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Doi K, Sogawa R, Eguchi Y, Matsuo M, Shimanoe C. Association between Early Guanfacine Discontinuation and Somnolence for Attention-Deficit/Hyperactivity Disorder. Biol Pharm Bull 2024; 47:1204-1208. [PMID: 38910124 DOI: 10.1248/bpb.b24-00147] [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: 06/25/2024]
Abstract
Guanfacine, used as a medication for attention-deficit/hyperactivity disorder (ADHD), leads to a high incidence of somnolence, in contrast to methylphenidate, which leads to a high incidence of insomnia. The impact of somnolence on continuing guanfacine treatment is unclear. Therefore, we investigated the reasons for discontinuing guanfacine and analyzed the factors associated with discontinuation caused by somnolence. We surveyed 96 patients under guanfacine from July 2017 to December 2021 at the Saga University Hospital. Patients who discontinued guanfacine by the end date of our study were divided into a median early and late group. We compared the reasons for discontinuation in both groups. Of all patients, 47 continued and 49 discontinued guanfacine. A higher percentage of patients discontinued guanfacine caused by somnolence for ≤70 d than for >70 d of treatment (44.0 vs. 8.3%; p = 0.008). When stratified by the concomitant use of other ADHD drugs, somnolence resulted in a higher discontinuation rate for ≤70 d than for >70 d of treatment without concomitant use (55.0 vs. 7.1%; p = 0.009). Nonetheless, concomitant use resulted in no difference. In conclusion, somnolence affects the early discontinuation of guanfacine as an ADHD drug. The combination of methylphenidate or atomoxetine may decrease withdrawal caused by somnolence.
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Affiliation(s)
- Kinuka Doi
- Department of Pharmacy, Saga University Hospital
| | | | | | - Muneaki Matsuo
- Department of Pediatrics, Faculty of Medicine, Saga University
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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.
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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
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Storebø OJ, Storm MRO, Pereira Ribeiro J, Skoog M, Groth C, Callesen HE, Schaug JP, Darling Rasmussen P, Huus CML, Zwi M, Kirubakaran R, Simonsen E, Gluud C. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database Syst Rev 2023; 3:CD009885. [PMID: 36971690 PMCID: PMC10042435 DOI: 10.1002/14651858.cd009885.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015. OBJECTIVES To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate. SELECTION CRITERIA We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life. DATA COLLECTION AND ANALYSIS Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach. MAIN RESULTS We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias. PRIMARY OUTCOMES methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68). SECONDARY OUTCOMES methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.
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Affiliation(s)
- Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | | | - Maria Skoog
- Clinical Study Support, Clinical Studies Sweden - Forum South, Lund, Sweden
| | - Camilla Groth
- Pediatric Department, Herlev University Hospital, Herlev, Denmark
| | | | | | | | | | - Morris Zwi
- Islington Child and Adolescent Mental Health Service, Whittington Health, London, UK
| | - Richard Kirubakaran
- Cochrane India-CMC Vellore Affiliate, Prof. BV Moses Centre for Evidence Informed Healthcare and Health Policy, Christian Medical College, Vellore, India
| | - Erik Simonsen
- Research Unit, Mental Health services, Region Zealand Psychiatry, Roskilde, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Zhang L, Yao H, Li L, Du Rietz E, Andell P, Garcia-Argibay M, D’Onofrio BM, Cortese S, Larsson H, Chang Z. Risk of Cardiovascular Diseases Associated With Medications Used in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2243597. [PMID: 36416824 PMCID: PMC9685490 DOI: 10.1001/jamanetworkopen.2022.43597] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Use of attention-deficit/hyperactivity disorder (ADHD) medications has increased substantially over the past decades, but there are concerns regarding their cardiovascular safety. OBJECTIVE To provide an updated synthesis of evidence on whether ADHD medications are associated with the risk of a broad range of cardiovascular diseases (CVDs). DATA SOURCES PubMed, Embase, PsycINFO, and Web of Science up to May 1, 2022. STUDY SELECTION Observational studies investigating the association between ADHD medications (including stimulants and nonstimulants) and risk of CVD. DATA EXTRACTION AND SYNTHESIS Independent reviewers extracted data and assessed study quality using the Good Research for Comparative Effectiveness (GRACE) checklist. Data were pooled using random-effects models. This study is reported according to the Meta-analyses of Observational Studies in Epidemiology guideline. MAIN OUTCOMES AND MEASURES The outcome was any type of cardiovascular event, including hypertension, ischemic heart disease, cerebrovascular disease, heart failure, venous thromboembolism, tachyarrhythmias, and cardiac arrest. RESULTS Nineteen studies (with 3 931 532 participants including children, adolescents, and adults; 60.9% male), of which 14 were cohort studies, from 6 countries or regions were included in the meta-analysis. Median follow-up time ranged from 0.25 to 9.5 years (median, 1.5 years). Pooled adjusted relative risk (RR) did not show a statistically significant association between ADHD medication use and any CVD among children and adolescents (RR, 1.18; 95% CI, 0.91-1.53), young or middle-aged adults (RR, 1.04; 95% CI, 0.43-2.48), or older adults (RR, 1.59; 95% CI, 0.62-4.05). No significant associations for stimulants (RR, 1.24; 95% CI, 0.84-1.83) or nonstimulants (RR, 1.22; 95% CI, 0.25-5.97) were observed. For specific cardiovascular outcomes, no statistically significant association was found in relation to cardiac arrest or arrhythmias (RR, 1.60; 95% CI, 0.94-2.72), cerebrovascular diseases (RR, 0.91; 95% CI, 0.72-1.15), or myocardial infarction (RR, 1.06; 95% CI, 0.68-1.65). There was no associations with any CVD in female patients (RR, 1.88; 95% CI, 0.43-8.24) and in those with preexisting CVD (RR, 1.31; 95% CI, 0.80-2.16). Heterogeneity between studies was high and significant except for the analysis on cerebrovascular diseases. CONCLUSIONS AND RELEVANCE This meta-analysis suggests no statistically significant association between ADHD medications and the risk of CVD across age groups, although a modest risk increase could not be ruled out, especially for the risk of cardiac arrest or tachyarrhythmias. Further investigation is warranted for the cardiovascular risk in female patients and patients with preexisting CVD as well as long-term risks associated with ADHD medication use.
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Affiliation(s)
- Le Zhang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
| | - Honghui Yao
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
| | - Lin Li
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ebba Du Rietz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
| | - Pontus Andell
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Division, Karolinska University Hospital, Stockholm, Sweden
| | | | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington
| | - Samuele Cortese
- Centre for Innovation in Mental Health-Developmental Lab, School of Psychology, University of Southampton and NHS Trust, Southampton, United Kingdom
- Hassenfeld Children’s Hospital at NYU Langone, New York University Child Study Center, New York
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden
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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: 13] [Impact Index Per Article: 4.3] [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.
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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
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Pang L, Sareen R. Retrospective analysis of adverse events associated with non-stimulant ADHD medications reported to the united states food and drug administration. Psychiatry Res 2021; 300:113861. [PMID: 33780716 DOI: 10.1016/j.psychres.2021.113861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/06/2021] [Indexed: 11/25/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children and although stimulant medications remain first line to treat the disorder, some families prefer nonstimulants. The goal is to analyze the adverse events (AE) associated with nonstimulant medications using post-marketing drug surveillance data. We aim to increase awareness and aide patient education. A retrospective study of adverse drug events with atomoxetine, clonidine, and guanfacine was performed using the Federal Drug Administration Adverse Event Reporting System (FAERS) Database. Results show that the most commonly reported AEs, as defined by FAERS, were ineffectiveness (9.91-14.15%) fatigue (8.93%), and somnolence (8.8-10.16%). Of those taking atomoxetine, suicidal and self-injurious ideation was reported to a similar degree amongst all age groups. Suicidal ideation was listed within the top 20 most reported AEs for all three medications. It is more likely that some patients will experience milder side effects. We suggest providing these data to patients to help overcome the stigma of starting medication, especially if they prefer nonstimulants. Serious AEs are still reported to a small degree, thus monitoring and consistent patient education remains important. We also recommend educating a wider demographic of patients about recognizing potential development of suicidal thoughts.
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Affiliation(s)
- Lindsy Pang
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Romil Sareen
- Stony Brook Medicine, Stony Brook, New York, USA.
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Findling RL, Candler SA, Nasser AF, Schwabe S, Yu C, Garcia-Olivares J, O'Neal W, Newcorn JH. Viloxazine in the Management of CNS Disorders: A Historical Overview and Current Status. CNS Drugs 2021; 35:643-653. [PMID: 34003459 PMCID: PMC8219567 DOI: 10.1007/s40263-021-00825-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
Viloxazine has a long history of clinical use in Europe as an antidepressant, and has recently been repurposed into an extended-release form for the treatment of attention-deficit/hyperactivity disorder in the USA. An immediate-release formulation was approved for the treatment of depression in the UK in 1974, and was subsequently marketed there and in several European countries for 30 years with no major safety concerns. In contrast to first-generation antidepressants (e.g., tricyclic antidepressants, monoamine oxidase inhibitors), viloxazine was associated with a relatively low risk for cardiotoxicity. Gastrointestinal symptoms were the most commonly reported side effects. The therapeutic effects of viloxazine are thought to be primarily the result of its action as a norepinephrine reuptake inhibitor, although in vitro and preclinical in vivo animal data suggest that viloxazine may also impact the serotoninergic system. This review summarizes the evolving knowledge of viloxazine based on information from previously published preclinical and clinical investigations, and acquired unpublished historical study reports from both open-label and blinded controlled clinical trials. We review the chemical properties, mechanism of action, safety, and tolerability across these studies, and discuss the contemporary rationale for the development of this agent as an extended-release oral formulation for the treatment of attention-deficit/hyperactivity disorder.
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Affiliation(s)
- Robert L Findling
- VCU Department of Psychiatry, 501 North 2nd Street, Richmond, VA, 23298-0308, USA.
| | | | | | | | - Chungping Yu
- Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | | | | | - Jeffrey H Newcorn
- Departments of Psychiatry and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Schulz J, Huber F, Schlack R, Hölling H, Ravens-Sieberer U, Meyer T, Poustka L, Rothenberger A, Wang B, Becker A. The Association between Low Blood Pressure and Attention-Deficit Hyperactivity Disorder (ADHD) Observed in Children/Adolescents Does Not Persist into Young Adulthood. A Population-Based Ten-Year Follow-Up Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041864. [PMID: 33672943 PMCID: PMC7918102 DOI: 10.3390/ijerph18041864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/30/2022]
Abstract
Background: Attention-deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in childhood and adolescence associated with relevant psychosocial impairments. The basic pathophysiology of ADHD may be related, at least partly, to a deficit in autonomic arousal processes, which not only influence core symptoms of the disorder, but may also lead to blood pressure (BP) deviations due to altered arousal regulation. Objectives: This study examined long-term changes in BP in children and adolescents with ADHD up to young adulthood. Methods: In children and adolescents aged between 7 and 17 years at baseline, we compared BP recordings in subjects with (n = 1219, 11.1%) and without (n = 9741, 88.9%) ADHD over a 10-year follow-up using data from the nationwide German Health Survey for Children and Adolescents (KiGGS). Propensity score matching was used to improve the comparability between children in the ADHD and control groups with now n = 1.190 in each group. Results: The results of these matched samples revealed that study participants with ADHD showed significantly lower systolic BP (107.6 ± 10.7 mmHg vs. 109.5 ± 10.9 mmHg, p < 0.001, Cohen’s d = 0.17) and diastolic BP (64.6 ± 7.5 mmHg vs. 65.8 ± 7.4 mmHg, p < 0.001, Cohen’s d = 0.16) at baseline. In a sensitivity analysis with a smaller (n = 272) and more stringently diagnosed ADHD group, the significant differences remained stable with somewhat higher Cohen’s d; i.e., 0.25 and 0.27, respectively. However, these differences did not persist after 10-year follow-up in a smaller matched longitudinal sub-group (ADHD n = 273; control n = 323), as subjects with and without ADHD had similar levels of systolic (123.4 ± 10.65 vs. 123.78 ± 11.1 mmHg, p = 0.675, Cohen’s d = 0.15) and diastolic BP (71.86 ± 6.84 vs. 71.85 ± 7.06 mmHg, p = 0.992, Cohen’s d = 0.16). Conclusions: At baseline, children and adolescents with ADHD had significantly lower BP (of small effect sizes) compared to the non-ADHD group, whereas this difference was no longer detectable at follow-up ten years later. These developmental alterations in BP from adolescence to early adulthood may reflect changes in the state of autonomic arousal, probably modulating the pathophysiology of ADHD.
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Affiliation(s)
- Jan Schulz
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.S.); (F.H.); (L.P.); (A.R.); (A.B.)
| | - Franziska Huber
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.S.); (F.H.); (L.P.); (A.R.); (A.B.)
| | - Robert Schlack
- Robert Koch Institute, Department of Epidemiology and Health Monitoring, Unit Mental Health, 13353 Berlin, Germany; (R.S.); (H.H.)
| | - Heike Hölling
- Robert Koch Institute, Department of Epidemiology and Health Monitoring, Unit Mental Health, 13353 Berlin, Germany; (R.S.); (H.H.)
| | - Ulrike Ravens-Sieberer
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Thomas Meyer
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Göttingen, 37075 Göttingen, Germany;
- German Centre for Cardiovascular Research, Partner Site Göttingen, 10115 Berlin, Germany
| | - Luise Poustka
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.S.); (F.H.); (L.P.); (A.R.); (A.B.)
| | - Aribert Rothenberger
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.S.); (F.H.); (L.P.); (A.R.); (A.B.)
| | - Biyao Wang
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.S.); (F.H.); (L.P.); (A.R.); (A.B.)
- Department of Clinical, Educational and Health Psychology, University College London, London WC1H 0AP, UK
- Correspondence:
| | - Andreas Becker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.S.); (F.H.); (L.P.); (A.R.); (A.B.)
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Bellato A, Arora I, Hollis C, Groom MJ. Is autonomic nervous system function atypical in attention deficit hyperactivity disorder (ADHD)? A systematic review of the evidence. Neurosci Biobehav Rev 2020; 108:182-206. [DOI: 10.1016/j.neubiorev.2019.11.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/26/2022]
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10
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Ching C, Eslick GD, Poulton AS. Evaluation of Methylphenidate Safety and Maximum-Dose Titration Rationale in Attention-Deficit/Hyperactivity Disorder: A Meta-analysis. JAMA Pediatr 2019; 173:630-639. [PMID: 31135892 PMCID: PMC6547117 DOI: 10.1001/jamapediatrics.2019.0905] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Evidence on the titration of stimulant medications for attention-deficit/hyperactivity disorder (ADHD) is lacking. However, this lack of evidence has not prevented medication guidelines from specifying apparently arbitrary dose limitations, which could discourage clinicians from titrating methylphenidate to higher and, perhaps for some patients, more efficacious doses. OBJECTIVE To determine the evidence on dose titration and adverse events associated with dose titration of stimulants for ADHD. DATA SOURCES MEDLINE from 1946, Embase from 1974, and PsycINFO from 1806 through April 1, 2019, were searched to identify relevant articles. STUDY SELECTION The inclusion criteria were that (1) the study was conducted on children up to 18 years of age; (2) children had a diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, or hyperkinetic disorder according to the International Classification of Diseases codes; and (3) the dose of methylphenidate was determined by titration. DATA EXTRACTION AND SYNTHESIS The PRISMA guidelines for abstracting data and assessing data quality and validity were followed. Quality assessment was undertaken using the Jadad scoring system. Statistical analysis was undertaken using a random-effects model. MAIN OUTCOMES AND MEASURES The outcomes of interest were (1) the doses used in published clinical trials, (2) the clinical justification given by researchers for their selected dose range, and (3) the adverse effects associated with methylphenidate when the dose is established by titration. RESULTS A total of 11 randomized clinical trials and 38 cohort studies were analyzed. The randomized clinical trials involved 1304 participants treated with methylphenidate and 887 controls; the 38 cohort studies included 5524 participants. Maximum doses of methylphenidate ranged from 0.8 to 1.8 mg/kg/d. Some studies detailed their method of titration, including starting dose, titration interval, increment dose, and maximum dose. Not all of these studies reported justification for the chosen dose range. Common adverse effects of methylphenidate included insomnia (odds ratio, 4.66; 95% CI, 1.99-10.92; P < .001), anorexia (5.11 higher than for those who took placebo; 95% CI, 1.99-13.14; P < .001), abdominal pain (1.9 times more likely; 95% CI, 0.77-4.77; P = .16), and headache (14% of participants; 95% CI, 10%-20%; P < .001). CONCLUSIONS AND RELEVANCE A range of maximum doses for methylphenidate was recommended in clinical studies; no discernable scientific justification for any particular dose was given. Reports of life-threatening adverse events were absent; further studies of the efficacy, tolerability, and safety of methylphenidate titrated purely on clinical grounds, without reference to any set maximum dose, are needed.
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Affiliation(s)
- Cellina Ching
- Western Sydney University, Sydney, New South Wales, Australia
| | - Guy D. Eslick
- The Whiteley-Martin Research Centre, Department of Surgery, The University of Sydney, Penrith, New South Wales, Australia
| | - Alison S. Poulton
- Charles Perkins Centre Nepean, The University of Sydney, Penrith, New South Wales, Australia
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11
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Pharmacological Treatment of Attention Deficit Hyperactivity Disorder During Pregnancy and Lactation. Pharm Res 2018; 35:46. [DOI: 10.1007/s11095-017-2323-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022]
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12
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Clavenna A, Bonati M. Pediatric pharmacoepidemiology - safety and effectiveness of medicines for ADHD. Expert Opin Drug Saf 2017; 16:1335-1345. [DOI: 10.1080/14740338.2017.1389894] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Antonio Clavenna
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
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13
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14
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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.
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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
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