminergic function, neuroinflammation and epigenetic changes after behavioral testing.Previous exposure to chronic METH did not have significant short-term effects on CPP response but led to a decreased CPP response in 10-month-old females. Previous exposure to METH induced some short-term changes to biochemical markers measured in a brain region and sex-dependent manner, while long-term changes were only observed with GFAP and KDM5C.In conclusion, our data suggest sex- and post-exposure duration-dependent outcomes and warrant further exploration of the long-term neurobehavioral consequences of psychostimulant use in both sexes.

Sex differences in neurobehavioral consequences of methamphetamine exposure in adult mice

RATIONALE

Recreational and medical use of stimulants is increasing, and their use may increase susceptibility to aging and promote neurobehavioral impairments. The long-term consequences of these psychostimulants and how they interact with age have not been fully studied.

OBJECTIVES

Our study investigated whether chronic exposure to the prototypical psychostimulant, methamphetamine (METH), at doses designed to emulate human therapeutic dosing, would confer a pro-oxidizing redox shift promoting long-lasting neurobehavioral impairments.

METHODS

Groups of 4-month-old male and female C57BL/6 J mice were administered non-contingent intraperitoneal injections of either saline or METH (1.4 mg/kg) twice a day for 4 weeks. Mice were randomly assigned to one experimental group: (i) short-term cognitive assessments (at 5 months), (ii) long-term cognitive assessments (at 9.5 months), and (ii) longitudinal motor assessments (at 5, 7, and 9 months). Brain regions were assessed for oxidative stress and markers of neurotoxicity after behavior testing.

RESULTS

Chronic METH exposure induced short-term effects on associative memory, gait speed, dopamine (DA) signaling, astrogliosis in females, and spatial learning and memory, balance, DA signaling, and excitotoxicity in males. There were no long-term effects of chronic METH on cognition; however, it decreased markers of excitotoxicity in the striatum and exacerbated age-associated motor impairments in males.

CONCLUSION

In conclusion, cognitive and motor functions were differentially and sex-dependently affected by METH exposure, and oxidative stress did not seem to play a role in the observed behavioral outcomes. Future studies are necessary to continue exploring the long-term neurobehavioral consequences of drug use in both sexes and the relationship between aging and drugs.

Factors associated with paternal perinatal depression in fathers of newborns in Nigeria

INTRODUCTION

There is a lack of information on paternal postnatal depression in developing countries such as Nigeria.

METHODS

This study aims to assess the prevalence of depression in fathers at the birth of their infants and the incidence of paternal postnatal depression at 6 weeks postpartum. We also examined the correlation between paternal postpartum depression (PPD) at 6 weeks and maternal PPD as well as the sociodemographic and other correlates of paternal PPD at 6 weeks.

RESULTS

All the 331 fathers recruited at baseline completed the study. Prevalence of depression in fathers at birth of their babies was 10 (3%). After excluding the 3%, the incidence of PPD in fathers (N = 321) at 6 weeks was 19 (5.9%). In all, 29 (8.8%) fathers had PPD. The prevalence of depression in mothers at 6 weeks postpartum was 57 (17.8%). The prevalence of depression in mothers at 6 weeks was significantly higher than the incidence of depression in fathers at 6 weeks (X² = 26.2, p < .001). There was no significant correlation between maternal PPD and paternal PPD. At baseline, prevalence of PPD among the unemployed fathers was higher than in the employed, 3 (21.4%) versus 7 (2.2%), this was significant (FE p < .01). There was no significant correlate of paternal PPD at 6 weeks.

DISCUSSION

Postpartum mental health services should be extended to fathers of newborns especially those who are unemployed. Our findings have implications for family health.

Amphetamines for attention deficit hyperactivity disorder (ADHD) in adults

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a childhood-onset disorder characterised by inattention, hyperactivity, and impulsivity. ADHD can persist into adulthood and can affects individuals' social and occupational functioning, as well as their quality of life and health. ADHD is frequently associated with other mental disorders such as substance use disorders and anxiety and affective disorders. Amphetamines are used to treat adults with ADHD, but uncertainties about their efficacy and safety remain.

OBJECTIVES

To examine the efficacy and safety of amphetamines for adults with ADHD.

SEARCH METHODS

In August 2017, we searched CENTRAL, MEDLINE, Embase, PsycINFO, 10 other databases, and two trials registers, and we ran citation searches for included studies. We also contacted the corresponding authors of all included studies, other experts in the field, and the pharmaceutical company, Shire, and we searched the reference lists of retrieved studies and reviews for other published, unpublished, or ongoing studies. For each included study, we performed a citation search in Web of Science to identify any later studies that may have cited it.

SELECTION CRITERIA

We searched for randomised controlled trials comparing the efficacy of amphetamines (at any dose) for ADHD in adults aged 18 years and over against placebo or an active intervention.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data from each included study. We used the standardised mean difference (SMD) and the risk ratio (RR) to assess continuous and dichotomous outcomes, respectively. We conducted a stratified analysis to determine the influence of moderating variables. We assessed trials for risk of bias and drew a funnel plot to investigate the possibility of publication bias. We rated the quality of the evidence using the GRADE approach, which yielded high, moderate, low, or very low quality ratings based on evaluation of within-trial risk of bias, directness of evidence, heterogeneity of data; precision of effect estimates, and risk of publication bias.

MAIN RESULTS

We included 19 studies that investigated three types of amphetamines: dexamphetamine (10.2 mg/d to 21.8 mg/d), lisdexamfetamine (30 mg/d to 70 mg/d), and mixed amphetamine salts (MAS; 12.5 mg/d to 80 mg/d). These studies enrolled 2521 participants; most were middle-aged (35.3 years), Caucasian males (57.2%), with a combined type of ADHD (78.8%). Eighteen studies were conducted in the USA, and one study was conducted in both Canada and the USA. Ten were multi-site studies. All studies were placebo-controlled, and three also included an active comparator: guanfacine, modafinil, or paroxetine. Most studies had short-term follow-up and a mean study length of 5.3 weeks.We found no studies that had low risk of bias in all domains of the Cochrane 'Risk of bias' tool, mainly because amphetamines have powerful subjective effects that may reveal the assigned treatment, but also because we noted attrition bias, and because we could not rule out the possibility of a carry-over effect in studies that used a cross-over design.Sixteen studies were funded by the pharmaceutical industry, one study was publicly funded, and two studies did not report their funding sources.Amphetamines versus placeboSeverity of ADHD symptoms: we found low- to very low-quality evidence suggesting that amphetamines reduced the severity of ADHD symptoms as rated by clinicians (SMD -0.90, 95% confidence interval (CI) -1.04 to -0.75; 13 studies, 2028 participants) and patients (SMD -0.51, 95% CI -0.75 to -0.28; six studies, 120 participants).Retention: overall, we found low-quality evidence suggesting that amphetamines did not improve retention in treatment (risk ratio (RR) 1.06, 95% CI 0.99 to 1.13; 17 studies, 2323 participants).Adverse events: we found that amphetamines were associated with an increased proportion of patients who withdrew because of adverse events (RR 2.69, 95% CI 1.63 to 4.45; 17 studies, 2409 participants).Type of amphetamine: we found differences between amphetamines for the severity of ADHD symptoms as rated by clinicians. Both lisdexamfetamine (SMD -1.06, 95% CI -1.26 to -0.85; seven studies, 896 participants; low-quality evidence) and MAS (SMD -0.80, 95% CI -0.93 to -0.66; five studies, 1083 participants; low-quality evidence) reduced the severity of ADHD symptoms. In contrast, we found no evidence to suggest that dexamphetamine reduced the severity of ADHD symptoms (SMD -0.24, 95% CI -0.80 to 0.32; one study, 49 participants; very low-quality evidence). In addition, all amphetamines were efficacious in reducing the severity of ADHD symptoms as rated by patients (dexamphetamine: SMD -0.77, 95% CI -1.14 to -0.40; two studies, 35 participants; low-quality evidence; lisdexamfetamine: SMD -0.33, 95% CI -0.65 to -0.01; three studies, 67 participants; low-quality evidence; MAS: SMD -0.45, 95% CI -1.02 to 0.12; one study, 18 participants; very low-quality evidence).Dose at study completion: different doses of amphetamines did not appear to be associated with differences in efficacy.Type of drug-release formulation: we investigated immediate- and sustained-release formulations but found no differences between them for any outcome.Amphetamines versus other drugsWe found no evidence that amphetamines improved ADHD symptom severity compared to other drug interventions.

AUTHORS' CONCLUSIONS

Amphetamines improved the severity of ADHD symptoms, as assessed by clinicians or patients, in the short term but did not improve retention to treatment. Amphetamines were associated with higher attrition due to adverse events. The short duration of studies coupled with their restrictive inclusion criteria limits the external validity of these findings. Furthermore, none of the included studies had an overall low risk of bias. Overall, the evidence generated by this review is of low or very low quality.

Toward quality care in ADHD: defining the goals of treatment

OBJECTIVE

Therapeutic goals for chronic mental disorders like major depressive disorder (MDD) and schizophrenia have evolved in parallel with the growing medical knowledge about the course and treatment of these disorders. Although the knowledge base regarding the clinical course of ADHD, a chronic psychiatric disorder, has evolved beyond symptomatic improvement and short-term treatment response, long-term goals, such as functional remission, have not yet been clearly defined.

METHOD

A PubMed literature search was conducted to investigate the therapeutic goals of pharmacologic treatment referenced in the published literature from January 1998 through February 2010 using the following commonly used ADHD treatments as keywords: amphetamine, methylphenidate, atomoxetine, lisdexamfetamine, guanfacine, and clonidine. This search was then combined with an additional search that included the following outcome keywords: remission, relapse, remit, response, normal, normalization, recovery, and effectiveness.

RESULTS

Our search identified 102 publications. The majority (88.2% [90/102]) of these contained predefined criteria for treatment response. Predefined criteria for normalization and remission and/or relapse were presented in 4.9% (5/102), 12.7% (13/102), and 3.9% (4/102) of publications, respectively. There was a lack of consistency between the instruments used to measure outcomes as well as the criteria used to define treatment response, normalization, and remission as well as relapse.

CONCLUSION

The therapeutic goals in treating ADHD should address optimal treatment outcomes that go beyond modest reductions of ADHD symptoms to include syndromatic, symptomatic, and functional remission. Future work should focus on reliable and valid tools to measure these outcomes in the clinical trial setting.

A multicenter, open-label trial to evaluate the quality of life in adults with ADHD treated with long-acting methylphenidate (OROS MPH): Concerta Quality of Life (CONQoL) study

The available literature provides few studies on the effectiveness of methylphenidate in improving quality of life in individuals with ADHD.

OBJECTIVE

To assess the effectiveness of methylphenidate OROS formulation (OROS MPH) through QoL in adults with ADHD.

METHOD

A 12-week, multicenter, open-label trial involving 60 patients was used. The measures used were Adult Self-Rating Scale, Adult ADHD Quality of Life Scale (AAQoL), State and Trait Anxiety Inventory (STAI), Hamilton Depression Rating Scale (HAM-D), Clinical Global Impression (CGI), and safety measures. A significance statistic level of 5% was adopted.

RESULTS

Analyses included 60 patients (66.7% male; M age = 31.1 years) for safety and 58 patients for effectiveness. All AAQoL subscales improved from baseline to Week 12 (p < .0001), as well as the Total AAQoL (p < .0001). A significant reduction on Clinical Global Impression-Improvement (CGI-I), HAM-D, STAI, and ASRS scores was observed (p < .0001). No serious adverse event was reported.

CONCLUSION

Treatment of adult ADHD patients with OROS MPH improves QoL.

Amphetamine, past and present--a pharmacological and clinical perspective

Amphetamine was discovered over 100 years ago. Since then, it has transformed from a drug that was freely available without prescription as a panacea for a broad range of disorders into a highly restricted Controlled Drug with therapeutic applications restricted to attention deficit hyperactivity disorder (ADHD) and narcolepsy. This review describes the relationship between chemical structure and pharmacology of amphetamine and its congeners. Amphetamine's diverse pharmacological actions translate not only into therapeutic efficacy, but also into the production of adverse events and liability for recreational abuse. Accordingly, the balance of benefit/risk is the key challenge for its clinical use. The review charts advances in pharmaceutical development from the introduction of once-daily formulations of amphetamine through to lisdexamfetamine, which is the first d-amphetamine prodrug approved for the management of ADHD in children, adolescents and adults. The unusual metabolic route for lisdexamfetamine to deliver d-amphetamine makes an important contribution to its pharmacology. How lisdexamfetamine's distinctive pharmacokinetic/pharmacodynamic profile translates into sustained efficacy as a treatment for ADHD and its reduced potential for recreational abuse is also discussed.

Do stimulants improve functioning in adults with ADHD? A review of the literature

ADHD is prevalent in adulthood and stimulant pharmacotherapy is the primary treatment for uncomplicated presentations. ADHD is associated with significant functional impairment in major life roles. Measurement of the efficacy of stimulant treatment for adult ADHD therefore should include assessment of improvement in role function. A literature search was conducted to identify studies that measured change in function with stimulant treatment in adult ADHD using measures other than global clinical impression or global assessment of function ratings. Five studies were identified that met our search criteria. Evidence of functional improvement with stimulant treatment was found with the following validated self-report measures of functional wellbeing employed across these studies: the Medical Outcome Study 36-item Short Form Health Survey; ADHD Impact Module for Adults; Quality of Life Enjoyment and Satisfaction scale-Short Form; Sheehan Disability Scale, and Social Adjustment Scale-Self-Report. We conclude that investigations using self-report scales provide evidence that stimulant treatment translates into measurable improvement in daily function for adults with ADHD. Further investigation could better characterize the mediators and moderators of individual improvement, an important step towards the personalization of treatment for ADHD in adulthood.

Sustained treatment effect in attention-deficit/hyperactivity disorder: focus on long-term placebo-controlled randomized maintenance withdrawal and open-label studies

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that often persists throughout life. Approximately two-thirds of patients with a childhood diagnosis of ADHD continue to experience clinically significant symptoms into adulthood. Nevertheless, most of these individuals consider themselves “well,” and a vast majority discontinue medication treatment during adolescence. As evidence concerning the adult presentation of ADHD becomes more widely accepted, increasing numbers of physicians and patients will face decisions about the benefits and risks of continuing ADHD treatment. The risks associated with psychostimulant pharmacotherapy, including abuse, dependence, and cardiovascular events, are well understood. Multiple clinical trials demonstrate the efficacy of psychostimulants in controlling ADHD symptoms in the short term. Recent investigations using randomized withdrawal designs now provide evidence of a clinically significant benefit with continued long-term ADHD pharmacotherapy and provide insight into the negative consequences associated with discontinuation. Because many patients lack insight regarding their ADHD symptoms and impairments, they may place a low value on maintaining treatment. Nevertheless, for patients who choose to discontinue treatment, physicians can remain a source of support and schedule follow-up appointments to reassess patient status. Medication discontinuation can be used as an opportunity to help patients recognize their most impairing symptoms, learn and implement behavioral strategies to cope with ADHD symptoms, and understand when additional supportive resources and the resumption of medication management may be necessary.

Evidence for a general factor model of ADHD in adults

OBJECTIVE

To examine factor structures of Diagnostic and Statistical Manual of Mental Disorders (4th ed.) symptoms of ADHD in adults.

METHOD

Two sets of models were tested: (a) models with inattention and hyperactivity/impulsivity as separate but correlated latent constructs and (b) hierarchical general factor models with a general factor for all symptoms and separate specific factors for inattention and hyperactivity/impulsivity. Participants were 751 adults with ADHD. Two models with correlated factors and two general factor models of ADHD symptoms were tested.

RESULTS

The general factor model provided a better fit of the data than the correlated models. The general factor model with one general and three (inattention, motoric, and verbal hyperactivity/impulsivity) specific factors best accounted for the adults' symptoms.

CONCLUSION

These results suggest a unitary component to ADHD symptoms as well as dimensional specific factors. The replication of a general factor in adults suggests continuity of symptom presentation from childhood into adulthood. Clinical implications are discussed.

Cost effectiveness of pharmacotherapies for attention-deficit hyperactivity disorder: a systematic literature review

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder that impairs the quality of life for patients and their families and is associated with considerable direct and indirect costs. Pharmacotherapies for ADHD, including stimulants and non-stimulants, are often used to treat patients with ADHD. However, the costs, effectiveness and adverse effects of these agents vary. Therefore, information regarding the cost effectiveness of different pharmacological treatments is needed to better inform payers in the allocation of limited resources.

OBJECTIVES

The objectives of this study were to conduct a systematic literature review of economic evaluations of pharmacotherapies for ADHD treatments and to assess the cost effectiveness of different interventions based on the existing studies.

METHODS

A systematic literature review of economic evaluations of pharmacotherapies for ADHD was conducted in MEDLINE, the National Health Services (NHS) Economic Evaluation database and EMBASE. For inclusion in this review, studies had to compare two or more ADHD interventions with at least one pharmacotherapy, assess both costs and outcomes, and be conducted between 1990 and 2011 in North America, Europe, Australia or New Zealand. Studies were excluded if they were not original research, were presented only as conference proceedings or abstracts or did not report costs associated with specific interventions. The study quality was assessed using the British Medical Journal (BMJ) health economics checklist. The literature search, data extraction and quality assessment were performed by one author and independently checked for accuracy by a second author. Discrepancies were resolved by consensus and referring to the original article. If necessary, a third reviewer was consulted.

RESULTS

The initial search returned 93 citations from MEDLINE, 10 from the NHS Economic Evaluation database and 377 from EMBASE. Thirteen papers met the inclusion/exclusion criteria and were included in the review. Based on the BMJ checklist, all these studies were considered to be of sufficient quality to be included in the literature review, but they varied substantially in target population, methodology and effectiveness measures. Identified pharmacotherapies were cost effective compared with no treatment, placebo, behavioural therapy or community care among children and adolescents with ADHD. Studies comparing non-stimulants with stimulants and amfetamine with methylphenidate stimulants showed inconsistent findings. A limited number of studies indicated that methylphenidate Osmotic-controlled Release Oral delivery System (OROS) was cost effective compared with short-acting methylphenidate. There were no published studies on the cost effectiveness of pharmacotherapy in the adult ADHD population, comparing stimulants, non-stimulants or adjuvant therapy. There is limited evidence on the long-term cost effectiveness of pharmacotherapies.

CONCLUSIONS

Among children and adolescents with ADHD, there was consistent evidence that pharmacotherapies are cost effective compared with no treatment or behavioural therapy. Adequate data are lacking to draw conclusions regarding the relative cost effectiveness of different pharmacological agents. More economic evaluations with standardized methods, such as effectiveness measures and cost components, are warranted. To better inform payers about the economic value of existing medications, future studies should also consider identifying subgroups that may have heterogeneous responses to different treatments, including analyses of recently approved treatments (e.g. lisdexamfetamine, guanfacine extended-release and clonidine extended-release) and expanding the time horizon to incorporate long-term outcomes.

The pharmacology and clinical outcomes of amphetamines to treat ADHD: does composition matter?

Attention-deficit hyperactivity disorder (ADHD) treatment options include pharmacological and nonpharmacological approaches. In North America, psychostimulants (amphetamine and methylphenidate) are considered first-line pharmacological treatments for patients (children, adolescents and adults) with ADHD. However, in the UK, National Institute for Health and Clinical Excellence (NICE) guidelines have placed short-acting d-amphetamine as a third-line treatment option due to a lack of contemporary, published clinical trials on its efficacy and the concerns from clinical and patient experts regarding the potential for increased abuse and/or misuse compared with methylphenidate. These guidelines do not account for some of the more recent amphetamine products that have been developed to alleviate some of these concerns, but that are not currently approved in the UK or other European countries. The purpose of this review is to describe the pharmacology and clinical efficacy of various amphetamine compositions, as well as to explore the apparent differences in these compositions and their associated risks and benefits. A PubMed literature search was conducted to investigate amphetamine pharmacology, clinical efficacy and safety and ADHD outcomes in the published literature from 1980 through March 2011. Search terms included the keywords 'ADHD' or 'ADD' or 'hyperkinetic disorder' and any of the following keywords combined with 'or': 'amphetamine', 'dexamphetamine', 'mixed amphetamine salts', 'lisdexamfetamine' and 'methamphetamine'. The search included English-language primary research articles and review articles but excluded editorial articles and commentaries. The literature search resulted in 330 articles. Pertinent articles relating to amphetamine pharmacology, compositions, clinical efficacy and safety, effectiveness and tolerability, ADHD outcomes and abuse liability were included in this review. The different delivery profiles of amphetamine compositions result in pharmacological and pharmacokinetic differences that contribute to varying effects in the clinical treatment of ADHD, ADHD outcomes and abuse liability. The efficacy and safety of amphetamine compositions for the treatment of ADHD have been demonstrated in clinical trials and meta-analyses, and the long-acting amphetamine compositions have been widely studied and found efficacious without increased adverse effects. Long-acting amphetamine compositions offer the obvious advantage of enhanced duration of action over short-acting amphetamine compositions, and lisdexamfetamine has been shown to have reduced abuse liability compared with short-acting amphetamine.

Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in adults

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a childhood onset disorder that can persist into adulthood. Amphetamines are used to treat adult ADHD, but uncertainties persist about their efficacy and safety.

OBJECTIVES

To examine the efficacy and safety of amphetamines for adults with ADHD, as well as the influence of dose, drug type and release formulation type.

SEARCH STRATEGY

We searched CENTRAL, PubMed, EMBASE, CINAHL, PsycINFO, clinicaltrials.gov, UK Clinical Trials Gateway and references obtained from articles and experts in the field. We conducted the electronic searches on 25 February 2010.

SELECTION CRITERIA

Randomized controlled trials comparing the efficacy of amphetamine derivatives against placebo or an active intervention.

DATA COLLECTION AND ANALYSIS

Two authors extracted data from each included study. We used the standardized mean difference (SMD) and the risk ratio (RR) to assess continuous and dichotomous outcomes, respectively. We conducted a stratified analysis to determine the influence of moderating variables. We assessed the trials for risk of bias and drew a funnel plot to investigate the possibility of publication bias.

MAIN RESULTS

We included seven studies, which enrolled 1091 participants. All studies were placebo-controlled and three included an active comparator: guanfacine, modafinil and paroxetine. Most studies had short-term follow-up, with a mean study length of 8.1 weeks. Amphetamines improved ADHD symptom severity (SMD = -0.72; 95% CI -0.87 to -0.57) but did not improve retention in treatment overall and were associated with increased dropout due to adverse events (RR 3.03; 95% CI 1.52 to 6.05). The three amphetamine derivatives investigated (dextroamphetamine, lisdexamphetamine and mixed amphetamine salts (MAS)) were all efficacious for reducing ADHD symptoms, but MAS also increased retention in treatment. Different doses did not appear associated with differences in efficacy. We investigated immediate and sustained drug release formulations but found no difference between them on any outcome. When amphetamines were compared to other drug interventions, no differences were found. We did not find any study to be at low risk of bias overall, mainly because amphetamines have powerful subjective effects that may reveal the assigned treatment.

AUTHORS' CONCLUSIONS

Amphetamines improved short-term ADHD symptom severity. MAS also increased retention in treatment. Amphetamines were associated with higher attrition due to adverse events. The short study length and the restrictive inclusion criteria limit the external validity of these findings. Furthermore, the possibility that the results of the included studies were biased was high, which could have led to an overestimation of amphetamine efficacy.

Safety of stimulant treatment in attention deficit hyperactivity disorder: part II

IMPORTANCE OF THE FIELD

Attention deficit hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder and in at least 50% of cases persists into adulthood. Treatment of ADHD with stimulants is one of the oldest and most effective pharmacological treatments in psychiatry. Yet, there continues to be controversy over the safety of stimulant medications in the treatment of ADHD.

AREAS COVERED IN THIS REVIEW

This paper is a continuation of an earlier paper that reviewed the safety profile of newer stimulant agents, especially in relation to special populations. This part II reviews, through essentially an organ-system approach, the various clinical concerns that have been raised over the safety of stimulant medications. This includes neuropsychiatric, cardiovascular effects on growth and development, and a number of other less common concerns.

WHAT THE READER WILL GAIN

A thorough review of safety concerns in stimulants that emphasizes clinical information, case reports, open series or controlled trials relating to stimulant use in the treatment of ADHD.

TAKE HOME MESSAGE

While many safety concerns have been raised in the use of stimulants, the vast majority of treatment complications are either quickly reversible or easily manageable with appropriate clinical care. The negative consequences of untreated ADHD clearly outweigh the risks of the stimulant medicines when used in an appropriate and careful manner.

The impact of medications on quality of life in attention-deficit hyperactivity disorder: a systematic review

Quality of life (QOL) describes an individual's subjective perception of their position in life as evidenced by their physical, psychological and social functioning. Although an established outcome measure in physical health, QOL has more recently become an increasingly important measure in mental health clinical work and research. This article reviews the evidence describing the impact of medications on QOL in attention-deficit hyperactivity disorder (ADHD). Databases were searched for research studies describing the effects of medication on QOL in ADHD: 25 relevant studies were identified. Most (n = 20) of these studies have focused on children and adolescents, and most have investigated a single molecule, atomoxetine (n = 15), with relatively few studies investigating methylphenidate (n = 5), amfetamines (n = 4) and manifaxine (n = 1). These studies support a positive short-term effect of medication on QOL in ADHD for children, adolescents and adults that mirrors, to some extent, the effects of these medications on ADHD symptoms, although with smaller effect sizes. Notwithstanding measurement issues, it will continue to be important that those designing and conducting clinical trials in ADHD, including both pharmacological and non-pharmacological treatments, continue to include measures of QOL as secondary outcome measures. In particular, information about QOL effects in adults and in subjects of all ages taking methylphenidate and amfetamine treatments is urgently needed. The lack of systematic studies of the impact on QOL of psychological therapies, either on their own or in multimodal combinations with medication, is a serious omission that should be urgently addressed.

ADHD-hyperactive/impulsive subtype in adults

This is the first study to evaluate ADHD-hyperactive/impulsive subtype in a large clinical sample of adults with ADHD. The Quality of Life, Effectiveness, Safety and Tolerability (QuEST) study included 725 adults who received clinician diagnoses of any ADHD subtype. Cross-sectional baseline data from 691 patients diagnosed with the hyperactive/impulsive (HI), inattentive (IA) and combined subtypes were used to compare the groups on the clinician administered ADHD-RS, clinical features and health-related quality of life. A consistent pattern of differences was found between the ADHD-I and combined subtypes, with the combined subtype being more likely to be diagnosed in childhood, more severe symptom severity and lower HRQL. Twenty-three patients out of the total sample of 691 patients (3%) received a clinician diagnosis of ADHD-hyperactive/impulsive subtype. Review of the ratings on the ADHD-RS-IV demonstrated, however, that this group had ratings of inattention comparable to the inattentive group. There were no significant differences found between the ADHD-HI and the other subtypes in symptom severity, functioning or quality of life. The hyperactive/impulsive subtype group identified by clinicians in this study was not significantly different from the rest of the sample. By contrast, significant differences were found between the inattentive and combined types. This suggests that in adults, hyperactivity declines and inattention remains significant, making the hyperactive/impulsive subtype as defined by childhood criteria a very rare condition and raising questions as to the validity of the HI subtype in adults.

Attention deficit hyperactivity disorder in adults

OBJECTIVE

To examine available literature regarding attention deficit hyperactivity disorder (ADHD) in adults.

METHODS

An electronic literature search of peer-reviewed English language articles using MEDLINE (without time limits) was undertaken.

RESULTS

Symptoms of ADHD in adults exert a substantial negative impact on daily life, including work, social life and relationships. Co-morbidities are common, further impairing quality of life. Diagnosis of adult ADHD can be difficult, as current criteria require evidence of symptom onset before the age of 7 years and impact on activities typically undertaken by children. Drug therapy is the first-line treatment for adult ADHD, particularly stimulant medication. However, methylphenidate (MPH) immediate-release tablets require three or more times daily dosing, which can impact on compliance, while demonstrating a loss of symptomatic benefit later in the day. Extended-release preparations of MPH, mixed amphetamine salts and dexamphetamine can provide symptom control for 6-12 h and the non-stimulant atomoxetine has demonstrated benefit in reducing ADHD symptoms. These therapies are generally well tolerated, but may be associated with adverse effects on the cardiovascular system, which need to be further assessed in controlled clinical trials. Psychological therapy may be beneficial in adults who continue to experience clinically significant symptoms while receiving pharmacotherapy.

CONCLUSION

Further research in all areas of adult ADHD is urgently needed.

Safety of stimulant treatment in attention deficit hyperactivity disorder: Part I

BACKGROUND

The safety profile of newer stimulant products is of interest. Because most studies focus on school-age children, there is also an increased interest in the treatment of other populations. Concern continues for the risk of substance abuse in the use of stimulants.

OBJECTIVE

The purpose of this paper is to review published data on the safety and tolerability of the newer forms of stimulants, treatment in special populations, and the risks of substance abuse and dependence in the treatment of attention deficit hyperactivity disorder.

METHODS

Literature obtained through Medline and Pubmed from 1995 were reviewed as well as key articles referenced in the literature.

CONCLUSIONS

The use of the newer stimulant agents shows a safety profile of frequent, but usually mild side effects. They are generally safe in special populations. The risk of developing long-term substance abuse with attention deficit hyperactivity disorder, without co-morbidities, is small and may decrease with proper treatment. More research is needed.

Switching from oral extended-release methylphenidate to the methylphenidate transdermal system: continued attention-deficit/hyperactivity disorder symptom control and tolerability after abrupt conversion

OBJECTIVE

To evaluate symptom control and tolerability after abrupt conversion from oral extended-release methylphenidate (ER-MPH) to methylphenidate transdermal system (MTS) via a dose-transition schedule in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a 4-week, prospective, multisite, open-label study, 171 children (164 intent-to-treat) with diagnosed ADHD aged 6-12 years abruptly switched from a stable dose of oral ER-MPH to MTS in nominal dosages of 10, 15, 20, and 30 mg using a predefined dose-transition schedule. After the first week on the scheduled dose, the dose was titrated to optimal effect. The primary effectiveness outcome was the change from baseline (while taking ER-MPH) to week 4 in ADHD-Rating Scale-IV (ADHD-RS-IV) total scores. Adverse events (AEs) were assessed throughout the study.

RESULTS

Most subjects (58%) remained on the initial MTS dose defined by the dose-transition schedule; 38% increased and 4% decreased their MTS dose for optimization. MTS dose optimization resulted in significantly better ADHD-RS-IV total (mean +/- SD) scores at week 4 than at baseline (9.9 +/- 7.47 vs. 14.1 +/- 7.48; p < 0.0001). The most commonly reported AEs included headache, decreased appetite, insomnia, and upper abdominal pain. Four subjects (2.3%) discontinued because of application site reactions and three discontinued because of other AEs.

CONCLUSIONS

Abrupt conversion from a stable dose of oral ER-MPH to MTS was accomplished using a predefined dose-transition schedule without loss of symptom control; however, careful titration to optimal dose is recommended. Most AEs were mild to moderate and, with the exception of application site reactions, were similar to AEs typically observed with oral MPH. Limitations of this study included its open-label sequential design without placebo, which could result in spurious attribution of improvement to the study treatment and precluded superiority determinations of MTS over baseline ER-MPH treatment. The apparent superiority of MTS was likely due to more careful titration and clinical monitoring rather than the product itself. ClinicalTrials.gov: NCT00151983.

Simulated driving changes in young adults with ADHD receiving mixed amphetamine salts extended release and atomoxetine

BACKGROUND

Psychostimulant treatment may improve simulated driving performance in young adults with attention-deficit/hyperactivity disorder (ADHD).

METHOD

This was a randomized, double-blind, placebo-controlled, crossover study of simulated driving performance with mixed amphetamine salts-extended release (MAS XR) 50 mg/day (Cohort 1) and atomoxetine 80 mg/day (Cohort 2) in young adults with ADHD.

RESULTS

Adults aged 19 to 25 years with AD/HD (N = 19) who were administered MAS XR significantly improved overall simulated driving performance versus placebo up to 12 hours after dosing. In contrast, there were no statistically significant differences in simulated-driving-performance scores between atomoxetine and placebo. At endpoint, MAS XR reduced ADHD Rating Scale scores > or = 30% in 80% of subjects, whereas atomoxetine achieved this level of improvement for 40%.

LIMITATIONS

Small sample size and use of simulated driving may limit generalizability of the findings.

CONCLUSION

MAS XR in young adults with ADHD yields significant improvements in simulated driving performance and ADHD symptoms.

Global issues related to the impact of untreated attention-deficit/hyperactivity disorder from childhood to young adulthood

Attention-deficit/hyperactivity disorder (ADHD) is a common, chronic, and costly disorder, with an impact that can span from preschool into adulthood. There are safe and effective therapies that can manage and help prevent many of the associated negative outcomes of ADHD, but treatment rates are far from optimal and considerable obstacles exist in achieving satisfactory treatment adherence. Individuals with untreated ADHD, their families, and other caregivers must be made aware of the impact that this disorder may have on them at every stage of life and, correspondingly, the improved outcomes that can be achieved with the successful management of ADHD.

The consequences of attention-deficit/hyperactivity disorder in adults

Until recently, attention-deficit/hyperactivity disorder (ADHD) was a diagnosis reserved for children and adolescents as it was believed to dissipate before adulthood. New evidence, however, supports the persistence of ADHD beyond adolescence, and it is now recognized as a chronic neurobehavioral disorder in adults. Adults with ADHD have difficulties with school, work, family interactions, and social activities. Although treatments are available for adult ADHD, many patients never receive an accurate diagnosis that would afford them appropriate therapeutic intervention. If left untreated, adult ADHD can cause significant personal, social, and economic burdens that can have a negative impact on overall quality of life. This article discusses how ADHD presents in adults and the effects of the disorder on educational, occupational, interpersonal, and social functioning. Currently available treatments for ADHD in adults are also reviewed.

Efficacy and safety of dexmethylphenidate extended-release capsules in adults with attention-deficit/hyperactivity disorder

BACKGROUND

This multicenter, randomized, fixed-dose, double-blind, placebo-controlled study evaluated efficacy of extended-release dexmethylphenidate (d-MPH-ER) in adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Randomized adults with ADHD (n=221) received once-daily d-MPH-ER 20 mg, 30 mg, or 40 mg or placebo for 5 weeks. The primary efficacy variable was change from baseline to final visit in DSM-IV ADHD Rating Scale (ADHD-RS) total score. Secondary efficacy parameters included the proportion of patients with improvement>or=30% in ADHD-RS total score and final scores on Clinical Global Impressions-Improvement (CGI-I) scale.

RESULTS

Of 218 evaluable patients, 184 completed the study. All d-MPH-ER doses were significantly superior to placebo in improving ADHD-RS total scores. Placebo scores improved by 7.9; d-MPH-ER, 20 mg, improved by 13.7 (p=.006); d-MPH-ER, 30 mg, improved by 13.4 (p=.012); and d-MPH-ER, 40 mg, improved by 16.9 (p<.001). Overall distribution of CGI-I ratings at final visit was significantly better with each d-MPH-ER dosage than with placebo. There were no unexpected safety or tolerability concerns, based on experience with racemic methylphenidate (MPH) in adults and dexmethylphenidate (d-MPH) in children.

CONCLUSIONS

Once-daily d-MPH-ER at 20 mg, 30 mg, or 40 mg is a safe and effective treatment for adults with ADHD.

Review of long-acting stimulants in the treatment of attention deficit hyperactivity disorder

A number of long-acting medications for the treatment of attention deficit hyperactivity disorder (ADHD) have recently been developed and approved for use in the US. These compounds are intended to optimize and maintain ADHD symptom control throughout the day, while eliminating problems associated with short-acting medications, such as the need for in-school, midday or multiple daily doses. Recent reports confirm that the safety and tolerability of long-acting medications are similar to those of short-acting medications, although long-acting medications appear to have a lower risk of abuse and diversion and may be associated with significant improvements in medication adherence. Distinctions can be made among the long-acting medications with regard to the onset, magnitude and duration of their clinical effects. Recognition of these differences is important for individualizing treatment for patients with ADHD.

Mixed amphetamine salts extended release: a clinical review of its use in the treatment of attention-deficit hyperactivity disorder

Mixed amphetamine salts extended release (MAS-XR) has been demonstrated in pediatric, adolescent and adult studies to be a well tolerated and effective treatment for attention-deficit hyperactivity disorder (ADHD). MAS-XR utilizes a double-pulse delivery system to replicate the pharmacokinetic properties of equal doses of immediate-release MAS administered 4 h apart. Doses of 20 mg MAS-XR produce significant reductions of core symptoms of ADHD over a 12-h period. Adverse effects observed in controlled studies include anorexia, weight loss, dry mouth, insomnia and abdominal pain, and rates of adverse effects are comparable to other stimulant agents approved for ADHD. At this time, there are no data to suggest that sudden death due to cardiovascular complications occurs more frequently in patients treated with MAS-XR than in the general population, but careful consideration of the risks and benefits of MAS-XR is warranted in patients with pre-existing structural heart disease and adult patients with a history of hypertension.