Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD)

Prevalence and Clinical Profile of Adults with ADHD Attending a Tertiary Care Hospital for Five Years

(1) Objectives: This study aimed to assess the 5-year prevalence and clinical profile of attention deficit hyperactive disorder (ADHD) among adult patients seeking care in a tertiary care hospital in Oman. (2) Methods: The data were analysed using descriptive and inferential statistics and standardised prevalence estimates were calculated. (3) Results: Of the 39,881 hospital visits, 1.77% were made by adults with ADHD. This is equivalent to 17.8 visits per 1000 outpatients. The year 2021 saw the highest prevalence among the five years considered, while 2020 had the lowest prevalence. Although the age distribution indicated that the age group 'under 20' had the highest prevalence, the gender distribution showed that ADHD was more common among adult men. Among the various subtypes of ADHD, inattention was the most common. (4) Conclusions: This study specifically compared the prevalence and associated factors between an adult cohort with ADHD and those other psychiatric clinic attendees during the same period. The study offers important information on the prevalence and clinical profile of adults with ADHD in the population under consideration.

Psychiatric and non-psychiatric drugs causing false positive amphetamines urine test in psychiatric patients: a pharmacovigilance analysis using FAERS

INTRODUCTION

Immunoassay urine drug screen (UDS) is frequently used in clinical practice for initial screening process, being generally available, fast, and inexpensive. Exposure to widely prescribed drugs might determine false positive UDS amphetamines, leading to diagnostic issues, wrong therapeutic choices, impairment of physician-patient relationship and legal implications.

AREAS COVERED

To summarize and comment on a comprehensive list of compounds responsible for UDS false positive for amphetamines, we conducted a literature review on PubMed along with a comparison with Real World Data from the Food and Drug Administration Adverse Event Reporting System (FAERS) database analysis between 2010 and 2022. Forty-four articles and 125 Individual Case Safety Reports (ICSR) involving false positive amphetamine UDS in psychiatric patients were retrieved in FAERS.

EXPERT OPINION

False positive results were described in literature for antidepressants, atomoxetine and methylphenidate, antipsychotics, but also for non-psychiatric drugs of common use, like labetalol, fenofibrate and metformin. Immunoassays method is usually responsible for false positive results and in most cases mass spectrometry (MS) do not eventually confirm the UDS positivity. Physicians should be aware of immunoassays' limitations and when turning to a confirmatory test. Any new cross-reaction should be reported to pharmacovigilance activities.

Challenges of Treating ADHD with Comorbid Substance Use Disorder: Considerations for the Clinician

Adults with attention deficit/hyperactivity disorder (ADHD) often present psychiatric comorbidities and, in particular, substance use disorder (SUD). ADHD-SUD comorbidity is characterized by greater severity of both disorders, earlier age of onset, higher likelihood of polydrug-abuse and suicidal behaviors, more hospitalizations, and lower treatment adherence. At the present stage, research focused on the pharmacological management of ADHD with comorbid SUD in both adolescents and adults is still lacking. Furthermore, while the short-term effects of stimulants are well studied, less is known about the chronic effects of these drugs on dopamine signaling. Current available evidence is consistent in reporting that high doses of stimulant medications in ADHD-SUD subjects have a mild to moderate efficacy on ADHD symptoms. Some data suggest that pharmacological treatment with stimulants may be beneficial for both ADHD symptoms and comorbid cocaine or amphetamine use. However, in the long run, stimulant medications may have a potential risk for misuse. For the absence of potential misuse, atomoxetine is often recommended for ADHD with comorbid cocaine or amphetamine use disorder. However, its efficacy in reducing addictive behavior is not demonstrated. In subjects with other subtypes of SUD, both atomoxetine and stimulant drugs seem to have scarce impact on addictive behavior, despite the improvement in ADHD symptomatology. In this population, ADHD treatment should be combined with SUD-specific strategies.

Attention Deficit Hyperactivity Disorder: What Are Pharmacists' Roles and Associated Outcomes?

Globally, the prevalence of attention deficit hyperactivity disorder (ADHD) is increasing. The treatment for ADHD is multifaceted and requires long-term care and support. Pharmacists are capable of assisting patients and their caretakers in achieving desired outcomes. This work discusses and summarizes pharmacists' roles in ADHD care and their associated outcomes. Overall, pharmacists are positioned to educate on ADHD, optimize medications in a collaborative practice model, manage and monitor side effects, and provide remote and virtual pharmaceutical care. Pharmacists could directly contribute to ensuring medication safety and increasing awareness regarding the optimal use of ADHD medications. Patients with ADHD can benefit from pharmacist involvement in a variety of ways, including, but not limited to, initial screening and referral, the provision of clinical consultation and feedback, and the improvement of self-management and self-awareness of the illness. Pharmacists also play a significant role in therapeutic decision making regarding the initiation, intensification, and monitoring of ADHD treatment to ensure its effectiveness and quality of life improvement. Lastly, pharmacists could help identify more cost-effective treatment approaches for ADHD patients based on the clinical scenario that is encountered.

Viloxazine, a Non-stimulant Norepinephrine Reuptake Inhibitor, for the Treatment of Attention Deficit Hyperactivity Disorder: A 3 Year Update

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in childhood. Current treatment options for ADHD include pharmacological treatment (stimulants, non-stimulants, anti-depressants, anti-psychotics), psychological treatment (behavioral therapy with or without parent training, cognitive training, neurofeedback), and complementary and alternative therapies (vitamin supplementation, exercise). Central nervous system (CNS) stimulants are the primary pharmacological therapy used in treatment; however, these stimulant drugs carry a high potential for abuse and severe psychological/physical dependence. Viloxazine, a non-stimulant medication without evidence of drug dependence, is a selective norepinephrine reuptake inhibitor that has historically been prescribed as an anti-depressant medication. The extended-release (ER) form was approved by the US Food and Drug Administration (FDA) in April 2021 for the treatment of ADHD in pediatric patients aged 6-17 years. Phase 2 and 3 randomized control trials have demonstrated significant efficacy of viloxazine in improving ADHD symptoms versus placebo. Related to its long-standing use as an antidepressant, the safety profile and pharmacokinetics of viloxazine are well understood. Viloxazine appears to be a suitable alternative to current standard-of-care pharmacotherapy for ADHD, but the further investigation remains to be done in comparing its efficacy to that of current treatments.

Reasons for treatment changes in adults with attention-deficit/hyperactivity disorder: a chart review study

BACKGROUND

Adults with attention-deficit hyperactivity disorder (ADHD) often cycle through multiple treatments for reasons that are not well documented. This study analyzed the reasons underlying treatment changes among adults treated for ADHD in a real-world setting.

METHODS

Data were collected via an online reporting form completed by eligible physicians between October and November 2020. Data for adult patients in the United States who were diagnosed with ADHD and initiated a treatment regimen within 1 to 5 years of chart abstraction were obtained. Reason for a treatment change was described for a randomly selected regimen episode, which spanned from treatment initiation until the earliest among treatment add-on/switch or discontinuation, death, or date of chart abstraction. The overall rate of ADHD/treatment-related complications were also described. Physician satisfaction with current treatment options for adult ADHD and opinions on areas for improvement were assessed.

RESULTS

Data on 320 patients were reported by 152 physicians specializing in psychiatry (40.1%), pediatrics (25.0%), family medicine (21.7%), and internal medicine (13.2%). Patients had a mean age of 29.3 years; most were diagnosed with ADHD as adults (57.5%) and within the previous 5 years (56.5%). Selected treatment regimens included stimulants (79.1%), nonstimulants (14.7%), and combination therapy (5.6%) for an average duration of 1.9 years. Among patients with treatment discontinuation (N = 59), the most common reasons for discontinuation were suboptimal symptom management (55.9%), occurrence of ADHD/treatment-related complications (25.4%), and patient attitude/dislike of medication (25.4%). The main reasons for other key treatment changes were inadequate/suboptimal management of symptoms and cost considerations. Over 40% of patients had ≥ 1 documented ADHD/treatment-related complication, irrespective of whether they led to a treatment change. One in 5 physicians (19.8%) were very dissatisfied, moderately dissatisfied, or neither satisfied nor dissatisfied with current treatment options for ADHD in adults; the top 3 suggested improvements were lower risk of abuse (71.7%), longer effect duration (65.1%), and fewer ADHD/treatment-related complications (61.2%).

CONCLUSIONS

The top reasons for treatment changes among adults with ADHD are lack of efficacy and ADHD/treatment-related complications, highlighting the importance of developing more effective and safer treatments to alleviate the burden of ADHD.

Personalization of pharmacological treatments for ADHD: Why it is advisable and possible options to achieve it

Abstract:

Attention-deficit hyperactivity disorder is a neurodevelopmental disorder diagnosed primarily in children, although it is also present in adults. Patients present inattention, impulsivity, and hyperactivity symptoms that create difficulties in their daily lives. Pharmacological treatment with stimulants or non-stimulants is used most commonly to reduce ADHD symptoms. Although generally effective and safe, pharmacological treatments have different effects among patients, including lack of response and adverse reactions. The reasons for these differences are not fully understood, but they may derive from the highly diverse etiology of ADHD. Strategies to guide optimal pharmacological treatment selection on the basis of individual patients’ physiological markers are being developed. In this review, we describe the main pharmacological ADHD treatments used and their main drawbacks. We present alternatives under study that would allow the customization of pharmacological treatments to overcome these drawbacks and achieve more reliable improvement of ADHD symptoms.

Differentiation and comorbidity of bipolar disorder and attention deficit and hyperactivity disorder in children, adolescents, and adults: A clinical and nosological perspective

Bipolar Disorder (BD) and Attention Deficit and Hyperactivity Disorder (ADHD) are mental disorders with high degree of lifetime comorbidity. Both BD and ADHD are disorders with onset in childhood and early adolescence. Both disorders are often undiagnosed, misdiagnosed, and sometimes overdiagnosed, leading to high rates of morbidity and disability. The psychiatric and behavioral symptoms associated with ADHD and BD have significant overlap. Albeit the existence of a large body of literature, it is far from being clear whether comorbidity can be explained by the confounding overlap of operationally defined criteria or whether it reflects a genuine comorbidity of two biologically distinct disorders. The aim of this paper is to recognize and/or differentiate the pattern of ADHD across the course of BD from a nosological point of view, focusing on specific clinical and neurobiological dimensions. We found that some critical issues may help to fulfill the purpose of our perspective. We suggest that the relationship between ADHD and BD, based on clinical, developmental, and epidemiological commonalities, can be better clarified using four different scenarios.

Adult-Attention Deficit Hyperactive Disorder Symptoms Seem Not to Influence the Outcome of an Enhanced Agonist Opioid Treatment: A 30-Year Follow-Up

The role of opioids and opioid medications in ADHD symptoms is still largely understudied. We tested the hypothesis that, in Heroin Use Disorder (HUD), when patients are treated with Agonist Opioid medications (AOT), treatment outcome is associated with the presence of Adult Attention-Deficit/Hyperactive Disorder (A-ADHD) symptomatology. A retrospective cohort study of 130 HUD patients in Castelfranco Veneto, Italy, covering 30 years, was divided into two groups according to the Adult ADHD Self-Report Scale (ASRS) score and compared them using demographic, clinical and pharmacological factors. Survival in treatment was studied by utilizing the available data for leaving treatment and relapsing into addictive behavior and for mortality during treatment as poor primary outcomes. Thirty-five HUD subjects (26.9%) were unlikely to have A-ADHD symptomatology, and 95 (73.1%) were likely to have it. Only current age and co-substance use at treatment entry differed significantly between groups. Censored patients were 29 (82.9%) for HUD patients and 70 (73.9%) for A-ADHD/HUD patients (Mantel-Cox test = 0.66 p = 0.415). There were no significant linear trends indicative of a poorer outcome with the presence of A-ADHD after adjustment for demographic, clinical and pharmacological factors. Conclusions: ADHD symptomatology does not seem to exert any influence on the retention in AOT of HUD patients.

ADHD: Reviewing the Causes and Evaluating Solutions

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder in which patients present inattention, hyperactivity, and impulsivity. The etiology of this condition is diverse, including environmental factors and the presence of variants of some genes. However, a great diversity exists among patients regarding the presence of these ADHD-associated factors. Moreover, there are variations in the reported neurophysiological correlates of ADHD. ADHD is often treated pharmacologically, producing an improvement in symptomatology, albeit there are patients who are refractory to the main pharmacological treatments or present side effects to these drugs, highlighting the importance of developing other therapeutic options. Different non-pharmacological treatments are in this review addressed, finding diverse results regarding efficacy. Altogether, ADHD is associated with different etiologies, all of them producing changes in brain development, leading to the characteristic symptomatology of this condition. Given the heterogeneous etiology of ADHD, discussion is presented about the convenience of personalizing ADHD treatment, whether pharmacological or non-pharmacological, to reach an optimum effect in the majority of patients. Approaches to personalizing both pharmacological therapy and neurofeedback are presented.

The effect of medication and question wording on self-reported symptoms and their accuracy in young adults with attention-deficit/hyperactivity disorder

OBJECTIVES

This study examined the effect of whether participants were on or off their medications and the effect of questionnaire wording on self-reported symptoms in young adults with ADHD. Additionally, this research evaluated the relationships between these self-reported symptoms and objective performance on measures of working memory.

DESIGN

This experimental study utilized a mixed factorial design with one between-subjects factor (whether participants were unmedicated or medicated at the time they completed their assessment) and one within-subjects factor (whether participants reported their on-medication or off-medication symptoms when describing their ADHD subjective symptomatology).

METHODS

Forty-five young adults with ADHD (ages 18-23) completed a brief neuropsychological evaluation and several self-report questionnaires.

RESULTS

Although being medicated or unmedicated while completing the questionnaires did not directly affect self-reported symptoms or their accuracy, questionnaire wording exerted a statistically significant effect on subjective symptomatology; participants described themselves as substantially more symptomatic at times when they are off than at times when they are on their medications. More importantly, their general self-perceptions (symptoms when medication state was not specified) of their Inattention/Memory Problems and their Hyperactivity/Restlessness aligned with their descriptions of their off-medication symptoms, whereas their general self-perceptions of their Impulsivity/Emotional Lability and Problems with Self-Concept related to both their self-reported off-medication and on-medication symptoms.

CONCLUSIONS

These results highlight the necessity of specifying medication state when asking patients to report their current symptomatology. Failing to do so risks an over-reporting of symptoms from patients who are typically on medications as they may describe the extent of their unmedicated, rather than medicated, symptomatology.

PRACTITIONER POINTS

Being medicated or unmedicated while completing questionnaires about subjective symptomatology did not directly affect self-reported symptoms of young adults with ADHD or the accuracy of these self-reports. When medication state was not specified on a questionnaire, young adults with ADHD reported symptoms similar to those they experience when they are not medicated. These results highlight the importance of specifying medication state when asking young adults with ADHD to report their current symptomatology. Failing to do so risks an over-reporting of symptoms from patients who are typically on medications. These findings open the door for further research with larger and more diverse and representative samples of adults with ADHD to evaluate the accuracy of their subjective symptomatology relative to their objective abilities. Future studies should also examine whether gender affects subjective symptoms, their accuracy, or the influence of question wording and medications on self-reported symptomatology of adults with ADHD, as the current study was unable to address this important issue.

Associations Between Attention Deficit/Hyperactivity Disorder and Internet Gaming Disorder Symptoms Mediated by Depressive Symptoms and Hopelessness Among College Students

PURPOSE

The mediating role of depressive symptoms and hopelessness on the relationship between attention deficit/hyperactivity disorder (ADHD) and internet gaming disorder (IGD) symptoms has not yet been elucidated. This study assessed this mediating effect in college students.

PARTICIPANTS AND METHODS

Participants consisted of 1236 freshmen recruited at a local university. Symptoms of ADHD, IGD, depression and hopelessness were measured using self-report scales. The effect of ADHD on IGD mediated by depression and hopelessness was analyzed by Haye's PROCESS macro for SPSS (Model 6) using the bias-corrected percentile bootstrap method with 5000 bootstrapped samples.

RESULTS

Symptoms of ADHD, depression and hopelessness were common in college students and were strongly associated with the appearance of IGD symptoms. ADHD symptoms of college students impacted their IGD symptoms directly and indirectly via depressive symptoms and hopelessness. The total effect of ADHD symptoms on IGD symptoms was 0.075 (standard error [SE]: 0.009, 95% confidence interval [CI] 0.057, 0.093), with a direct effect of 0.037 (SE: 0.010, 95% CI 0.018, 0.056, effect ratio: 49.3%), and total indirect effect was 0.038 (SE: 0.005, 95% CI 0.029, 0.050, effect ratio: 50.7%).

CONCLUSION

Depressive symptoms and hopelessness can mediate the relationship between ADHD and IGD symptoms among college students. These findings point to the importance of evaluating ADHD, depressive and hopelessness symptoms for the prevention and treatment of adult IGD.