ADHD Symptom Rebound and Emotional Lability With Lisdexamfetamine Dimesylate in Children Aged 6 to 12 Years

A Post-Hoc Analysis of Emotional Lability With Delayed-Release/Extended-Release Methylphenidate in Children Aged 6 to 12 Years of Age Participating in Two Phase 3 Clinical Trials

OBJECTIVE

DR/ER-MPH (formerly HLD200) is an evening-dosed delayed-release and extended-release methylphenidate approved for the treatment of ADHD in patients ≥6 years. Post hoc analyses of two pivotal Phase 3 trials: HLD200-107 (NCT02493777) and HLD200-108 (NCT02520388) evaluated emotional lability (EL) with DR/ER-MPH treatment.

METHODS

Differences in Conners Global Index-Parent (CGI-P) EL subscale scores and age- and gender-adjusted T-scores over an open-label titration phase (HLD200-107) and between treatment and placebo groups at endpoint (HLD200-108) were evaluated.

RESULTS

In HLD200-107 (N = 117) mean CGI-P EL subscale scores improved from 5.3 to 1.3 (p < .0001) after 6 weeks; in HLD200-108 significant improvements were observed in the treatment group (n = 81) versus placebo (n = 80; 3.11 vs. 4.08; p = .0053). T-scores showed an improvement with DR/ER-MPH treatment in both trials. Few emotional adverse events (AEs) were reported.

CONCLUSION

DR/ER-MPH treatment resulted in statistically significant improvements in EL to the level of non-ADHD peers as contextualized by T-scores.

A Dimensional Approach to Emotional Lability in Youth

Emotional lability (EL) is a common symptom dimension in youth. It manifests in the context of a number of psychiatric illnesses and is a promising transdiagnostic construct that is recognizable and treatable and warrants further study. Multiple terms and assessment tools exist to define and measure EL, and it has a phenomenology distinct from the related construct of irritability. This clinical perspective reviews the neurobiological and clinical evidence in support of EL as an important symptom dimension that responds to a variety of behavioral and medication interventions and highlights the significant limitations of this approach.

Revisiting stimulant use for emotional dysregulation in attention-deficit/hyperactivity disorder (ADHD)

INTRODUCTION

Emotional dysregulation (ED) symptoms are present in a considerable portion of patients with attention-deficit/hyperactivity disorder (ADHD). In recent years, an increasing number of studies investigated the effects of stimulant medications on ED in patients with ADHD.

AREAS COVERED

A narrative review of the literature on stimulant treatment for ED is provided, including controlled and observational clinical studies conducted on pediatric and adult samples and neurobiological investigations. Positive effects of stimulants on irritability have been demonstrated in children. Comorbidity with disruptive behavior disorders (DBD) and disruptive mood dysregulation disorder does not prevent stimulant effectiveness. Methylphenidate has also been found to reduce temper problems, affective instability, and emotional over-reactivity in adults with ADHD, although with variable effect sizes. A variety of adverse emotional effects have been reported, especially at high doses and in special populations. However, several possible confounders of treatment-emergent ED have been highlighted. Finally, according to neuroimaging studies, stimulants may mitigate emotional processing anomalies associated with ADHD.

EXPERT OPINION

The findings are consistent with models including ED within the core features of ADHD. Stimulant treatment should be prioritized over antipsychotics in ADHD-DBD. It remains to be elucidated whether other medications may be more effective in specific populations with ADHD and/or ED.

Adult Patient Preferences for Long-Acting ADHD Treatments: A Discrete Choice Experiment

BACKGROUND AND OBJECTIVE

Treatment for attention deficit hyperactivity disorder (ADHD) requires a multifaceted approach including psychosocial interventions and pharmacological treatment. This study evaluates preferences for specific attributes associated with different long-acting stimulant treatment among US adults with ADHD.

METHODS

Patients completed an online, cross-sectional survey, incorporating a discrete choice experiment to assess preferences for attributes.

RESULTS

Analyses included 200 adults with ADHD (mean age 33.0 years; 60% self-reporting moderate severity); the mean (SD) Adult ADHD Self-Report Scale-v1.1 score was 45.9 (12.4). Overall, patients valued speed of onset most and risk of rebound least. Three population groups with distinct preferences were identified: side effect-driven (n=69, 35%), quick onset-driven (n=47, 24%) and quick onset and long duration-driven (n=84, 42%).

CONCLUSION

This study shows differences in how adults with ADHD value and assess benefit-risk trade-offs when considering the desired attributes of stimulant treatments, highlighting the importance of patient-physician shared decision-making to optimize the desired benefits of individualized treatment.

Stimulant Withdrawal in a Child with Autism Spectrum Disorder and ADHD - A Case Report

OBJECTIVE

To consider whether the concepts of tolerance and withdrawal to stimulant medications apply to a preadolescent female, affected by autism spectrum disorder (ASD) and treated for associated attention-deficit/hyperactivity disorder (ADHD).

METHODS

We describe the case history and review scientific English language literature pertaining to acute withdrawal effects associated with methylphenidate and amphetamine derivatives in children.

RESULTS

An 11-year-old female with ASD and ADHD referred to our clinic experienced vomiting, headaches, and light sensitivity following abrupt discontinuation of methylphenidate; she subsequently presented with migraines and marked malaise immediately after a dose reduction in lisdexamfetamine. Evidence supports the notion that ADHD symptoms in children with ASD can be effectively treated with methylphenidate; however, beneficial effects are less robust relative to children with a primary ADHD diagnosis. Children affected by ASD are also more susceptible to adverse effects. Literature on withdrawal from stimulants in children is limited to case studies; in contrast, in the adult population more information is available, especially in adults with substance abuse disorders. Adults experiencing stimulant withdrawal often experience depression, fatigue, changes in appetite, and insomnia or hypersomnia.

CONCLUSIONS

We argue that tolerance to stimulants was conceivably developing in this young female, and consequently discontinuation of methylphenidate and dose reduction of lisdexamfetamine resulted in withdrawal symptoms. Children with ASD are more sensitive to stimulant medications and we wonder whether this extends to an increased sensitivity to developing tolerance to stimulant medication. Clinicians ought to be vigilant about the emergence of symptomology suggestive of withdrawal phenomena following stimulant discontinuation.

The Impact of Emotional Lability Symptoms During Childhood in Adults With ADHD

OBJECTIVE

To determine whether emotional lability (EL) in adult ADHD patients can already be identified during their childhood and the extent to which this childhood symptomatology can predict EL in adulthood.

METHOD

Seven hundred eighteen adults with ADHD were examined. EL in adulthood was assessed using the Conners' Adult ADHD Rating Scales (CAARS). According to Conners' definition of EL, seven items from the Wender Utah Rating Scale (WURS) were used to determine this symptomatology in childhood.

RESULTS

EL was identified in 31.1% of the participants, and 29.6% of this subgroup reported EL symptoms in childhood. Childhood EL was the strongest predictor of these symptoms in adulthood (odds ratio [OR] = 6.18). ADHD subtype, female sex, family history of ADHD, psychiatric comorbidities, and physical abuse were also related to EL development/persistence.

CONCLUSION

Screening for EL symptoms in children with ADHD is important, as they are the strongest predictor of this symptomatology in adulthood.