An open-label trial of reboxetine in children and adolescents with attention-deficit/hyperactivity disorder

Reboxetine in therapy-resistant enuresis: A randomized placebo-controlled study

INTRODUCTION

A significant minority of children with enuresis do not respond to either desmopressin or the enuresis alarm. Anticholinergics have not proven as successful as expected. The fourth evidence-based treatment, the tricyclic antidepressant imipramine, is cardiotoxic when overdosed, which has led to diminished use.

AIM

The aim was to determine whether there is a role for the noradrenergic antidepressant reboxetine, as monotherapy or combined with desmopressin, in the treatment of enuresis in children who have not responded to standard therapy, and whether there are side effects involved. We also sought prognostic factors in anamnestic data and in the voiding chart.

PATIENTS AND METHODS

The study was a randomized placebo-controlled study with a double-blind cross-over design, in which all patients underwent treatment during three 4-week periods, one with reboxetine 4 mg and placebo, one with reboxetine 4 mg and desmopressin, and one with double placebo treatment. The proportion of wet nights out of 14 was compared before treatment and during the last 2 weeks of each treatment period.

RESULTS

Eighteen patients were included. The reduction of wet nights was much better with either reboxetine in monotherapy or in combination with desmopressin than during the placebo period (p = 0.002) (Figure). However, only one patient achieved complete dryness, this during monotherapy. There were three intermediate responders to monotherapy and five to combination treatment. With reboxetine in monotherapy, six children experienced negative side effects compared with three with combination therapy, and two with placebo. All of these side effects were mild and reversible. Only one patient chose to cease treatment because of side effects. No prognostic factors were found in either the case history or in voiding chart data.

DISCUSSION

The present study, the first placebo-controlled trial, confirms that reboxetine is an evidence-based alternative to cardiotoxic antidepressant treatment in therapy-resistant enuresis. The fact that few patients achieved complete dryness may be due to the low dosage used. In our clinical practice we increase the dose to 8 mg when dryness is not achieved with the lower dose. Our experience is that this leaves more children with full response, but the evidence of this has yet to be shown.

CONCLUSION

Reboxetine seems to be an alternative in the treatment of enuretic children who have not responded to standard treatment.

Agomelatine as a Treatment for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Double-Blind, Randomized Clinical Trial

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder. Due to lack of response to the medication and significant side effects of the treatment with stimulants, alternative medications should be considered. The aim of this study is to evaluate efficacy of agomelatine in treatment of ADHD.

METHODS

Fifty-four outpatients, children 6-15 years old, with diagnosis of ADHD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria participated in a 6-week, parallel, double-blind, randomized clinical trial. Fifty patients completed 6 weeks of treatment with either ritalin (methylphenidate hydrochloride [MPH]) (20 mg/day in participants below 30 kg and 30 mg/day in patients with weight ≥30 kg) or agomelatine (15 mg/day in patients with weight ≥30 kg and 25 mg/day in patients with weight ≥45 kg). Participants were assessed using Parent and Teacher ADHD Rating Scale-IV at baseline and at weeks 3 and 6.

RESULTS

General linear model repeated measures showed no significant differences between the two groups on Parent and Teacher Rating Scale scores (F = 1.13, df = 1.26, p = 0.305, and F = 0.95, df = 1.25, p = 0.353, respectively). Changes in Teacher and Parent ADHD Rating Scale scores from baseline to the study end were not significantly different between the agomelatine group (9.28 ± 8.72 and 24.12 ± 7.04, respectively) and the MPH group (6.64 ± 11.04 and 25.76 ± 7.82, respectively) (p = 0.46 and p = 0.44, respectively). There was a trend for less insomnia in the agomelatine group versus MPH-treated group (4% vs. 24%, p = 0.09).

CONCLUSIONS

A treatment course of 6 weeks with agomelatine demonstrated a favorable safety and efficacy profile in children and adolescents with ADHD. Nonetheless, larger controlled studies with longer treatment periods are necessary.

Effect of adenotonsillectomy on ADHD symptoms of children with adenotonsillar hypertrophy and sleep disordered breathing

BACKGROUND

Adenotonsillar hypertrophy is the most common etiologic agent for the obstruction of the upper airways in children, which might be associated with attention-deficit hyperactivity disorder (ADHD), one of the most common psychiatric disorders of childhood. Despite the concurrence of these two conditions, i.e., obstruction of the airways and ADHD, no exact etiologic relationship has been established between adenotonsillectomy (AT) and ADHD symptoms. This study was undertaken to evaluate the effect of AT on the ADHD symptoms in children with adenotonsillar hypertrophy and sleep disordered breathing (SDB).

METHODS

The design of the present study consisted of pre-test and post-test, followed by post hoc tests. Fifty-three children aged 3-12 were included in this study, selected from those referring to the Pediatric Hospital of Tabriz University of Medical Sciences, with SDB, adenotonsillar hypertrophy and ADHD based on DSM-IV criteria, by availability of the subjects undergoing adenotonsillectomy after evaluation of the severity of ADHD symptoms. The scores of ADHD symptoms were evaluated before AT and at 3- and 6-month postoperative intervals based on Conner's Parent Rating Scale-Revised (CPRS-R) Questionnaire. Repeated-measures ANOVA and Fisher's exact test were used for data analysis.

RESULTS

AT resulted in a significant decrease in the severity of ADHD symptoms (oppositional behavior, cognitive disorders, inattention, hyperactivity and ADHD index) at 3- and 6-month postoperative intervals (P<0.001), with more significant decreases at 6-month postoperative interval compared to 3-month interval (P<0.001).

CONCLUSIONS

Based on the results of this pilot study, AT in children with SDB associated with ADHD resulted in a significant decrease in the severity of ADHD symptoms.

A systematic review of reboxetine for treating patients with attention deficit hyperactivity disorder

BACKGROUND

No published systematic review has ever assessed the efficacy and safety of reboxetine for treating of patients with attention deficit hyperactivity disorder (ADHD).

AIM

This systematic review aimed to review the available evidence regarding the efficacy of reboxetine for treating ADHD.

METHOD

The databases of Pubmed/Medline, Google scholar, SCOPUS and Web of Science were searched using the Keywords: "reboxetine", "ADHD" and "attention deficit hyperactivity disorder". The reference lists of the included studies were screened to find any possible other relevant articles. All the non-controlled and controlled clinical trials were included.

RESULTS

The current evidence mainly consists of un-controlled studies, such as case series. Only three of 33 studies were controlled clinical trials. They are from single sites and included a sub-sample of patients with ADHD.

CONCLUSION

Non-controlled studies and controlled trials support the promising effect of reboxetine for treating ADHD in a sub-sample of patients that are without co-morbid psychiatric disorder and mental retardation. Reboxetine is tolerated well. However, more controlled trials are needed to reach any firm conclusion.

Prefrontal grey and white matter neurometabolite changes after atomoxetine and methylphenidate in children with attention deficit/hyperactivity disorder: a (1)H magnetic resonance spectroscopy study

Attention deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral childhood disorder. Dysfunction of prefrontal neural circuits which are responsible for executive and attentional functions has been previously shown in ADHD. We investigated the neurometablite changes in areas included in dorsolateral prefrontal neural circuits after 2 months of long-acting methylphenidate or atomoxetine medication in children with ADHD who were responders to treatment. Twenty-one ADHD children were examined by single voxel (1)H-magnetic resonance spectroscopy (MRS) before and after 2 months of medication with OROS methylphenidate (n=10) or atomoxetine (n=11). The spectra were taken from the dorsolateral prefrontal cortex (DLPFC, 8ml) and white matter behind the DLPFC (anterior semioval center, 7.5ml), bilaterally. NAA and NAA/Cr (N-acetylaspartate/creatine) decreased in the left DLPFC and Cho/Cr (choline/creatine) increased in the right DLPFC after atomoxetine medication. Glu+Gln and Glu+Gln/Cr (glutamate/glutamine) increased in the left white matter after methylphenidate medication. We hypothesize that atomoxetine could decrease hyperactivation of DLPFC neurons and methylphenidate could lead to increased activation of cortical glutamatergic projections with the consequences of increased tonic dopamine release in the mesocortical system.

Efficacy of reboxetine in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled clinical trial

OBJECTIVE

The main aim of this study is to evaluate the efficacy of reboxetine, a specific noradrenergic reuptake inhibitor, in adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a double blind placebo-controlled clinical trial, the efficacy of 8 mg/day of reboxetine (twice daily) was compared with placebo in 40 adults diagnosed with ADHD during 6 weeks. The measures were Conners' Adult ADHD Rating Scale-Self-Report, Screening Version (CAARS-S, SV), Hamilton Anxiety and Depression Rating Scales, Clinical Global Impression - Severity Scale (CGI-S), and Global Assessment of Functioning Scale (GAF).

RESULTS

There was a main effect of time and significant time X treatment (reboxetine vs. placebo) interaction on CAARS subscales and CGI scores which decreased along the study (p < 0.01). There was also a main effect of time and time X treatment interaction on GAF score which increased at the end point of the study (p < 0.01). In terms of Hamilton Anxiety and Depression Rating Scales there was just a main effect of time on Hamilton Depression Scale (p < 0.01). Irritability, anxiety, sleep disturbance, and dry mouth were the common side effects of reboxetine.

CONCLUSION

Reboxetine could be used and tolerated as an effective treatment for adults with ADHD.