Weight loss on stimulant medication: how does it affect body composition and bone metabolism? - A prospective longitudinal study

Effect of methylphenidate on height in pediatric attention-deficit hyperactivity disorder patients: a systematic review and meta-analysis

Methylphenidate (MPH), a first-line treatment for attention-deficit hyperactivity disorder (ADHD) management, has been the focus of debate for decades regarding its effect on growth. The aim of this PRISMA meta-analysis was to determine the effect of MPH on height in children/adolescents with ADHD and its predictive factors based on literature reports. Available full-text articles were systematically reviewed to identify clinical studies of pediatric ADHD patients with height Z-score (HZS) data for monotherapy MPH-treated and non-treated groups. We estimated standardized mean differences (SMDs) of HZS or its changes from baseline (ΔHZS) between groups, then identified associated factors through subgroup analyses and meta-regression. For before-after treatment studies, the paired standard errors of ΔHZS were re-estimated to demonstrate in the forest plot. Risk of bias was analyzed using the Newcastle-Ottawa Scale. Among the 29 eligible studies, 26 reported ΔHZS with self-control groups, and ΔHZS or absolute HZS were compared to other external controls in 11 studies. A significant reduction was observed between post-MHP and pre-MPH use, with high heterogeneity (SMD =  - 0.40; 95% confidence interval = [ - 0.54,  - 0.27]; I2 = 91%). The study region, ADHD subtype, and stimulant-naïve status of patients at baseline may modify the effect on HZS. Because of the high clinical heterogeneity in observational studies, clinicians should consider the negative effect of MPH on height in ADHD patients by determining whether patients fulfill appropriate high-risk criteria. Further well-designed longitudinal studies are required to better quantify this effect, especially with prolonged treatment.

The Impact of Methylphenidate on Pubertal Maturation and Bone Age in ADHD Children and Adolescents: Results from the ADHD Drugs Use Chronic Effects (ADDUCE) Project

OBJECTIVE

The short-term safety of methylphenidate (MPH) has been widely demonstrated; however the long-term safety is less clear. The aim of this study was to investigate the safety of MPH in relation to pubertal maturation and to explore the monitoring of bone age.

METHOD

Participants from ADDUCE, a two-year observational longitudinal study with three parallel cohorts (MPH group, no-MPH group, and a non-ADHD control group), were compared with respect to Tanner staging. An Italian subsample of medicated-ADHD was further assessed by the monitoring of bone age.

RESULTS

The medicated and unmedicated ADHD groups did not differ in Tanner stages indicating no higher risk of sexual maturational delay in the MPH-treated patients. The medicated subsample monitored for bone age showed a slight acceleration of the bone maturation after 24 months, however their predicted adult height remained stable.

CONCLUSION

Our results do not suggest safety concerns on long-term treatment with MPH in relation to pubertal maturation and growth.

Breaking It Down: A Systematic Review Unravelling the Impact of Attention Deficit Hyperactivity Disorder and Methylphenidate on Childhood Fractures

Limb fractures are a common cause of pediatric hospital admissions and surgeries, with a significant prevalence in the United Kingdom across all injury categories. Among psychiatric conditions in children, attention deficit hyperactivity disorder (ADHD) stands out as frequently associated with fractures, particularly those involving extremities. ADHD, with diagnoses prevalent among a significant proportion of school-age children and adolescents, has witnessed a growing global incidence. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist for our systematic literature search, using various databases and specific search terms related to ADHD and fractures. We considered articles from 2018 to 2023, focusing on English language papers with free full-text access. Our selection process used the PRISMA flowchart. We began with 1,890 articles and, after deduplication, title screening, abstract assessment, and quality evaluation included nine research papers in our review. Our primary focus was on examining fracture-related outcomes in individuals with ADHD compared to those without, considering medication status. These studies encompassed various designs, with a focus on the ADHD-fracture relationship and methylphenidate's (MPH) impact. Our study confirms that ADHD increases fracture risk and suggests that MPH may help mitigate this risk. Early ADHD detection is vital for nonpharmacological interventions. Orthopedic surgeons should proactively identify ADHD, while healthcare professionals should offer injury prevention guidance, particularly for at-risk groups.

Influence of psychostimulants on bone mineral density and content among children with attention deficit hyperactivity disorder. A systematic review

There is a controversy over the influence of psychostimulant medications on bone mineral density (BMD) and bone mineral content (BMC) among children with attention-deficit-hyperactivity-disorder (ADHD). The aim of the present systematic review was to assess the influence of psychostimulant medications on BMD and BMC among children with ADHD. A comprehensive search of electronic databases, including PubMed, Scopus, Embase, and Cochrane Library, was conducted to identify relevant studies published up until July 2023. Clinical studies that addressed the focused question "Do psychostimulant medications affect bone mineral density and content in children with ADHD?" were included. Letters to the Editor, studies on animal-models, ex-vivo and in-vitro studies, commentaries and reviews were excluded. The primary outcome measures were changes in BMD and BMC. Study quality was assessed using the risk of bias for non-randomized studies-exposure tool. Five non-randomized clinical studies were included. The number of participants ranged from 18 to 6489 with mean ages ranging from 7.3 to 13.75 years. The study durations ranged between five and seven years. In all studies osseous evaluation was done using dual-energy X-ray absorptiometry. The bone locations examined included total body, lumbar-spine, femur, femoral-neck, femoral body, and pelvis. Two studies reported that psychostimulant medications reduce BMC and BMD. In one study, bone turnover, serum leptin and fat levels were reduced in children using psychostimulant medications but no unusual reduction recorded among controls. In general, 80 % of the studies concluded that psychostimulant medications compromise BMC and BMD. Power analysis was done in one study. One study had a low RoB and the remaining demonstrated some concerns. Given the methodological concerns observed in the included studies, arriving at a definitive conclusion regarding the effects of psychostimulant medications on BMC, BMD, and bone turnover in children with ADHD is challenging. However, it is important to acknowledge that an association between psychostimulant medications and these bone-related parameters cannot be disregarded.

Chronic oral methylphenidate plus fluoxetine treatment in adolescent rats increases cocaine self-administration

Background

Depression and attention deficit hyperactivity disorder are known to be comorbid. Treatment of these commonly coexisting diseases typically involves the combined prescription of methylphenidate (MP), a psychostimulant, and fluoxetine (FLX), a selective serotonin reuptake inhibitor (SSRI). MP and cocaine have similar mechanisms of action and this study examined the effects of chronic treatment of MP combined with FLX on cocaine consumption in rats.

Methods

Four groups of rats received access to drinking solutions of water (control), MP (30/60 mg/kg/day), FLX (20 mg/kg/day), or the combination of MP (30/60 mg/kg/day) plus FLX (20 mg/kg/day), during 8 h per day for one month. Following these drug treatments, rats were allowed to self-administer cocaine for 14 days.

Results

Our results showed that, during the first week of cocaine self-administration, the MP-treated rats had significantly greater numbers of active lever presses (plus 127%) and increased consumption of cocaine compared to the control rats. In contrast, during week two of cocaine self-administration, the rats treated with the MP + FLX combination showed significantly more lever presses (plus 198%) and significantly greater cocaine consumption (plus 84%) compared to the water controls.

Conclusion

Chronic oral treatment during adolescence with the combination of MP plus FLX resulted in increased cocaine use after 2 weeks of cocaine self-administration in rats. These novel findings suggest that the combined exposure to these two drugs chronically, during adolescence, may produce increased vulnerability towards cocaine abuse during young adulthood.

Adverse Effects of Stimulant Interventions for Attention Deficit Hyperactivity Disorder (ADHD): A Comprehensive Systematic Review

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.

Combined methylphenidate and fluoxetine treatment in adolescent rats significantly impairs weight gain with minimal effects on skeletal development

Methylphenidate (MP) is frequently prescribed to treat Attention-Deficit/Hyperactivity Disorder (ADHD); however, many patients with ADHD experience depression and anxiety. As such, concomitant administration of selective serotonin reuptake inhibitors such as fluoxetine (FLX) is common. Our laboratory and others have shown that MP impairs skeletal development in preclinical and clinical settings, and FLX has also been linked to skeletal deficits. Unfortunately, little is known about the effects of combined MP and FLX treatment on skeletal development. The objective of this study was to investigate the effects of MP and FLX on bone morphology and biomechanical properties in adolescent rats. Four-week-old male Sprague-Dawley rats were randomly divided into the following 4 groups: Water, MP, FLX, and MP + FLX. As body weights in the MP, FLX, and MP + FLX groups were all lower than Water, the data were compared directly and after adjusting to body weight via linear regression. The direct comparison revealed that MP + FLX rats had significantly shorter (~12 %) and narrower femora and tibiae (~10 %) compared to most other groups, along with shorter (26-35 %), disorganized tibial growth plates. MicroCT analyses of the trabecular compartment of the proximal tibia identified reductions of 47 % for TV, 86 % for BV, 74 % for BV/TV, 68 % for Tb.N, 25 % in Tb.Th, and 74 % in vBMD concomitant with increases of 44 % for Tb.Sp for MP + FLX compared to Water. Similar analyses of femoral midshaft cortical bone identified reductions of 29 % for Ct.V, 30 % for Ps.V, 30 % for Ec. V, and 51 % for pMOI, as well as increases of 17 % for Ct.Th and 2 % for TMD for MP + FLX compared to Water. Biomechanically, MP + FLX femora were weaker, as indicated by a reduction in ultimate force (14 %) in MP + FLX compared to Water. The microstructural and biomechanical effects of MP + FLX were eliminated after adjustment for body weight, though the detrimental effects on growth plate morphology remained. We conclude that while the adverse microstructural and biomechanical effects of MP + FLX seen via direct comparison are predominantly attributable to reductions in body weight rather than direct effects on bone, MP and FLX, particularly in combination show detrimental effects on growth plate structure and chondrocyte morphology. These findings warrant further research into the effect of these drugs on weight gain, skeletal development and growth plate morphology, as well as consideration by physicians treating children and adolescents with ADHD.

Effects of methylphenidate on femoral bone growth in male rats

The use of Methylphenidate (MP) can have adverse effects on bone growth and mineralization. This study aimed to investigate the underlying pathophysiology of MP-induced skeletal deficits in growing rats using stereological and immunohistochemical methods. Male rats, aged 4 weeks, were orally treated with MP through an 8-h/day water drinking protocol. The rats (n=30) were randomly divided into three groups: MP-High Dose (30/60 mg/kg/day MP), MP-Low Dose (4/10 mg/kg/day MP), and control (water only). After 13 weeks, the femoral bones were assessed using calliper measurements, dual-energy X-ray absorptiometry, and biomechanical evaluation. The total femur volume, cartilage volume, growth zone volume, and volume fractions were determined using the Cavalieri method. Immunohistochemical analyses were conducted using alkaline phosphatase and anti-calpain antibody staining. Rats exposed to MP exhibited significant reductions in weight gain, femoral growth, bone mineralization, and biomechanical integrity compared to the control group. The total femoral volume of MP-treated rats was significantly lower than that of the control group. The MP-High Dose group showed significantly higher ratios of total cartilage volume/total femoral volume and total growth zone volume/total femoral volume than the other groups. Immunohistochemical evaluation of the growth plate revealed reduced osteoblastic activity and decreased intracellular calcium deposition with chronic MP exposure. The possible mechanism of MP-induced skeletal growth retardation may involve the inhibition of intracellular calcium deposition in chondrocytes of the hypertrophic zone in the growth plate. In this way, MP may hinder the differentiation of cartilage tissue from bone tissue, resulting in reduced bone growth and mineralization.

Combined Chronic Oral Methylphenidate and Fluoxetine Treatment During Adolescence: Effects on Behavior

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) can be comorbid with depression, often leading to the prescription of both methylphenidate (MP) and selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (FLX). Moreover, these drugs are often misused as cognitive enhancers. This study examined the effects of chronic oral co-administration of MP and FLX on depressive- and anxiety-like behaviors.

METHODS

Adolescent rats received daily either water (control), MP, FLX, or the combination of MP plus FLX in their drinking water over the course of 4 weeks.

RESULTS

Data analysis shows a decrease in food consumption and body weight for rats exposed to FLX or the combination of MP and FLX. Sucrose consumption was significantly greater in FLX or MP+FLX groups compared to controls. FLX-treated rats showed no effect in the elevated plus maze (EPM; open arm time) and forced swim test (FST; latency to immobility). However, rats treated with the combination (MP+FLX) showed significant anxiolytic-like and anti-depressive-like behaviors (as measured by EPM and FST), as well as significant increases in overall activity (distance traveled in open field test). Finally, the combined MP+FLX treatment induced a decrease in anxiety and depressive- like behaviors significantly greater than the response from either of these drugs alone.

CONCLUSION

These behavioral results characterize the long-term effects of these drugs (orally administered) that are widely co-administered and co-misused and provide important insight into the potential neurobiological and neurochemical effects. Future research will determine the potential risks of the long-term use of MP and FLX together.

Is there any relationship between fixed orthodontic treatment and developmental indicators in children and adolescents? A prospective cohort study

Background

Fixed orthodontic treatment may cause discomfort four to six weeks after the initiation of the treatment as it may change the type and amount of food consumed by children. This temporary change may have a long-term effect on the growth status of such children. This study aimed to detect the longitudinal relationship between fixed orthodontic treatment and developmental indicators in children and adolescents.

Methods

The study population encompassed adolescents undergoing fixed orthodontic treatment as the exposure group (n = 30) and adolescents with no orthodontic treatment as the control group (n = 90). The patients' dental age, weight, height, body mass index (BMI), and wrist circumference were assessed at the baseline, as well as 1, 3, and 6 months after the orthodontic treatment. The significance level was set to be p = 0.05.

Results

One-hundred twenty participants were included in this study. In the two groups, all growth parameters revealed an increasing trend. In the exposure group, weight-related indices (i.e., weight, BMI, and wrist circumference) decreased in the first month and then increased during the next five months. All indices in the control group and height in the exposure group exhibited a continuous increase.

Conclusion

Fixed orthodontic treatment affects childhood growth indices. However, these effects are probably short-term, and the catchup growth mechanism can offset these effects and modify the changes in growth indices. A longer follow-up period is recommended to be considered by future researchers.

Possible Association between Methylphenidate and Mandibular Bone Characteristics Detected by Dental Panoramic Radiograph in Children and Adolescents with ADHD

Some studies have shown that children treated with psychostimulants for attention-deficit hyperactivity disorder (ADHD) have decreased bone mineral density (BMD). Mandibular cortical width (MCW) may be used as a surrogate measure for evaluating BMD. We compared the MCW measured on digital panoramic radiographs (DPR) of 38 children and adolescents with ADHD who were treated with methylphenidate for at least 12 months to the MCW of 58 children and adolescents without ADHD (control). The two groups had a similar mean age (p = 0.3). Mean MCW was significantly lower among children with ADHD compared to those in the control group (2.77 ± 0.33 mm vs. 3.04 ± 0.46 mm, p = 0.004). Additionally, each of the MCW sides were significantly smaller in the group with ADHD compared with the control group. In conclusion, treatment with methylphenidate is associated with low MCW in children and adolescents with ADHD. Analysis of MCW on DPR may help in screening children that are at risk of bone health alterations that may result in low BMD in adulthood. Dentists may be the first to identify bone health abnormalities and should be aware of their role in referring their patients to further follow-up.

Stimulant use and bone health in US children and adolescents: analysis of the NHANES data

Stimulants have become the most popular psychopharmacologic drugs used in therapy for attention-deficit/hyperactivity disorder (ADHD). Childhood and adolescence are crucial periods for optimizing bone health to prevent osteoporosis-related fractures in old age. However, controversy remains regarding the relationship between stimulant use and bone health. The present study was designed to examine the bone mineral content (BMC) and bone mineral density (BMD) of 5472 individuals aged 8-16 years with or without stimulant use based on National Health and Nutrition Examination Survey (NHANES) 2011-2018 data and to further assess the association between stimulant use and bone health. Among these, 284 (5.2%) participants were using stimulants. In analyses stratified by sex, the BMC and BMD at the level of the lumbar spine, pelvis, and total body were generally lower among stimulant users than among nonusers in males (all P < 0.001), while the differences were not statistically significant in females. In multivariable linear regression models, the increasing range of BMCs and BMDs with age was lower in participants using stimulants than in those not using stimulants after fully adjusting for potential confounding factors. Compared to participants not using stimulants, stimulant use ≥ 3 months was associated with significantly lower BMCs [lumbar spine: β =  - 1.35, (95% CI: - 2.56, - 0.14); pelvis: β =  - 9.06, (95% CI: - 15.21, - 2.91); and total: β =  - 52.96, (95% CI: - 85.87, - 20.04)] and BMDs [pelvis: β =  - 0.03, (95% CI: - 0.04, - 0.01), total: β =  - 0.01, (95% CI: - 0.02, - 0.00)].

CONCLUSIONS

Children and adolescents using stimulants exhibited reductions in BMC and BMD at the lumbar spine, pelvis, and total body compared to those who were not using stimulants, especially among males.

WHAT IS KNOWN

• Childhood and adolescence are crucial periods for optimizing bone health to prevent osteoporosis-related fractures in old age. • Controversy remains regarding the relationship between stimulant use and bone health.

WHAT IS NEW

• The bone mineral content and bone mineral density at the level of the lumbar spine, pelvis, and total body were generally lower among stimulant users than among nonusers in males, while the differences were not statistically significant in females. • Body mass index and serum alkaline phosphatase may be predictors for loss of bone mineral content and bone mineral density in stimulant users.

A 24-Month Effects of Methylphenidate Use on Growth in Children and Adolescents With Attention Deficit Hyperactivity Disorder

OBJECTIVE

The primary objective of this study was to investigate the effect of methylphenidate (MPH) on height, weight, and body mass index (BMI) in drug-naive children and adolescents with attention deficit hyperactivity disorder (ADHD) over 24 months. The secondary objective was to investigate whether the age of MPH initiation and sex act as risk factors for growth retardation.

METHODS

A total of 82 patients with ADHD were included. Weight, height, and BMI were measured at baseline and every 6 months up to 24 months. Weight, height, and BMI data were converted to z-scores and analyzed using two-way repeated-measures ANOVA and multiple linear regression.

RESULTS

The z-score of height, weight and BMI decreased from the baseline values. The z-scores of height were at baseline 0.002; 6 months -0.100; 12 months -0.159; 18 months -0.159; 24 months -0.186. The z-scores of weight were at baseline 0.104; 6 months -0.155; 12 months -0.256; 18 months -0.278; 24 months -0.301. Here were no age and sex differences of height, weight, and BMI.

CONCLUSION

The use of MPH was associated with attenuation of weight and height gain rates in children and adolescents with ADHD.

Two-Month administration of Methylphenidate improves olfactory sensitivity and suppresses appetite in individuals with obesity

INTRODUCTION

Olfaction contributes to feeding behaviour and is modulated by changes in dopamine levels. Methylphenidate (MPH) increases brain dopamine levels and has been shown to reduce appetite and promote weight loss in patients with attention deficit hyperactivity disorder. The objectives of this study were to test the effect of MPH on olfaction, appetite, energy intake and body weight on individuals with obesity.

METHODS

In a randomized, double-blind study, 12 participants (age 28.9±6.7 yrs) (BMI 36.1±4.5 kg/m2) were assigned to MPH (0.5mg/kg) (n=5) or Placebo (n=7) twice daily for 2 months. Appetite (Visual Analog Scale), odour threshold (Sniffin' Sticks®), energy intake (food menu), and body weight (DEXA scan) were measured at day 1 and day 60.

RESULTS

MPH intake significantly increased odour threshold scores (6.3±1.4 vs. 9.4±2.1 and 7.9±2.3 vs. 7.8±1.9, respectively; p=0.029) vs. Placebo. There was a significantly greater suppression of appetite sensations (desire to eat (p=0.001), hunger (p=0.008), and prospective food consumption (p=0.003)) and an increase in fullness (p=0.028) over time in the MPH vs. Placebo.

CONCLUSIONS

MPH suppressed appetite and improved olfactory sensitivity in individuals with obesity. These data provide novel findings on the favourable effects of MPH on appetite and weight regulation in individuals living with obesity.

Effect of methylphenidate at different doses on new bone formation with rapid maxillary expansion: A micro-CT and histomorphometric study in rats

OBJECTIVES

This study aimed to evaluate the effect of systemically administered methylphenidate hydrochloride (MPH) on new bone formation in premaxillary suture after rapid maxillary expansion (RME).

SETTING AND SAMPLE POPULATION

Thirty-three Wistar rats were divided into four groups: Group 1 (high dose, 30/60 mg/kg MPH), Group 2 (low dose, 4/10 mg/kg MPH), Group 3 (positive control) and Group 4 (negative control).

METHODS

RME was applied on the 70th day of the study. A 5-day RME period was followed by a 12-day retention period. The experiment was terminated on the 87th day. Micro-CT for radiological evaluation, haematoxylin-eosin and Masson's trichrome staining methods were used for histomorphometric evaluation.

RESULTS

Among experimental groups with RME, the lowest number of osteoblasts and capillaries in Group 1 (P < .05). New bone formation, fibrous callus formation, distal osteotomy line, proximal osteotomy union and cortex remodelling were observed to be lower in Group 1 and Group 2 than Group 3 (P < .05). There was a statistically significant difference between Group 4 and each of the other groups (P = .000) in the evaluation of the results for bone mineral density, bone volume, bone volume percentage, trabecular thickness and trabecular number.

CONCLUSIONS

MPH reduces cellular activity for new bone formation in suture in RME groups. Before performing rapid maxillary expansion in patients using MPH, the use of the drug should be postponed after a multidisciplinary decision process or clinical doses should be lowered.

Effects of methylphenidate on height, weight and blood biochemistry parameters in prepubertal boys with attention deficit hyperactivity disorder: an open label prospective study

Background: Adverse effects of stimulants on growth in children have long been studied, but the results remain to be clarified, because metabolic changes or predictors accompanying the growth deviations were not sufficiently studied. Objective: This open label-prospective study investigated the effects of methylphenidate (MPH) on weight, height, blood biochemistry in children with attention deficit hyperactivity disorder (ADHD). Method: Prepubertal boys treated with MPH in Child and Adolescent Psychiatry Clinic at Antalya Training and Research Hospital in Health Sciences University, Turkey were recruited. Height and weight z-scores and fasting blood samples were taken at baseline and 6^th month. Changes were compared by paired-samples t-test or Wilcoxon signed-rank test. Any association between the changes in growth and biochemical values was analyzed by Spearman's Rank-Order Correlation. The statistical significance threshold was p<0.01. Results: 31 boys aged 74 to 104 months were enrolled in the study sample (mean=87.6, Standard Deviation (SD)=9.2). Osmotic release oral system-MPH (18 mg/day) was used in 77.4% (N=24) and immediate release-MPH (5 mg three times a day) in 22.5% (N=7). Average daily drug dose was 0.66 mg/kg (SD=0.12). Baseline weight z-score was 0.63 (SD=1.12), decreased significantly at 6 months (0.24 [SD=1.04]) (Z=-4.44, p=0.000, r=0.5) (median z-score was 0.53 at baseline, -0.11 at 6 months). Baseline height z-score (0.23[SD=0.87]) was not suppressed significantly at 6 months (0.28[SD=0.85])(t(30) = ‒1.50, p=0.14). Glucose (t(30) = -4.33, p=0.000, r=0.6), creatinine (t(30)=-3.28, p=0.003, r=0.5) and 25OH-VitD (N=29, Z=-3.98, p=0.000, r=0.5) increased but alkaline phosphatase (ALP) decreased (t(28)=3.63, p=0.001, r=0.5). The differences in W-SDS and ALP were positively correlated (r=0.47, p=0.009). Conclusions: Our results indicate the importance of monitoring blood variables that may accompany growth changes early in MPH treatment and should be further assessed in larger samples.

Impact of CNS Stimulants for Attention-Deficit/Hyperactivity Disorder on Growth: Epidemiology and Approaches to Management in Children and Adolescents

Central nervous system stimulants are established treatments for pediatric attention-deficit/hyperactivity disorder with robust efficacy data. Reductions in appetite, weight, and growth velocity are some of the most common concerns regarding the long-term use of central nervous system stimulants in developing children. They are associated with suppression of weight and body mass index in childhood. However, both weight and body mass index often progressively increase over adolescence at rates faster than those seen in non-attention-deficit/hyperactivity disorder youth to the degree that attention-deficit/hyperactivity disorder is associated with elevated body mass index by the end of adolescence regardless of medication use. The capacity of central nervous system stimulants to slow growth was identified 50 years ago. Recent work has established that the growth deficits accumulate during the first 2 years of use and may persist provided medication is used. Early initiation coupled with persistent use through adolescence is most likely to be associated with clinical impactful growth suppression. There has been limited formal investigation of treatments for stimulant-associated reductions in weight and height. The most robust evidence exists for drug holidays improving weight gain. Observational studies suggest that limiting lifetime exposure or discontinuing medication is associated with greater adult height. Additional research is needed to identify the causal mechanisms driving the observed slowing in growth as well as the identification of predictors of clinically impactful growth suppression.

ADHD, stimulant medication use, and the risk of fracture: a systematic review and meta-analysis

We performed a meta-analysis to quantify the relationships among a diagnosis of attention-deficit/hyperactivity disorder (ADHD), the use of stimulant medication, and the risk of fracture. There was a significant positive association between ADHD and the risk of fracture. However, stimulant ADHD medication therapy appears to be associated with a reduced risk of fracture in patients with ADHD.

INTRODUCTION

ADHD is associated with an increased fracture risk due to a lack of impulse control. ADHD medication may have a protective effect via behavior modification. However, previous research found an adverse effect of stimulant use on bone mass. Therefore, this meta-analysis study assessed the relationships among ADHD, the use of stimulant medication, and fracture risk.

METHODS

A literature search was conducted using PubMed and EMBASE from inception through December 2020. Random-effects models were used to determine overall pooled estimates and 95% confidence intervals (CIs).

RESULTS

The meta-analysis included 10 observational studies. Our results showed that ADHD diagnosis is associated with an increased risk of fracture (OR = 1.17; 1.01-1.35, p = 0.035). Notably, a higher risk of fracture (OR = 1.37, 95% CI 1.2-1.58, p < 0.001) was observed in non-stimulant-treated ADHD. However, no significant association, but a trend toward a lower risk, was observed for stimulant-treated ADHD patients compared with non-stimulant-treated ADHD patients (OR = 0.7, 95% CI 0.47-1.03, p = 0.073). In terms of fracture type, non-stimulant-treated ADHD was associated with traumatic fracture (OR = 1.79, 95% CI 1.54-2.08, p < 0.001) or stress fracture (OR = 1.12, 95% CI 1.04-1.2, p = 0.004) compared to healthy control (HC). In addition, further findings from our systematic review showed that the risk of traumatic (OR = 1, 95% CI 0.88-1.13, p = 0.954) or stress (OR = 0.84, 95% CI 0.62-1.14, p = 0.256) fracture was comparable between treated stimulant-ADHD patients and HC.

CONCLUSIONS

Individuals with ADHD are at higher risk of fracture than the general population. Stimulant ADHD medication appears to be associated with a lower risk of traumatic fracture but not with a higher risk of stress fracture.

ADHD and Drug Holidays: Effects on Anthropometric Changes during Methylpenidate Treatment

OBJECTIVES

The current study evaluated the long-term effects of methylphenidate (MPH) discontinuation on growth parameters in Turkish children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

EXPERIMENTAL DESIGN

432 children and adolescents (aged 6-18 years) with ADHD receiving MPH for at least 1 year between March 2012 and January 2019 were included in a retrospective cohort study. We analyzed weight, height, and body mass index (BMI) standard deviation z scores (SDS) of groups that either did (ADHD-C) or did not (ADHD-DC) discontinue MPH. Growth parameters were converted to z scores as normative values for the Turkish population to compare the measurements at baseline and the last follow-up visit by using the paired sample t-test.

PRINCIPAL OBSERVATIONS

In patients from the ADHD-C group, statistically significant negative correlations were found between age at starting MPH and differences in weight and height SDS between baseline and follow-up. Children had a greater reduction in weight and height compared to adolescents. When we evaluated the differences in pre-and post-treatment growth factors, we found no significant differences between the groups in terms of growth parameters.

CONCLUSIONS

Our data showed that chronic use of MPH was likely responsible for changes in height and weight parameters.

[Overweight/Obesity of Children and Adolescents and its Association with Internalising and Externalising Disorders]

Overweight/Obesity of Children and Adolescents and its Association with Internalising and Externalising Disorders Research in child and adolescent psychiatry increasingly deals with the association between mental disorder and weight. This paper provides an overview of national and international studies on the relationship between body composition and mental illness in children and adolescents, with a focus on the representation of individual internalizing and externalizing disturbance patterns. The majority of studies in this area are based on the so-called one-compartment model of body composition in terms of the Body Mass Index (BMI) or on the classification as "overweight" or "obese". Associations between mental disorders and body composition were described in two directions: On one hand, both externalising and internalising symptoms are associated with obesity, and on the other hand there are also more psychopathological symptoms among overweight children and adolescents. Longitudinal studies suggest effects in both directions. While externalising symptoms and weight are thought to be related from infancy on, this connection seems to be evident for internalising disorders not earlier than for early school age. It is also known from the literature that psychopharmacological medication affects weight and body growth - especially with psychostimulants, but also with neuroleptics and antidepressants. We found only a few studies describing the relationship between body composition and psyche in more complex models with two or more compartments.

Long term methylphenidate exposure and growth in children and adolescents with ADHD. A systematic review and meta-analysis

BACKGROUND

Methylphenidate (MPH) is an efficacious treatment for ADHD but concerns have been raised about potential adverse effects of extended treatment on growth.

OBJECTIVES

To systematically review the literature, up to December 2018, conducting a meta-analysis of association of long-term (> six months) MPH exposure with height, weight and timing of puberty.

RESULTS

Eighteen studies (ADHD n = 4868) were included in the meta-analysis. MPH was associated with consistent statistically significant pre-post difference for both height (SMD = 0.27, 95% CI 0.16-0.38, p < 0.0001) and weight (SMD = 0.33, 95% CI 0.22-0.44, p < 0.0001) Z scores, with prominent impact on weight during the first 12 months and on height within the first 24-30 months. No significant effects of dose, formulation, age and drug-naïve condition as clinical moderators were found. Data on timing of puberty are currently limited.

CONCLUSIONS

Long-term treatment with MPH can result in reduction in height and weight. However, effect sizes are small with possible minimal clinical impact. Long-term prospective studies may help to clarify the underlying biological drivers and specific mediators and moderators.

Dose Adjustment of Stimulants for Children with Attention-Deficit/Hyperactivity Disorder: A Retrospective Chart Review of the Impact of Exceeding Recommended Doses

BACKGROUND

When children with attention-deficit/hyperactivity disorder (ADHD) are treated with stimulant medication, the dose is established clinically by dose adjustment over time. Little is known about children who are not adequately treated when they reach a designated maximum dose, or the consequences of exceeding this dose.

OBJECTIVE

The aim of this study was to determine the characteristics of and side effects observed in children optimised to high dose (HD) versus regular dose (RD) stimulants.

METHOD

Children treated by one paediatrician (AP) in Western Sydney, Australia with HD stimulants (n = 52) were identified using an electronic database; controls on RD stimulant (n = 118) were matched by prescription date with the cases' first HD prescription. HD was defined as methylphenidate > 2 mg/kg/day or > 108 mg/day; dexamphetamine > 1 mg/kg/day or > 50 mg/day; lisdexamfetamine > 70 mg/day. In all children, the dose was adjusted over time to optimise the clinical response. Clinical characteristics, anthropometric measures, reported side effects and reasons for dose changes were extracted from the clinical charts by LR, VS and CS. The HD and RD cohorts were compared using chi-square for categorical data and t tests for continuous data.

RESULTS

The HD cohort included more boys (88% vs 75%, p = 0.041) and more oppositional defiant disorder (83% vs 55%, p = 0.001). They started stimulants younger (6.40 ± 1.67 vs 8.28 ± 2.77 years, p < 0.001) and had more growth attenuation (Δ height z-score - 0.41 ± 0.55 vs - 0.09 ± 0.58, p = 0.001; Δ weight z-score  - 0.56 ± 0.82 vs - 0.18 ± 0.66, p = 0.002). The growth attenuation mainly occurred before the dose reached the HD range. Diminishing stimulant effectiveness was the commonest reason for a dose increase in either cohort, the most prominent recurring symptoms being persistent anger/aggression in the HD and poor concentration in the RD cohort. The commonest reason for dose reduction in the HD cohort was that a dose increase gave no added benefit; dose reduction or change of drug due to subdued/depressed behaviour was more frequent in RD children. Apart from growth attenuation, no serious complications were reported in the HD group.

CONCLUSIONS

In this preliminary study, dose adjustment over time in some patients meant using higher doses than those generally recommended. These children experienced more growth attenuation but recorded no other significant treatment complications. Determining the dose purely on clinical grounds by careful dose adjustment over time appears reasonable, but more data on this issue is required to clarify the efficacy and tolerability of exceeding the recommended doses of stimulants when treating ADHD.

The Role of Higher Levels of Care for Eating Disorders in Youth

Many eating disorder patients are successfully treated in outpatient settings. Family-based treatment allows youth to recover at home. Higher levels of care may be necessary for medical or psychiatric stabilization, or to provide added structure. Historically, hospital lengths of stay were long. Currently, insurance limitations encourage intermediate care levels to support patients not requiring inpatient treatment but not ready for outpatient care. Options include inpatient medical stabilization, locked units for individuals with suicidal ideation, and outpatient programs offering daily meal support and group therapy. Outpatient teams and families collaborate to determine the appropriate level of care.

Pharmacotherapy of obesity: Available medications and drugs under investigation

Obesity is a chronic disease with a continuously rising prevalence that currently affects more than half a billion people worldwide. Energy balance and appetite are highly regulated via central and peripheral mechanisms, and weight loss triggers a homeostatic response leading to weight regain. Lifestyle and behavioral modifications are the cornerstones of obesity management; however, they often fail to achieve or sustain long-term weight loss. Pharmacotherapy added onto lifestyle modifications results in an additional, albeit limited, weight reduction. Regardless, this weight reduction of 5-10% conveys multiple cardiovascular and metabolic benefits. In this review, evidence on the food and drug administration (FDA)-approved medications, i.e., orlistat, lorcaserin, phentermine/topiramate, liraglutide and naltrexone/bupropion, is summarized. Furthermore, anti-obesity agents in the pipeline for potential future therapeutic use are presented.

Impact of the Autonomic Nervous System on the Skeleton

It is from the discovery of leptin and the central nervous system as a regulator of bone remodeling that the presence of autonomic nerves within the skeleton transitioned from a mere histological observation to the mechanism whereby neurons of the central nervous system communicate with cells of the bone microenvironment and regulate bone homeostasis. This shift in paradigm sparked new preclinical and clinical investigations aimed at defining the contribution of sympathetic, parasympathetic, and sensory nerves to the process of bone development, bone mass accrual, bone remodeling, and cancer metastasis. The aim of this article is to review the data that led to the current understanding of the interactions between the autonomic and skeletal systems and to present a critical appraisal of the literature, bringing forth a schema that can put into physiological and clinical context the main genetic and pharmacological observations pointing to the existence of an autonomic control of skeletal homeostasis. The different types of nerves found in the skeleton, their functional interactions with bone cells, their impact on bone development, bone mass accrual and remodeling, and the possible clinical or pathophysiological relevance of these findings are discussed.

Lower risk of fractures under methylphenidate treatment for ADHD: A dose-response effect

Methylphenidate (MP), a widely used and abused stimulant medication for ADHD, negatively affects bone mass. However, previous epidemiological studies demonstrated that MP is not associated with increased incidence of fractures in children, and may even have a protective effect due to behavior modification. This study aimed to investigate the association between MP and fracture risk in a retrospective cohort of healthy military recruits, aged 18-25, with at least 1 year of service between 2008 and 2017. Subjects were divided into five groups: subjects without ADHD; untreated subjects with ADHD; and subjects with ADHD and prescriptions of 1-90, 91-180, or 181+ tablets during the study period. The primary outcome was at least one fracture diagnosis during the study. Among 682,110 subjects (409,175 men [60%]), 50,999 (7.5%) had fractures. MP was used by 1,681 (0.4%) men and 2.828 (1%) women. The fracture rates in the no ADHD, untreated ADHD, ADHD 0-90, ADHD 91-180, and ADHD 181+ groups were 10.4%, 16.4%, 8.7%, 4.8% and 5.8% in men, and 3.6%, 7.1%, 4.6%, 4.4% and 3% in women, respectively. Multivariate regression analysis confirmed an inverse dose-response association between MP and fractures in men (p < 0.001). In women, untreated ADHD was associated with a significantly higher fracture risk, compared to healthy controls (OR = 1.82, p < 0.001). The study confirms previous literature and demonstrates an inverse dose-response association between MP and fracture risk in men. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3328-3333, 2018.

The Impact of Psychotropic Medications on Bone Health in Youth

PURPOSE OF REVIEW

Psychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use.

RECENT FINDINGS

Through a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health. Awareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.

The Effect of Previous Methylphenidate Use on Incidence of Stress Fractures in Military Recruits: A Retrospective Cohort

BACKGROUND

Previous research has detected an increased risk of stress fractures among subjects who reported previous use of methylphenidate. Conversely, stimulant medication use has been associated with traumatic fracture risk reduction, possibly because of the improved control of the underlying symptoms of attention deficit hyperactivity disorder (ADHD). The goal of this study was to investigate the effect of previous methylphenidate use on the incidence of traumatic and stress fractures among combat soldiers with previously treated and untreated ADHD.

METHODS

The retrospective cohort included 100,000 combat soldiers recruited to the Israeli Defense Forces from 2005 through 2015. Diagnosis of ADHD and previous exposure to methylphenidate were determined on the basis of self-reported recruitment questionnaires and medical records. Accordingly, the cohort was divided into 3 groups: subjects with ADHD who were previously treated with methylphenidate (n = 689), untreated subjects with ADHD reporting no medication use (n = 762), and controls having no ADHD diagnosis (n = 98,549). Logistic regressions were fitted to determine the odds ratios (ORs) of study subjects for stress and non-stress (traumatic) fractures. Multivariate analysis incorporated baseline characteristics, including age, sex, weight, duration of service, and diagnosis of anemia, at some point during the service.

RESULTS

After adjustment for sex, anemia, weight, age, and duration of service, the risk of traumatic fractures was increased in both subjects with treated ADHD (OR, 1.03 [95% confidence interval (CI), 1.00 to 1.05]) and subjects with untreated ADHD (OR, 1.04 [95% CI, 1.02 to 1.07]) compared with controls. Subjects in the treated ADHD group were at a higher risk of stress fractures (OR, 1.04 [95% CI, 1.02 to 1.07]). Interestingly, a diagnosis of anemia was an independent predictor of stress fractures (OR, 1.05 [95% CI, 1.04 to 1.06]).

CONCLUSIONS

Methylphenidate use is associated with an increased risk of stress fractures but a decreased risk of traumatic fractures in individuals diagnosed with ADHD. These and previous findings may serve as sufficient basis for screening for other risk factors and perhaps taking prevention measures in all those using stimulant medications, especially those planning to engage in strenuous physical activity.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents - assessment of adverse events in non-randomised studies

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in childhood. The psychostimulant methylphenidate is the most frequently used medication to treat it. Several studies have investigated the benefits of methylphenidate, showing possible favourable effects on ADHD symptoms, but the true magnitude of the effect is unknown. Concerning adverse events associated with the treatment, our systematic review of randomised clinical trials (RCTs) demonstrated no increase in serious adverse events, but a high proportion of participants suffered a range of non-serious adverse events.

OBJECTIVES

To assess the adverse events associated with methylphenidate treatment for children and adolescents with ADHD in non-randomised studies.

SEARCH METHODS

In January 2016, we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, 12 other databases and two trials registers. We also checked reference lists and contacted authors and pharmaceutical companies to identify additional studies.

SELECTION CRITERIA

We included non-randomised study designs. These comprised comparative and non-comparative cohort studies, patient-control studies, patient reports/series and cross-sectional studies of methylphenidate administered at any dosage or formulation. We also included methylphenidate groups from RCTs assessing methylphenidate versus other interventions for ADHD as well as data from follow-up periods in RCTs. Participants had to have an ADHD diagnosis (from the 3rd to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders or the 9th or 10th edition of theInternational Classification of Diseases, with or without comorbid diagnoses. We required that at least 75% of participants had a normal intellectual capacity (intelligence quotient of more than 70 points) and were aged below 20 years. We excluded studies that used another ADHD drug as a co-intervention.

DATA COLLECTION AND ANALYSIS

Fourteen review authors selected studies independently. Two review authors assessed risk of bias independently using the ROBINS-I tool for assessing risk of bias in non-randomised studies of interventions. All review authors extracted data. We defined serious adverse events according to the International Committee of Harmonization as any lethal, life-threatening or life-changing event. We considered all other adverse events to be non-serious adverse events and conducted meta-analyses of data from comparative studies. We calculated meta-analytic estimates of prevalence from non-comparative cohorts studies and synthesised data from patient reports/series qualitatively. We investigated heterogeneity by conducting subgroup analyses, and we also conducted sensitivity analyses.

MAIN RESULTS

We included a total of 260 studies: 7 comparative cohort studies, 6 of which compared 968 patients who were exposed to methylphenidate to 166 controls, and 1 which assessed 1224 patients that were exposed or not exposed to methylphenidate during different time periods; 4 patient-control studies (53,192 exposed to methylphenidate and 19,906 controls); 177 non-comparative cohort studies (2,207,751 participants); 2 cross-sectional studies (96 participants) and 70 patient reports/series (206 participants). Participants' ages ranged from 3 years to 20 years. Risk of bias in the included comparative studies ranged from moderate to critical, with most studies showing critical risk of bias. We evaluated all non-comparative studies at critical risk of bias. The GRADE quality rating of the evidence was very low.Primary outcomesIn the comparative studies, methylphenidate increased the risk ratio (RR) of serious adverse events (RR 1.36, 95% confidence interval (CI) 1.17 to 1.57; 2 studies, 72,005 participants); any psychotic disorder (RR 1.36, 95% CI 1.17 to 1.57; 1 study, 71,771 participants); and arrhythmia (RR 1.61, 95% CI 1.48 to 1.74; 1 study, 1224 participants) compared to no intervention.In the non-comparative cohort studies, the proportion of participants on methylphenidate experiencing any serious adverse event was 1.20% (95% CI 0.70% to 2.00%; 50 studies, 162,422 participants). Withdrawal from methylphenidate due to any serious adverse events occurred in 1.20% (95% CI 0.60% to 2.30%; 7 studies, 1173 participants) and adverse events of unknown severity led to withdrawal in 7.30% of participants (95% CI 5.30% to 10.0%; 22 studies, 3708 participants).Secondary outcomesIn the comparative studies, methylphenidate, compared to no intervention, increased the RR of insomnia and sleep problems (RR 2.58, 95% CI 1.24 to 5.34; 3 studies, 425 participants) and decreased appetite (RR 15.06, 95% CI 2.12 to 106.83; 1 study, 335 participants).With non-comparative cohort studies, the proportion of participants on methylphenidate with any non-serious adverse events was 51.2% (95% CI 41.2% to 61.1%; 49 studies, 13,978 participants). These included difficulty falling asleep, 17.9% (95% CI 14.7% to 21.6%; 82 studies, 11,507 participants); headache, 14.4% (95% CI 11.3% to 18.3%; 90 studies, 13,469 participants); abdominal pain, 10.7% (95% CI 8.60% to 13.3%; 79 studies, 11,750 participants); and decreased appetite, 31.1% (95% CI 26.5% to 36.2%; 84 studies, 11,594 participants). Withdrawal of methylphenidate due to non-serious adverse events occurred in 6.20% (95% CI 4.80% to 7.90%; 37 studies, 7142 participants), and 16.2% were withdrawn for unknown reasons (95% CI 13.0% to 19.9%; 57 studies, 8340 participants).

AUTHORS' CONCLUSIONS

Our findings suggest that methylphenidate may be associated with a number of serious adverse events as well as a large number of non-serious adverse events in children and adolescents, which often lead to withdrawal of methylphenidate. Our certainty in the evidence is very low, and accordingly, it is not possible to accurately estimate the actual risk of adverse events. It might be higher than reported here.Given the possible association between methylphenidate and the adverse events identified, it may be important to identify people who are most susceptible to adverse events. To do this we must undertake large-scale, high-quality RCTs, along with studies aimed at identifying responders and non-responders.

Preliminary Evidence of an Association Between ADHD Medications and Diminished Bone Health in Children and Adolescents

BACKGROUND

The US Centers for Disease Control and Prevention estimate that 3.5 million children use psychotropic drugs for attention-deficit hyperactivity disorder (ADHD). With an increase in use of these types of drugs, thorough understanding of their potential side effects on the growing skeleton is needed. The purpose of this study was to determine whether there is an association between use of ADHD medication and diminished bone health.

METHODS

Three waves of the National Health and Nutrition Examination Survey public-use data set, collected from 2005 through 2010, were compiled for this study (N=5315). Bone health was measured using dual-energy x-ray absorptiometry scans, which were performed for participants aged 8 to 17 years to determine bone mineral density (BMD) for 3 regions: (1) total femur; (2) femoral neck; and (3) lumbar. Use of ADHD medications was determined by self-reported responses to questions regarding prescription drug use, which were answered by either the respondent or the respondent's parent or guardian. Multiple statistical techniques were used to produce estimates of association between ADHD medication use and z score age and sex standardized BMD measures, including survey adjusted univariate, survey adjusted multiple linear regression, and generalized estimating equations with a propensity-matched subsample (N=1967). Multivariate models adjusted for covariates including time period, age, sex, race/ethnicity, family income to poverty ratio, and total number of prescription medications.

RESULTS

Conservative estimates of the difference in standardized BMD measures between the ADHD medication group and the nonmedicated group range from -0.4855 (±0.27; P<0.001) for total femoral, -0.4671 (±0.27; P<0.001) for femoral neck, and -0.3947 (±0.29; P<0.01) for lumbar. Significantly more children on ADHD medications versus match subjects on no medication had BMDs with in osteopenic range (38.3% vs. 21.6%, P<0.01).

DISCUSSION

The findings suggest that there are real and nontrivial differences in BMD for children and adolescents taking ADHD medications, as compared with similar children not taking any prescription medications. Prescribing physicians and parents should be aware of potential bone health risks associated with these medications.

LEVEL OF EVIDENCE

Level III-case-control study.

Growth perturbations from stimulant medications and inhaled corticosteroids

Stimulant medications for the treatment of attention deficit hyperactivity disorder (ADHD) and inhaled corticosteroids (ICS) for the treatment of asthma are two classes of medications that are commonly prescribed in pediatrics. Among other adverse effects of these medications, growth attenuation has long been a focus of investigation. With stimulants, growth deficits of 1-1.4 cm/year have been observed in the short term, mainly in the first 2 years of treatment, in a dose-dependent manner. Long-term studies on stimulants have reported divergent effects on growth, with many studies showing no clinically significant height deficits by adulthood. The study that followed the largest cohort of children on stimulants, however, reported an overall adult height deficit of 1.29 cm in subjects who had received stimulant medications, with mean adult height deficit of 4.7 cm among those taking the medication consistently. With ICS use, mild growth suppression is seen in the short term (particularly in the first year of therapy) with growth rates reduced by 0.4-1.5 cm/year. Available current evidence indicates that the impact of ICS use on adult height is not clinically significant, with effects limited to 1.2 cm or less. There is significant individual variability in growth suppression with ICS use, with the specific pharmacologic agent, formulation, dose exposure, age, puberty, medication adherence, and timing of administration being important modifying factors. Based on currently available evidence, the therapeutic benefits of ICS for management of asthma and stimulant medications for management of ADHD outweigh the potential risk for growth suppression. Strategies to minimize growth attenuation and other potential adverse effects of these medications include using the lowest efficacious dose, frequent assessments and dose titration. Particular vigilance is essential with concomitant use of multiple medications that can attenuate growth and to evaluate for potential adrenal insufficiency from ICS use.

Guanfacine Extended Release: A New Pharmacological Treatment Option in Europe

Children/adolescents with attention-deficit/hyperactivity disorder (ADHD) may have a poor or inadequate response to psychostimulants or be unable to tolerate their side-effects; furthermore, stimulants may be inappropriate because of co-existing conditions. Only one non-stimulant ADHD pharmacotherapy, the noradrenaline transporter inhibitor atomoxetine, is currently approved for use in Europe. We review recent advances in understanding of the pathophysiology of ADHD with a focus on the roles of catecholamine receptors in context of the α2A-adrenergic receptor agonist guanfacine extended release (GXR), a new non-stimulant treatment option in Europe. Neuroimaging studies of children/adolescents with ADHD show impaired brain maturation, and structural and functional anomalies in brain regions and networks. Neurobiological studies in ADHD and medication response patterns support involvement of monoaminergic neurotransmitters (primarily dopamine and noradrenaline). Guanfacine is a selective α2A-adrenergic receptor agonist that has been shown to improve prefrontal cortical cognitive function, including working memory. The hypothesized mode of action of guanfacine centres on direct stimulation of post-synaptic α2A-adrenergic receptors to enhance noradrenaline neurotransmission. Preclinical data suggest that guanfacine also influences dendritic spine growth and maturation. Clinical trials have demonstrated the efficacy of GXR in ADHD, and it is approved as monotherapy or adjunctive therapy to stimulants in Canada and the USA (for children and adolescents). GXR was approved recently in Europe for the treatment of ADHD in children and adolescents for whom stimulants are not suitable, not tolerated or have been shown to be ineffective. GXR may provide particular benefit for children/adolescents who have specific co-morbidities such as chronic tic disorders or oppositional defiant disorder (or oppositional symptoms) that have failed to respond to first-line treatment options.

Stimulant medication effects on growth and bone age in children with attention-deficit/hyperactivity disorder: a prospective cohort study

Stimulant medication is known to cause transient weight loss and slowing down of growth, but whether it delays physical maturation is unclear. We studied growth and bone age over the first 3 years of treatment in children with attention-deficit/hyperactivity disorder (patients) compared with healthy siblings (controls). Bone age was estimated blindly by two independent radiologists using Tanner and Whitehouse version 3. Dexamphetamine or methylphenidate was titrated and continued when clinically indicated. Forty out of 73 patients, together with 22 controls, completed the study. There were no significant growth differences between the two groups at baseline. Despite slower growth on treatment [5.1 cm/year, 95% confidence interval (CI): 4.7-5.5, vs. 6.3 cm/year, 95% CI: 5.7-6.8, P=0.002; and 2.7 kg/year, 95% CI: 2.1-3.3, vs. 4.4 kg/year, 95% CI: 3.5-5.3, P=0.005], the patients showed no significant maturational delay (RUS score: 49 U/year, 95% CI: 44-55, vs. 55 U/year, 95% CI: 47-63, P=0.27). A subgroup of patients underwent serial biochemistry and dual-energy X-ray absorptiometry, recording a significant reduction in fat (5.61±3.56-4.22±3.09 kg, P<0.001) and leptin (3.88±2.87-2.57±1.94 ng/ml, P=0.017). The pattern of change in height z-score over time was modified by the dose of medication (P for interaction=0.024). We found no medication effect on the rate of maturation, which was instead predicted by baseline leptin (P=0.035 controlling for age and sex).

Assessment of potential cardiovascular risks of methylphenidate in comparison with sibutramine: do we need a SCOUT (trial)?

With the recent approval of methylphenidate (MPH) for treating attention-deficit/hyperactivity disorder (ADHD) in adults, the number of patients exposed will increase tremendously. The ongoing debate on the cardiovascular safety of MPH has triggered two large retrospective cohort studies in children and adolescents as well as in young to middle-aged adults. These studies looked into serious cardiovascular events (sudden cardiac death, acute myocardial infarction and stroke) as primary endpoints and concluded that MPH was safe after a mean duration of 2.1 years of follow-up in children and adolescents and mean duration of 0.33 years of current use in adults. The results are encouraging with respect to the short- and medium-term use of MPH. Without the inherent limitations of retrospective cohort studies, a prospective randomized, double-blind, placebo-controlled, multicenter trial in individuals stratified for cardiovascular risk factors would allow for an optimized risk assessment. With many millions of patients treated per year and drawing parallels to the lately discovered risks of sibutramine, another sympathomimetic with an overlapping mode of action and similar side effects on heart rate and blood pressure, we hypothesize that such a trial might be a dedicated risk mitigation strategy for public health. A critical assessment of cardiovascular side effects of MPH appears particularly warranted, because ADHD is associated with obesity, smoking and poor health in general. We summarize recent findings with the focus on cardiovascular risks of MPH in humans; we additionally analyze the limited number of rodent studies that have addressed cardiovascular risks of MPH.

Piloting a new approach to the treatment of obesity using dexamphetamine

BACKGROUND AND AIMS

There is a clear need for a new approach to the treatment of obesity, which is inexpensive and is effective for establishing lifestyle change. We conducted a pilot study to evaluate whether dexamphetamine can be used safely, combined with diet and exercise, for treating obesity. Our ultimate aim is to develop a 6-month treatment program for establishing the lifestyle changes necessary for weight control, utilizing dexamphetamine for its psychotropic effect on motivation. We viewed the anorexigenic effect as an additional advantage for promoting initial weight loss.

METHODS

Obese adults were treated with dexamphetamine for 6 months (maximum of 30 mg twice daily), diet, and exercise. Weight, electrocardiogram, echocardiogram, and blood pressure were monitored.

RESULTS

Twelve out of 14 completed 6 months treatment. Weight loss by intention to treat was 10.6 kg (95% CI 5.8-15.5, p < 0.001). The mean weight gain in the 6 months after ceasing dexamphetamine was 4.5 kg (95% CI 1.9-7.2, p = 0.003), leaving a mean weight loss at 12 months from baseline of 7.0 kg (95% CI -13.4 to -0.6, p = 0.03). All reported favorable increases in energy and alertness. Dose-limiting symptoms were mood changes (2) and insomnia (2). None had drug craving on ceasing dexamphetamine, and there were no cardiac complications. Among the seven women, there was a significant correlation for those who lost most weight on treatment to have the least regain in the following 6 months (r = 0.88, p = 0.009).

CONCLUSION

Our treatment with dexamphetamine, diet, and exercise was well tolerated and effective for initial weight loss. Future research will focus on identifying baseline predictive variables associated with long-term weight control.

Prevalence and correlates of attention deficit hyperactivity disorder in adults from a French community sample

Validated tools are lacking in languages such as French to diagnose attention deficit hyperactivity disorder (ADHD) in adults. The Adult ADHD Symptoms Self-Report (ASRS) was filled out by 1171 parents of 900 school-aged youths in the context of the Children and Parents With ADHD and Related Disorders study. Prevalence estimates based on three scoring methods are compared (6-item screener, all 18 items, or the screener followed by the 12 remaining items). On the basis of the recommended and more conservative scoring method, the overall prevalence of ADHD symptoms is estimated to be 2.99%, without significant group differences between sexes or between younger and older adults. Potential correlates of ADHD symptoms were also examined in their relatives (children, brothers/sisters, uncles/aunts, and parents) as follows: birth order, level of education, body mass index categories, enuresis, suicide attempts, depression, and learning disabilities. Adults can be screened for ADHD symptoms using the ASRS; negative long-term outcomes should be assessed in patients' relatives too.