1
|
Pujalte GGA, Narducci DM, Smith MS, King R, Logan K, Callender SS, Liebman CA, Kane SF, Israel MP, Wolf SF, Nuti R, Khodaee M. Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine. Clin J Sport Med 2023; 33:195-208. [PMID: 37185161 DOI: 10.1097/jsm.0000000000001152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 05/17/2023]
Abstract
ABSTRACT Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.
Collapse
Affiliation(s)
- George G A Pujalte
- Department of Family Medicine and Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Dusty Marie Narducci
- Department of Family Medicine, University of South Florida College of Medicine, Tampa, Florida
| | - Michael Seth Smith
- Sports Medicine Institute, Department of Orthopaedics, Florida Health, Gainesville, Florida
| | - Rebecca King
- Primary Care National Landing, Virginia Hospital Center, Arlington, Virginia
| | - Kelsey Logan
- Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Shelley Street Callender
- Departments of Pediatrics and Family Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Catherine A Liebman
- Department Family Medicine and Community Health, Penn Health, Philadelphia, Pennsylvania
| | - Shawn F Kane
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael P Israel
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sigrid F Wolf
- Division of Orthopaedic Surgery and Sports Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Morteza Khodaee
- AF Williams Family Medicine Clinic, UCHealth, Denver, Colorado
| |
Collapse
|
2
|
Hammerness P, Berger A, Angelini MC, Wilens TE. Cardiovascular Considerations for Stimulant Class Medications. Child Adolesc Psychiatr Clin N Am 2022; 31:437-448. [PMID: 35697394 DOI: 10.1016/j.chc.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The cardiovascular (CV) impact of stimulants has been examined for decades, with investigations ranging from small sample targeted studies of heart rate (HR) and blood pressure (BP), to large scale epidemiologic investigations. The preponderance of evidence is reassuring, albeit generally based on healthy samples using variable methodology, excluding those at theoretic high risk (eg, comorbid cardiac illness). Screening for theoretically vulnerable patients are recommended, as well as monitoring for CV symptoms and BP/HR, with shared inquiry/further evaluation if concerned. Future investigations to support the identification of risk are needed, while attention to stimulant-associated CV risk is an opportunity for clinicians to engage in general CV risk identification and intervention.
Collapse
Affiliation(s)
- Paul Hammerness
- Psychiatry Services, Southcoast Health, 101 Page Street, New Bedford, MA, USA.
| | - Amy Berger
- Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Michael C Angelini
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - Timothy E Wilens
- Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| |
Collapse
|
3
|
Thom RP, Pober BR, McDougle CJ. Psychopharmacology of Williams syndrome: safety, tolerability, and effectiveness. Expert Opin Drug Saf 2021; 20:293-306. [PMID: 33369485 DOI: 10.1080/14740338.2021.1867535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Williams syndrome (WS) is a neurogenetic disorder characterized by a hyper-social personality, intellectual disability, and multiple medical co-morbidities. Psychiatric co-morbidities are also common. Since medical co-morbidities are common in this population, the risk-benefit of the use of psychiatric medications must be carefully considered and monitoring for safety and tolerability is needed.Areas covered: We review the cognitive profile and common medical co-morbidities in WS. We then discuss the common presentations of psychiatric disorders and review the available evidence on the use of psychiatric medications in WS. No prospective psychiatric medication trials have been conducted. We highlight the side effect profile of common psychiatric medications as they pertain to WS.Expert opinion: Psychiatric disorders can have a major effect on the quality of life of individuals with WS. The lack of long-term safety data and high likelihood of medical co-morbidities in WS make the judicious use of psychiatric medications more challenging; however, they can play an important role in decreasing distress and improving functioning. We provide recommendations for first- and second-line classes of medications based on our clinical experience and consideration of adverse effect profiles, as well as safety monitoring parameters at baseline and periodically.
Collapse
Affiliation(s)
- Robyn P Thom
- Lurie Center for Autism, Lexington, MA, USA.,Massachusetts General Hospital, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Barbara R Pober
- Massachusetts General Hospital, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Christopher J McDougle
- Lurie Center for Autism, Lexington, MA, USA.,Massachusetts General Hospital, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
4
|
Houghton R, de Vries F, Loss G. Psychostimulants/Atomoxetine and Serious Cardiovascular Events in Children with ADHD or Autism Spectrum Disorder. CNS Drugs 2020; 34:93-101. [PMID: 31768949 PMCID: PMC6982643 DOI: 10.1007/s40263-019-00686-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Psychostimulants and atomoxetine have been shown to increase blood pressure, heart rate, and QT interval in children and adolescents; however, based on current literature, it is unclear if these "attention-deficit/hyperactivity disorder (ADHD) medications" are also associated with serious cardiovascular (SCV) events. We addressed this question in commonly exposed groups of children and adolescents with either ADHD or autism spectrum disorder (ASD). METHODS Using commercial (years 2000-2016) and Medicaid (years 2012-2016) administrative claims data from the United States (US), we conducted two case-control studies, nested within respective cohorts of ADHD and ASD children aged 3-18 years. We defined cases by a composite outcome of stroke, myocardial infarction, or serious cardiac arrhythmia. For each case, we matched ten controls on age, sex, and insurance type. We conducted conditional logistic regression models to test associations between SCV outcomes and a primary exposure definition of current ADHD medication use. Additionally, we controlled for resource use, cardiovascular and psychiatric comorbidities, and use of medications in a variety of sensitivity analyses. RESULTS We identified 2,240,774 children for the ADHD cohort and 326,221 children for the ASD cohort. For ADHD, 33.9% of cases (63 of 186) versus 32.2% of controls (598 of 1860) were exposed, which yielded an odds ratio (OR) and 95% confidence interval (CI) of 1.08 (0.78-1.49). For ASD, 12.5% of cases (6 of 48) versus 22.1% of controls (106 of 480) were exposed [OR 0.49 (0.20-1.20)]. Covariate-adjusted results and results for individual outcomes and other exposure definitions were consistent with no increased risk of SCV events. CONCLUSION Using large US claims data, we found no evidence of increased SCV risk in children and adolescents with ADHD or ASD exposed to ADHD medications.
Collapse
Affiliation(s)
- Richard Houghton
- Personalized Health Care Data Science, Real World Data, F. Hoffmann-La Roche Ltd., Grenzacherstrasse. 124, 4070, Basel, Switzerland. .,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands. .,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Frank de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands ,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Georg Loss
- Personalized Health Care Data Science, Real World Data, F. Hoffmann-La Roche Ltd., Grenzacherstrasse. 124, 4070 Basel, Switzerland
| |
Collapse
|
5
|
Duflou J. Psychostimulant use disorder and the heart. Addiction 2020; 115:175-183. [PMID: 31321853 DOI: 10.1111/add.14713] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 05/08/2019] [Accepted: 06/10/2019] [Indexed: 01/07/2023]
Abstract
Psychostimulants are a diverse range of substances that encompass cocaine and the phenylethylamines, the latter including the amphetamines, cathinones and some 'novel psychoactive substances'. This paper examines the range of pathophysiological processes, clinical presentations and treatment options involving the heart and cardiovascular system both in the acute setting and where long-term effects of psychostimulant use have affected the cardiovascular system. A common feature of these drugs is their effect on the cardiovascular system, where their major action is that of sympathomimetic amines with short- and long-term stimulation of the adrenergic system and consequent effects on blood pressure, cardiac modelling, atherogenesis and cellular calcium signalling. Cocaine additionally exhibits a variety of prothrombotic effects, effects on inflammatory mediators and alterations in myocardial gene expression. Persistent psychostimulant use results in progressive cardiovascular pathology, largely in the form of accelerated atherosclerosis, hypertension and myocardial ischaemia. Abstinence results in at least partial reversal of pathology. To a large extent, an assumption is made that treatment protocols used for cocaine-associated cardiovascular pathology apply to the amphetamines and other phenylethylamines, but there appears to be little research in this area, despite acknowledgement that cocaine and the better-known amphetamines have different modes of action.
Collapse
Affiliation(s)
- Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia.,Sydney Medical School, University of Sydney, NSW, Australia
| |
Collapse
|
6
|
Stewman CG, Liebman C, Fink L, Sandella B. Attention Deficit Hyperactivity Disorder: Unique Considerations in Athletes. Sports Health 2017; 10:40-46. [PMID: 29144831 PMCID: PMC5753970 DOI: 10.1177/1941738117742906] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Context: Attention deficit hyperactivity disorder (ADHD) is a common psychiatric condition in the general population, with evidence suggesting that it may be more common among athletes. Evidence Acquisition: Literature searches were performed on PubMed, MEDLINE, and Cochrane databases for the years 2000 to 2016 utilizing the following key search terms: ADHD, ADD, guidelines, diagnosis, athlete, sports, treatment, pharmacotherapy, stimulants, risk, cardiovascular effects, concussion, and traumatic brain injury (TBI). Study Design: Clinical review. Level of Evidence: Level 4. Results: ADHD exists among athletes at all levels of play, and symptomatology overlaps significantly with that of concussion. Treatment with stimulants has cardiovascular effects and may not be permitted by the athlete’s governing body. An athlete’s level of competition and individual cardiovascular risk factors may therefore affect medication choices. Conclusion: ADHD diagnosis and treatment are paramount to optimal quality of life and functioning in affected individuals. Pharmacologic treatment options should not specifically be avoided in athletes; however, stimulant use is an independent risk factor for heat illness. Concussion, a common athletic injury, may have an altered course in those affected by ADHD, specifically with regard to neurocognitive testing and recovery.
Collapse
Affiliation(s)
- Chaney G Stewman
- Christiana Care Health System, University of Delaware, Newark, Delaware
| | - Catherine Liebman
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Fink
- Department of Family Medicine, Saint Alphonsus Medical Group, Boise, Idaho
| | - Brad Sandella
- Associate Lead Musculoskeletal Service Line, Christiana Care Health System, Newark, Delaware
| |
Collapse
|
7
|
Moran B, Bryan S, Farrar T, Salud C, Visser G, Decuba R, Renelus D, Buckley T, Dressing M, Peterkin N, Coris E. Diagnostic Evaluation of Nontraumatic Chest Pain in Athletes. Curr Sports Med Rep 2017; 16:84-94. [PMID: 28282354 DOI: 10.1249/jsr.0000000000000342] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article is a clinically relevant review of the existing medical literature relating to the assessment and diagnostic evaluation for athletes complaining of nontraumatic chest pain. The literature was searched using the following databases for the years 1975 forward: Cochrane Database of Systematic Reviews; CINAHL; PubMed (MEDLINE); and SportDiscus. The general search used the keywords chest pain and athletes. The search was revised to include subject headings and subheadings, including chest pain and prevalence and athletes. Cross-referencing published articles from the databases searched discovered additional articles. No dissertations, theses, or meeting proceedings were reviewed. The authors discuss the scope of this complex problem and the diagnostic dilemma chest pain in athletes can provide. Next, the authors delve into the vast differential and attempt to simplify this process for the sports medicine physician by dividing potential etiologies into cardiac and noncardiac conditions. Life-threatening causes of chest pain in athletes may be cardiac or noncardiac in origin, which highlights the need for the sports medicine physician to consider pathology in multiple organ systems simultaneously. This article emphasizes the importance of ruling out immediately life threatening diagnoses, while acknowledging the most common causes of noncardiac chest pain in young athletes are benign. The authors propose a practical algorithm the sports medicine physician can use as a guide for the assessment and diagnostic work-up of the athlete with chest pain designed to help the physician arrive at the correct diagnosis in a clinically efficient and cost-effective manner.
Collapse
Affiliation(s)
- Byron Moran
- 1Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL; 2Department of Orthopedics and Sports Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL; 3The University of South Carolina School of Medicine, Greenville, SC; 4Primary Care Sports Medicine Fellowship, University of South Florida-Morton Plant Mease, Clearwater, FL; 5Baycare Medical Group Primary Care, St. Petersburg, FL; 6Premiere Med Family and Sports Medicine, Ocoee, FL; 7Family Medicine Residency Program, University of South Florida-Morton Plant Mease, Clearwater, FL; 8Bayfront Primary Care Sports Medicine Fellowship, St. Petersburg, FL; 9Morsani College of Medicine, University of South Florida, Tampa, FL; 10Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL; and 11Baptist Primary Care, Jacksonville, FL; and 12Department of Family Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Ahmed R, Borst J, Wei YC, Aslani P. Parents' Perspectives About Factors Influencing Adherence to Pharmacotherapy for ADHD. J Atten Disord 2017; 21:91-99. [PMID: 23995052 DOI: 10.1177/1087054713499231] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of the present study was to explore factors influencing parents' decisions to adhere and persist with ADHD pharmacotherapy in children. METHOD Focus groups ( n = 3) were conducted with 16 parents recruited from metropolitan Sydney. Group discussions explored factors impacting on treatment initiation, continuation, and cessation. Focus groups were audio-recorded, transcribed verbatim, and thematically content analyzed. RESULTS Parents commenced and continued pharmacotherapy due to its positive impact on their child's behavior. Improvements in the child's academic performance and social interactions encouraged persistence with therapy. Parents elected to cease therapy after their children experienced side effects including appetite suppression, weight loss, and sleep disturbances. Concerns about long-term effects of ADHD medication use including potential for addiction and growth stunting, in addition to the stigma surrounding ADHD also contributed to parents ceasing treatment. CONCLUSION The findings highlight a need for the provision of accurate information about ADHD and its treatments to parents to empower their treatment decisions and promote adherence.
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW Attention deficit hyperactivity disorder (ADHD) is quite common in the general pediatric population, Its incidence is thought to be even higher in the population of patients with congenital heart disease, especially in those patients with complex disease and who have had cardiac surgical interventions early in life. There has been controversy as to the safety of ADHD medications, especially in the latter population of patients. This compendium is meant to review the effects of the ADHD medications and the safety of these medications in patients with either known or undiagnosed congenital heart disease. RECENT FINDINGS The concern with regard to the use of ADHD medications has been as a result of the reports of sudden unexpected deaths among patients taking stimulant drugs for ADHD. Therefore, the question of whether or not stimulant drugs increase the risk of adverse cardiovascular events has led to a discussion of the appropriate use of these drugs in patients with known cardiovascular disease, as well as a discussion as to the appropriate evaluation in order to identify undiagnosed 'at-risk' patients with congenital heart disease or arrhythmias. This article will review and amplify these discussions, as well as the conclusions that have come forth as a result of these discussions. SUMMARY Currently available data suggest that there is no evidence for serious adverse cardiovascular complications in children with known cardiovascular diseases including patients of congenital heart disease who are treated with stimulant medications. Despite this, if the patient does have known cardiac disease, or if the history and physical examination is suggestive of cardiac disease, it is suggested that consultation/evaluation with a pediatric cardiologist occur. It is extremely unlikely that stimulant medications would be contraindicated in almost any condition that falls under this category. However, a few specific cardiac conditions might tailor the choice of the specific ADHD medication. Therefore the coordination of care between the primary care physician, the ADHD medication-prescribing physician, and the pediatric cardiologist may be very important in this circumstance.
Collapse
Affiliation(s)
- Stuart Berger
- University of California - Davis, Sacramento, California, USA
| |
Collapse
|
10
|
Stevens JR, Rodgers JJ, Stern TA. Idiosyncratic Adverse Reactions to Psychotropic Medications. Psychiatr Ann 2016. [DOI: 10.3928/00485713-20160622-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
11
|
Zhang C, Kutyifa V, Moss AJ, McNitt S, Zareba W, Kaufman ES. Long-QT Syndrome and Therapy for Attention Deficit/Hyperactivity Disorder. J Cardiovasc Electrophysiol 2015; 26:1039-44. [PMID: 26149510 PMCID: PMC4607606 DOI: 10.1111/jce.12739] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/18/2015] [Accepted: 06/03/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Stimulants are the mainstay therapy for attention deficit/hyperactivity disorder (ADHD) and are associated with adrenergic side effects. There are limited data on the clinical course of patients treated for ADHD who have long-QT syndrome (LQTS), for which β-blockade is the goal of therapy. METHODS LQTS patients from the Rochester-based LQTS Registry (open-enrollment between 1979 and 2003; follow-up from 1979 to present) treated with stimulant or nonstimulant ADHD medications (n = 48) were compared to a 2:1 age-, gender-, and QTc-duration matched LQTS control group not exposed to ADHD medications (n = 96). Kaplan-Meier and Cox proportional hazards regression analyses were used to evaluate risk of cardiac events (syncope, aborted cardiac arrest, and sudden cardiac death) in LQTS patients treated with ADHD medications. RESULTS During a mean follow-up of 7.9 ± 5.4 years after initiation of ADHD medication at a mean age 10.7 ±7.3 years, there was a 62% cumulative probability of cardiac events in the ADHD treatment group compared to 28% in the matched LQTS control group (P < 0.001). Time-dependent use of ADHD medication was associated with an increased risk for cardiac events (HR = 3.07; P = 0.03) in the multivariate Cox model adjusted for time-dependent β-blocker use and prior cardiac events. Subgroup gender analyses showed that time-dependent ADHD medication was associated with an increased risk in male LQTS patients (HR = 6.80, P = 0.04). CONCLUSIONS LQTS patients treated with ADHD medications have increased risk for cardiac events, particularly syncope, and this risk is augmented in males. The findings highlight the importance of heightened surveillance for LQTS patients on ADHD medications.
Collapse
Affiliation(s)
- Claire Zhang
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Valentina Kutyifa
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Arthur J Moss
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Scott McNitt
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Wojciech Zareba
- University of Rochester Medical Center, Heart Research Follow-Up Program, Rochester, NY, USA
| | - Elizabeth S Kaufman
- MetroHealth Campus of Case Western Reserve University, Heart and Vascular Research Center, Cleveland, Ohio, USA
| |
Collapse
|
12
|
Antel J, Albayrak Ö, Heusch G, Banaschewski T, Hebebrand J. Assessment of potential cardiovascular risks of methylphenidate in comparison with sibutramine: do we need a SCOUT (trial)? Eur Arch Psychiatry Clin Neurosci 2015; 265:233-47. [PMID: 25149468 DOI: 10.1007/s00406-014-0522-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 08/01/2014] [Indexed: 12/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jochen Antel
- Research-Unit of the Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, LVR-Klinikum Essen, University of Duisburg-Essen, IG1 Virchowstr. 171, 45147, Essen, Germany,
| | | | | | | | | |
Collapse
|
13
|
Hammerness PG, Karampahtsis C, Babalola R, Alexander ME. Attention-deficit/hyperactivity disorder treatment: what are the long-term cardiovascular risks? Expert Opin Drug Saf 2015; 14:543-51. [PMID: 25648243 DOI: 10.1517/14740338.2015.1011620] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION This drug safety review provides an update on the long-term cardiovascular risks of therapeutic stimulant class medication for children and adults with attention-deficit/hyperactivity disorder (ADHD). AREAS COVERED Relevant literature on the long-term (defined as ≥ 12 months) cardiovascular effects of stimulant class medications for ADHD was sought using PubMed searches for clinical literature, epidemiological reports, as well as reviews of post-marketing data and clinical guidelines/consensus statements. Comparison was made to the non-stimulant atomoxetine. EXPERT OPINION Long-term cardiovascular risks of stimulants for healthy children and adults with ADHD are limited to minor mean elevations in blood pressure (≤ 7 mmHg) and heart rate (≤ 10 bpm). In a sizeable minority of individuals these elevations are greater and/or reach a clinical threshold. Subjective complaints may also be anticipated during long-term treatment, yet without an increase in serious cardiac outcomes above background rates per age. Future research is needed on possible latent or cumulative cardiovascular risks in healthy individuals, as well as the longer-term cardiovascular safety in vulnerable populations.
Collapse
|
14
|
Trenque T, Herlem E, Abou Taam M, Drame M. Methylphenidate off-label use and safety. SPRINGERPLUS 2014; 3:286. [PMID: 25279275 PMCID: PMC4162523 DOI: 10.1186/2193-1801-3-286] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 05/25/2014] [Indexed: 12/17/2022]
Abstract
Introduction Methylphenidate is a piperidine derivative structurally and pharmacologically similar to amphetamine. Methylphenidate is indicated for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 6 years of age and over when remedial measures alone prove insufficient. In adults, its indication, except in narcolepsy, is not defined. Methylphenidate received regulatory approval almost sixty years ago with a first registration in Switzerland in October 1954. Objective To evaluate the off-label use of methylphenidate and its characteristics from a database of spontaneous reports. Methods This study analysed data from the French Pharmacovigilance Database of adverse drug reactions spontaneously reported by health professionals from 1985 to December 2011. Off-label use was evaluated according to age. Results In the French Pharmacovigilance database, 181 cases of adverse drug reactions were reported with methylphenidate. Neuropsychiatric effects were the most frequent adverse event reported (41%) followed by cardiovascular and cutaneous side effects (14%). 143 reports concerned children (113 boys, 30 girls, mean age 10.6 ± 3.3 years) of which 46 (30%) were off-label uses. There were 38 adults (20 men, 18 women), of which 32 (88%) off-label use. In adults, methylphenidate was prescribed for depression, and this practice was associated with serious adverse events of drug dependence, overdose and suicide attempt. Overall, off-label use was detected in 43% (78/181) of all cases reported. Conclusion More than 40% of the patients with drug reactions received methylphenidate for off-label indications. Additional long-term exposures and independent clinical studies are necessary to establish the long-term profile safety of methylphenidate.
Collapse
Affiliation(s)
- Thierry Trenque
- Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Reims University Hospitals, Avenue du General Koenig, 51092, Reims, France ; Faculty of Medicine, University of Reims Champagne-Ardenne, EA 3797, F-51095 Reims, France
| | - Emmanuelle Herlem
- Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Reims University Hospitals, Avenue du General Koenig, 51092, Reims, France
| | - Malak Abou Taam
- Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Reims University Hospitals, Avenue du General Koenig, 51092, Reims, France
| | - Moustapha Drame
- Faculty of Medicine, University of Reims Champagne-Ardenne, EA 3797, F-51095 Reims, France ; Department of Research and Innovations, Reims University Hospitals, Avenue du General Koenig, 51092 Reims, France
| |
Collapse
|
15
|
Abstract
OBJECTIVES Potential side effects of stimulants for attention deficit disorder are in the focus of scientific discussions, intensified by the higher number of prescriptions. Children with known arrhythmias or other severe cardiac problems should not receive stimulants because of their sympathomimetic effects. METHODS This is a retrospective analysis of 24-hour Holter electrocardiograms from 100 consecutive children with attention deficit disorder from January, 2006 to April, 2012. RESULTS In all, nine children had significant ventricular arrhythmia (mean age 11.4 ± 3.1 years, 77% male, 77% received methylphenidate). All these children had ventricular parasystole - four of them with an accelerated idioventricular rhythm. A significant circadian rhythm of premature ventricular contractions in seven children and the effect of standing and exercise clearly indicate the influence of the autonomic nervous system. In these children, hourly analysis of circadian rhythm within a 24-hour period showed a highly significant correlation between premature ventricular contractions and the vagal tone indicated by the heart rate variability parameter RMSSD (r = -0.83; p < 0.001). Ventricular arrhythmia was unaffected in seven children who received methylphenidate before diagnosis and decreased during metoprolol treatment in two children. CONCLUSION By Holter electrocardiogram analysis, we observed a remarkably high incidence of ventricular parasystole and accelerated idioventricular rhythm in nine of 100 children with attention deficit disorder, which depends on autonomic imbalance and not on stimulant treatment.
Collapse
|
16
|
Stevens JR, Jarrahzadeh T, Brendel RW, Stern TA. Strategies for the prescription of psychotropic drugs with black box warnings. PSYCHOSOMATICS 2013; 55:123-33. [PMID: 24360525 DOI: 10.1016/j.psym.2013.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/21/2013] [Accepted: 08/26/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The Black Box Warning (BBW) is the Food and Drug Administration's highest level of drug warning. It signifies that a medication has serious (or potentially life-threatening) side effects and is prominently displayed on a medication's package insert. It literally consists of the medication warning and is surrounded by a bold black border. OBJECTIVE This article aims to review data related to BBWs on psychotropic medications currently used in clinical practice, with special attention to clinical situations and questions relevant to consultation-liaison psychiatrists. RESULTS We review 3 clinical advisories or BBWs for psychotropic medications (i.e., antidepressant medication and suicidality in the pediatric population, stimulant medication and sudden death in the pediatric population, and antipsychotic medication and increased mortality in the elderly) and discuss the effect they have had on prescribing practices. We provide a table of current BBWs relevant to psychotropic medications. CONCLUSIONS BBWs can have unintended and far-reaching consequences, albeit with a limited ability to target specific populations and practice patterns. Although it is critical for clinicians to be aware of these serious potential side effects and to inform patients about these warnings, medications with boxed warnings remain Food and Drug Administration-approved and may have critically important therapeutic roles.
Collapse
Affiliation(s)
- Jonathan R Stevens
- Henry Ford Health Systems, Dearborn, MI; Wayne State University, Detroit, MI.
| | | | - Rebecca Weintraub Brendel
- Red Sox Foundation and Massachusetts General Hospital (MGH), Home Base Program, Boston, MA; Harvard Medical School (HMS), Boston, MA
| | - Theodore A Stern
- Harvard Medical School (HMS), Boston, MA; Avery D. Weisman Psychiatry Consultation Service at MGH, Boston, MA
| |
Collapse
|
17
|
Hammerness P, Zusman R, Systrom D, Surman C, Baggish A, Schillinger M, Shelley-Abrahamson R, Wilens TE. A cardiopulmonary study of lisdexamfetamine in adults with attention-deficit/hyperactivity disorder. World J Biol Psychiatry 2013; 14:299-306. [PMID: 22559155 DOI: 10.3109/15622975.2012.678884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Due to concerns about the safety of stimulants for ADHD, novel assessments of the cardiopulmonary impact of these agents are needed. METHODS An open design of lisdexamfetamine (LDX) in 15 adults with DSM-IV ADHD. Following a psychiatric evaluation and medical history, subjects underwent echocardiography (TTE) and cardiopulmonary exercise testing (CPET). LDX was titrated to 70 mg daily over 6 weeks, followed by monthly visits to 6 months. Change in TTE and CPET measures were examined following up to 6 months of LDX. RESULTS At endpoint, there were no significant alterations in indices of cardiac systolic performance, or in metabolic and ventilatory variables at maximum exertion (P values >0.05). We found significant mean changes in resting LV systolic dimension and Doppler diastolic indices. Change in heart rate recovery at 1 min met statistical significance (P = 0.05). CONCLUSIONS We did not detect clinically meaningful changes in cardiac structure and function or in metabolic and ventilatory variables at maximum exertion in ADHD adults receiving open LDX. The clinical significance of changes in resting LV dimension and indices of diastolic function are not in the direction of cardiomyopathy. Future large sample controlled study can examine these findings, as well as stimulants' impact on heart rate recovery.
Collapse
Affiliation(s)
- Paul Hammerness
- Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital (MGH), Cambridge, MA 02138, USA.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Long-acting stimulants for treatment of attention-deficit/hyperactivity disorder: a focus on extended-release formulations and the prodrug lisdexamfetamine dimesylate to address continuing clinical challenges. ACTA ACUST UNITED AC 2013; 5:249-65. [PMID: 23564273 PMCID: PMC3751218 DOI: 10.1007/s12402-013-0106-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/16/2013] [Indexed: 11/25/2022]
Abstract
Individuals with attention-deficit/hyperactivity disorder (ADHD) show pervasive impairments across family, peer, and school or work functioning that may extend throughout the day. Psychostimulants are highly effective medications for the treatment of ADHD, and the development of long-acting stimulant formulations has greatly expanded the treatment options for individuals with ADHD. Strategies for the formulation of long-acting stimulants include the combination of immediate-release and delayed-release beads, and an osmotic-release oral system. A recent development is the availability of the first prodrug stimulant, lisdexamfetamine dimesylate (LDX). LDX itself is inactive but is cleaved enzymatically, primarily in the bloodstream, to release d-amphetamine (d-AMP). Several clinical trials have demonstrated that long-acting stimulants are effective in reducing ADHD symptoms compared with placebo. Analog classroom and simulated adult workplace environment studies have shown that long-acting stimulants produce symptom reduction for at least 12 h. Long-acting stimulants exhibit similar tolerability and safety profiles to short-acting equivalents. While variations in gastric pH and motility can alter the availability and absorption of stimulants released from long-acting formulations, the systemic exposure to d-AMP following LDX administration is unlikely to be affected by gastrointestinal conditions. Long-acting formulations may also improve adherence and lower abuse potential compared with their short-acting counterparts. The development of long-acting stimulants provides physicians with an increased range of medication options to help tailor treatment for individuals with ADHD.
Collapse
|
19
|
Stevens JR, Wilens TE, Stern TA. Using stimulants for attention-deficit/hyperactivity disorder: clinical approaches and challenges. Prim Care Companion CNS Disord 2013; 15:12f01472. [PMID: 23930227 DOI: 10.4088/pcc.12f01472] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/22/2012] [Indexed: 01/20/2023] Open
|
20
|
Batra AS, Alexander ME, Silka MJ. Attention-deficit/hyperactivity disorder, stimulant therapy, and the patient with congenital heart disease: evidence and reason. Pediatr Cardiol 2012; 33:394-401. [PMID: 22298228 DOI: 10.1007/s00246-012-0162-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 08/16/2011] [Indexed: 10/14/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood, and congenital heart disease (CHD) is the most common form of birth defect. Children with CHD are at increased risk for neurodevelopmental disorders such as ADHD. Stimulant medications, specifically methylphenidates and amphetamines, are frequently prescribed and effective in reducing the symptoms of ADHD. Despite their efficacy and long history of use, the safety of these medications has recently come into question due to isolated reports describing sudden unexplained death of children undergoing treatment. This review summarizes the current literature on the cardiovascular risks associated with the use of pharmacologic therapy for ADHD, with an emphasis on patients who had CHD.
Collapse
Affiliation(s)
- Anjan S Batra
- Division of Pediatric Cardiology, Children’s Hospital of Orange County, University of California at Irvine, 455 S Main Street, Orange, CA 92868, USA.
| | | | | |
Collapse
|
21
|
Wilens TE, Morrison NR, Prince J. An update on the pharmacotherapy of attention-deficit/hyperactivity disorder in adults. Expert Rev Neurother 2012; 11:1443-65. [PMID: 21955201 DOI: 10.1586/ern.11.137] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adults with attention-deficit/hyperactivity disorder (ADHD) are more frequently presenting for diagnosis and treatment. Medication is considered to be appropriate among available treatments for ADHD; however, the evidence supporting the use of pharmacotherapeutics for adults with ADHD remains less established. In this article, the effectiveness and dosing parameters of the various agents investigated for adult ADHD are reviewed. In adults with ADHD, short-term improvements in symptomatology have been documented through the use of stimulants and antidepressants. Studies suggest that methylphenidate and amphetamine maintained an immediate onset of action, whereas the ADHD response to the nonstimulants appeared to be delayed. At a group level, there appears to be some, albeit not entirely consistent, dose-dependent responses to amphetamine and methylphenidate. Generally speaking, variability in diagnostic criteria, dosing parameters and response rates between the various studies was considerable, and most studies were of a relatively short duration. The aggregate literature shows that the stimulants and catecholaminergic nonstimulants investigated had a clinically significant beneficial effect on treating ADHD in adults.
Collapse
Affiliation(s)
- Timothy E Wilens
- Clinical Research Program in Pediatric Psychopharmacology, Child Psychiatry Service, Massachusetts General Hospital, Boston, MA, USA.
| | | | | |
Collapse
|
22
|
Cooper WO, Habel LA, Sox CM, Chan KA, Arbogast PG, Cheetham TC, Murray KT, Quinn VP, Stein CM, Callahan ST, Fireman BH, Fish FA, Kirshner HS, O'Duffy A, Connell FA, Ray WA. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med 2011; 365:1896-904. [PMID: 22043968 PMCID: PMC4943074 DOI: 10.1056/nejmoa1110212] [Citation(s) in RCA: 271] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Adverse-event reports from North America have raised concern that the use of drugs for attention deficit-hyperactivity disorder (ADHD) increases the risk of serious cardiovascular events. METHODS We conducted a retrospective cohort study with automated data from four health plans (Tennessee Medicaid, Washington State Medicaid, Kaiser Permanente California, and OptumInsight Epidemiology), with 1,200,438 children and young adults between the ages of 2 and 24 years and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs. We identified serious cardiovascular events (sudden cardiac death, acute myocardial infarction, and stroke) from health-plan data and vital records, with end points validated by medical-record review. We estimated the relative risk of end points among current users, as compared with nonusers, with hazard ratios from Cox regression models. RESULTS Cohort members had 81 serious cardiovascular events (3.1 per 100,000 person-years). Current users of ADHD drugs were not at increased risk for serious cardiovascular events (adjusted hazard ratio, 0.75; 95% confidence interval [CI], 0.31 to 1.85). Risk was not increased for any of the individual end points, or for current users as compared with former users (adjusted hazard ratio, 0.70; 95% CI, 0.29 to 1.72). Alternative analyses addressing several study assumptions also showed no significant association between the use of an ADHD drug and the risk of a study end point. CONCLUSIONS This large study showed no evidence that current use of an ADHD drug was associated with an increased risk of serious cardiovascular events, although the upper limit of the 95% confidence interval indicated that a doubling of the risk could not be ruled out. However, the absolute magnitude of such an increased risk would be low. (Funded by the Agency for Healthcare Research and Quality and the Food and Drug Administration.).
Collapse
Affiliation(s)
- William O Cooper
- Division of General Pediatrics, Vanderbilt University, Nashville, TN 37232-4313, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Shetty I, Silver ES, Hordof AJ, Goldberg PH, Liberman L. Ablation of supraventricular tachycardia allows more liberal therapy in some children with attention-deficit-hyperactivity disorder. Pediatr Int 2011; 53:715-717. [PMID: 21261787 DOI: 10.1111/j.1442-200x.2011.03326.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND First-line therapy for children with attention-deficit-hyperactivity disorder (ADHD) is stimulant medication, which may have potential cardiovascular side-effects. In patients with supraventricular tachycardia or Wolf-Parkinson-White syndrome (WPW), therapy for ADHD could become challenging. The purpose of the present study was to review the authors' experience of performing electrophysiologic study (EPS) with or without ablation to determine how it affected ADHD therapy. METHODS Retrospective chart review of patients who underwent EPS between 2002 and 2009 was carried out. All patients under 21 years of age who had prior diagnosis of ADHD were included. RESULTS Twenty patients met the inclusion criteria. The mean age was 12.1 ± 2.7 years (range: 5.6-16.8 years). The patients were diagnosed with ADHD on average 3.9 ± 2.7 years (range: 6 months-9 years) prior to the EPS. All patients had a structurally normal heart. Sixteen patients had cardiac symptoms. Seventeen patients underwent ablation of the arrhythmia substrate (16/17, 94% successful). Three patients with asymptomatic WPW were at low risk for life-threatening arrhythmias and did not have ablation. After the EPS, two patients had increased doses of their ADHD medications, and two patients whose health-care providers stopped the stimulant medication prior to EPS because of recurrent tachycardia were restarted on medications. All other patients on ADHD medications continued therapy. CONCLUSIONS EPS for risk stratification and ablation of arrhythmia substrate is safe and effective, allowing more liberal therapy in patients with ADHD and supraventricular tachycardia or WPW.
Collapse
Affiliation(s)
- Ira Shetty
- Pediatric Arrhythmia Service, Department of PediatricsDepartment of Psychiatry, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Eric S Silver
- Pediatric Arrhythmia Service, Department of PediatricsDepartment of Psychiatry, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Allan J Hordof
- Pediatric Arrhythmia Service, Department of PediatricsDepartment of Psychiatry, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Pablo H Goldberg
- Pediatric Arrhythmia Service, Department of PediatricsDepartment of Psychiatry, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| | - Leonardo Liberman
- Pediatric Arrhythmia Service, Department of PediatricsDepartment of Psychiatry, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University, College of Physicians and Surgeons, New York, New York, USA
| |
Collapse
|
24
|
Hammerness PG, Perrin JM, Shelley-Abrahamson R, Wilens TE. Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity disorder: update and clinical recommendations. J Am Acad Child Adolesc Psychiatry 2011; 50:978-90. [PMID: 21961773 DOI: 10.1016/j.jaac.2011.07.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 07/13/2011] [Accepted: 07/25/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This review provides an update on the cardiovascular impact of therapeutic stimulant-class medication for children and adolescents with attention-deficit/hyperactivity disorder (ADHD). METHOD Relevant clinical literature was ascertained using PubMed searches limited to human studies and the English language as of May 2011. Current practice guidelines and consensus statements also were reviewed. RESULTS Stimulant-class medications for healthy children and adolescents with ADHD are associated with mean elevations in blood pressure (≤5 mmHg) and heart rate (≤10 beats/min) without changes in electrocardiographic parameters. A subset (5-15%) of children and adolescents treated may have a greater increase in heart rate or blood pressure at a given assessment or may report a cardiovascular-type complaint during stimulant treatment. It is extremely rare for a child or adolescent receiving stimulant medication to have a serious cardiovascular event during treatment, with the risk appearing similar to groups of children not receiving stimulant medication. CONCLUSIONS Clinicians should adhere to current recommendations regarding the prescription of stimulant medications for youth with ADHD. Scientific inquiry is indicated to identify patients at heightened risk and to continue surveillance for the longer-term cardiovascular impact of these agents.
Collapse
Affiliation(s)
- Paul G Hammerness
- Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital, and Harvard Medical School, USA.
| | | | | | | |
Collapse
|
25
|
Sichilima T, Rieder MJ. Adderall and cardiovascular risk: A therapeutic dilemma. Paediatr Child Health 2011; 14:193-5. [PMID: 20190905 DOI: 10.1093/pch/14.3.193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2009] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tangu Sichilima
- Division of Clinical Pharmacology, Departments of Paediatrics, Physiology & Pharmacology, and Medicine, Children's Health Research Institute, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario
| | | |
Collapse
|
26
|
Huang YS, Tsai MH. Long-term outcomes with medications for attention-deficit hyperactivity disorder: current status of knowledge. CNS Drugs 2011; 25:539-54. [PMID: 21699268 DOI: 10.2165/11589380-000000000-00000] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Attention-deficit hyperactivity disorder (ADHD), a common neurobehavioural disorder characterized by inattention, hyperactivity and impulsivity, is a chronic disorder and often persists into adulthood. CNS stimulants have been the most well known treatment for ADHD for several decades due to their high effectiveness, good safety profiles and relatively minor adverse effects. Non-stimulant agents, including atomoxetine, extended-release guanfacine and extended-release clonidine (US FDA approved), and several non-FDA-approved agents, such as bupropion and tricyclic antidepressants (TCAs), were recently proven to be effective alternatives to the stimulants in several open-label and placebo-controlled trials. However, most medication trials for ADHD have been short term and thus have not provided information on the long-term outcomes of ADHD treatment. Since the medical treatment of many children with ADHD, especially those with more severe symptoms or co-morbid disorders, has to be continued for several years, recent studies have shifted their focus from the acute effectiveness of stimulants or non-stimulant drugs to the long-term outcomes of medications for ADHD. Evidence has shown that stimulants, along with the non-stimulants atomoxetine and extended-release guanfacine, are continuously effective for 24-month treatment periods with few and tolerable adverse effects.
Collapse
Affiliation(s)
- Yu-Shu Huang
- Department of Child Psychiatry and Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan, R.O.C
| | | |
Collapse
|
27
|
Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011; 127:511-28. [PMID: 21321035 PMCID: PMC3065144 DOI: 10.1542/peds.2009-3592] [Citation(s) in RCA: 456] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To review the effects, adverse consequences, and extent of energy drink consumption among children, adolescents, and young adults. METHODS We searched PubMed and Google using "energy drink," "sports drink," "guarana," "caffeine," "taurine," "ADHD," "diabetes," "children," "adolescents," "insulin," "eating disorders," and "poison control center" to identify articles related to energy drinks. Manufacturer Web sites were reviewed for product information. RESULTS According to self-report surveys, energy drinks are consumed by 30% to 50% of adolescents and young adults. Frequently containing high and unregulated amounts of caffeine, these drinks have been reported in association with serious adverse effects, especially in children, adolescents, and young adults with seizures, diabetes, cardiac abnormalities, or mood and behavioral disorders or those who take certain medications. Of the 5448 US caffeine overdoses reported in 2007, 46% occurred in those younger than 19 years. Several countries and states have debated or restricted energy drink sales and advertising. CONCLUSIONS Energy drinks have no therapeutic benefit, and many ingredients are understudied and not regulated. The known and unknown pharmacology of agents included in such drinks, combined with reports of toxicity, raises concern for potentially serious adverse effects in association with energy drink use. In the short-term, pediatricians need to be aware of the possible effects of energy drinks in vulnerable populations and screen for consumption to educate families. Long-term research should aim to understand the effects in at-risk populations. Toxicity surveillance should be improved, and regulations of energy drink sales and consumption should be based on appropriate research.
Collapse
Affiliation(s)
- Sara M. Seifert
- Department of Pediatrics and the Pediatric Integrative Medicine Program, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Judith L. Schaechter
- Department of Pediatrics and the Pediatric Integrative Medicine Program, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Eugene R. Hershorin
- Department of Pediatrics and the Pediatric Integrative Medicine Program, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| | - Steven E. Lipshultz
- Department of Pediatrics and the Pediatric Integrative Medicine Program, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida
| |
Collapse
|
28
|
Brinkman WB, Epstein JN. Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences. Patient Prefer Adherence 2011; 5:45-56. [PMID: 21311701 PMCID: PMC3034298 DOI: 10.2147/ppa.s10647] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is a common condition that often results in child and family functional impairments. Although there are evidence-based treatment modalities available, implementation of and persistence with treatment plans vary with patients. Family preferences also vary and may contribute to variability in treatment utilization. OBJECTIVE The objective of this study is to describe the evidence-based treatments available for ADHD, identify patterns of use for each modality, and examine patient and parent treatment preferences. METHOD Literature review. RESULTS Treatment options differ on benefits and risks/costs. Therefore, treatment decisions are preference sensitive and depend on how an informed patient/parent values the tradeoffs between options. Literature on patient and parent ADHD treatment preferences is based on quantitative research assessing the construct of treatment acceptability and qualitative and quantitative research that assesses preferences from a broader perspective. After a child is diagnosed with ADHD, a variety of factors influence the initial selection of treatment modalities that are utilized. Initial parent and child preferences are shaped by their beliefs about the nature of the child's problems and by information (and misinformation) received from a variety of sources, including social networks, the media, and health care providers. Subsequently, preferences become further informed by personal experience with various treatment modalities. Over time, treatment plans are revisited and revised as families work with their health care team to establish a treatment plan that helps their child achieve goals while minimizing harms and costs. CONCLUSIONS Studies have not been able to determine the extent to which utilization rates are consistent with the underlying distribution of informed patient/parent treatment preferences. There are challenges to ensure that patient/parent preferences are consistently well informed, elicited, and discussed in the treatment planning process. Interventions are needed to promote such interactions.
Collapse
Affiliation(s)
- William B Brinkman
- Correspondence: William B Brinkman, Department of Pediatrics, Cincinnati Children’s Hospital, Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7035, Cincinnati, OH 45229, USA, Tel +1 513 636 2576, Fax +1 513 636 4402, Email
| | | |
Collapse
|
29
|
Winhusen TM, Somoza EC, Brigham GS, Liu DS, Green CA, Covey LS, Croghan IT, Adler LA, Weiss RD, Leimberger JD, Lewis DF, Dorer EM. Impact of attention-deficit/hyperactivity disorder (ADHD) treatment on smoking cessation intervention in ADHD smokers: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry 2010; 71:1680-8. [PMID: 20492837 PMCID: PMC3151610 DOI: 10.4088/jcp.09m05089gry] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Accepted: 07/10/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE High smoking rates in adults with attention-deficit/hyperactivity disorder (ADHD) and nicotine's amelioration of ADHD suggest that effective ADHD treatment might facilitate abstinence in smokers with ADHD. The present study evaluated if using osmotic-release oral system methylphenidate (OROS-MPH) to treat ADHD enhances response to smoking cessation treatment in smokers with ADHD. METHOD A randomized, double-blind, placebo-controlled, 11-week trial with a 1-month follow-up was conducted at 6 clinical sites between December 2005 and January 2008. Adults (aged 18-55 years) meeting DSM-IV criteria for ADHD and interested in quitting smoking were randomly assigned to OROS-MPH titrated to 72 mg/d (n = 127) or placebo (n = 128). All participants received brief weekly individual smoking cessation counseling for 11 weeks and 21 mg/d nicotine patches starting on the smoking quit day (day 27) through study week 11. Outcome measures included prolonged smoking abstinence and DSM-IV ADHD Rating Scale (ADHD-RS) score. RESULTS Of 255 randomly assigned participants, 204 (80%) completed the trial. Prolonged abstinence rates, 43.3% and 42.2%, for the OROS-MPH and placebo groups, respectively, did not differ significantly (OR = 1.1; 95% CI, 0.63-1.79; P = .81). Relative to placebo, OROS-MPH evidenced a greater reduction in DSM-IV ADHD-RS score (P < .0001) and in cigarettes per day during the post-quit phase (P = .016). Relative to placebo, OROS-MPH increased blood pressure and heart rate to a statistically, but not clinically, significant degree (P < .05); medication discontinuation did not differ significantly between treatments. CONCLUSIONS Treatment for ADHD did not improve smoking cessation success; OROS-MPH, relative to placebo, effectively treated ADHD and was safe and generally well tolerated in this healthy sample of adult ADHD smokers. TRIAL REGISTRATION clinical trials.gov Identifier: NCT00253747.
Collapse
Affiliation(s)
- Theresa M. Winhusen
- Department of Psychiatry, University of Cincinnati College of Medicine, 3210 Jefferson Avenue, Cincinnati, OH 45220, USA
| | - Eugene C. Somoza
- Department of Psychiatry, University of Cincinnati College of Medicine, 3210 Jefferson Avenue, Cincinnati, OH 45220, USA,Veterans Affairs Medical Center (VISN 10), 3200 Vine Street, Cincinnati, OH 45220, USA
| | - Gregory S. Brigham
- Department of Psychiatry, University of Cincinnati College of Medicine, 3210 Jefferson Avenue, Cincinnati, OH 45220, USA,Maryhaven, 1791 Alum Creek Drive, Columbus, Ohio 43207, USA
| | - David S. Liu
- National Institute on Drug Abuse, Center for the Clinical Trials Network, 6001 Executive Blvd, Rm 3118, Bethesda, MD 20892, USA
| | - Carla A. Green
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave. Portland, OR 97227, USA
| | - Lirio S. Covey
- New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Drive, Unit 116, New York, NY 10032, USA
| | - Ivana T. Croghan
- Mayo Clinic Nicotine Research Program, 200 First Street SW, Colonial Building, Rochester, MN 55905, USA
| | - Lenard A. Adler
- VA NY Harbor Healthcare System (VA NYHHS),423 East 23rd St. New York, NY 10010, USA
| | - Roger D. Weiss
- Department of Psychiatry, Harvard Medical School, and Alcohol and Drug Abuse Treatment Program, McLean Hospital, 115 Mill St, Belmont, MA 02478
| | | | - Daniel F. Lewis
- Department of Psychiatry, University of Cincinnati College of Medicine, 3210 Jefferson Avenue, Cincinnati, OH 45220, USA
| | - Emily M. Dorer
- Department of Psychiatry, University of Cincinnati College of Medicine, 3210 Jefferson Avenue, Cincinnati, OH 45220, USA
| |
Collapse
|
30
|
Stiefel G, Besag FM. Cardiovascular Effects of Methylphenidate, Amphetamines and Atomoxetine in the Treatment of Attention-Deficit Hyperactivity Disorder. Drug Saf 2010; 33:821-42. [DOI: 10.2165/11536380-000000000-00000] [Citation(s) in RCA: 234] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
31
|
Silva RR, Skimming JW, Muniz R. Cardiovascular safety of stimulant medications for pediatric attention-deficit hyperactivity disorder. Clin Pediatr (Phila) 2010; 49:840-51. [PMID: 20693523 DOI: 10.1177/0009922810368289] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a common neurobehavioral disorder that is often treated with stimulants such as methylphenidate and mixed amphetamine salts. Despite their efficacy and long history of use, there is concern about their potential for adverse cardiovascular effects in children and adolescents. Data from placebo-controlled and open-label extension trials published after 2000 were reviewed, and cardiovascular adverse event data were compared. Both placebo-controlled and open-label extension trials have repeatedly shown stimulant-induced increases in mean blood pressure, heart rate, and QT interval in children, adolescents, and adults. Although these increases seem relatively minor, their existence raises questions regarding whether stimulants could influence the likelihood of sudden death or other serious cardiovascular consequences, especially in patients with underlying heart problems. Moreover, questions have been raised regarding the necessity of screening patients for occult or unrecognized heart problems that are felt to be adversely affected by stimulant use. Obtaining a baseline electrocardiogram for any patient starting stimulant treatment is reasonable if access to such screening is readily available and not too costly.
Collapse
Affiliation(s)
- Raul R Silva
- New York University Langone Medical Center, New York, NY, USA.
| | | | | |
Collapse
|
32
|
|
33
|
Abstract
Attention-deficit-hyperactivity disorder (ADHD) is a common neuropsychiatric disorder that impairs social, academic, and occupational functioning in children, adolescents, and adults. In patients with ADHD, neurobiologic research has shown a lack of connectivity in key brain regions, inhibitory control deficits, delayed brain maturation, and noradrenergic and dopaminergic dysfunction in multiple brain regions. The prevalence of this disorder in the United States is 6-9% in youth (i.e., children and adolescents) and 3-5% in adults. Prevalence rates for youth are similar worldwide. Children with ADHD are at greater risk than children without ADHD for substance abuse and delinquency whether or not they receive drug therapy; however, early treatment with psychoeducation as well as drug therapy and/or behavioral intervention may decrease negative outcomes of ADHD, including the rate of conduct disorder and adult antisocial personality disorder. Drug therapy is effective for all age groups, even preschoolers, and for late-onset ADHD in adults. Stimulants, such as methylphenidate and amphetamine, are the most effective therapy and have a good safety profile; although recent concerns of sudden unexplained death, psychiatric adverse effects, and growth effects have prompted the introduction of other therapies. Atomoxetine, a nonstimulant, has no abuse potential, causes less insomnia than stimulants, and poses minimal risk of growth effects. Other drug options include clonidine and guanfacine, but both can cause bradycardia and sedation. Polyunsaturated fatty acids (fish oil), acetyl-L-carnitine, and iron supplements (for youth with low ferritin levels) show promise in improving ADHD symptoms. As long-term studies show that at least 50% of youth are nonadherent with their drug therapy as prescribed over a 1-year period, long-acting formulations (administered once/day) may improve adherence. Comorbid conditions are common in patients with ADHD, but this patient population can be treated effectively with individualized treatment regimens of stimulants, atomoxetine, or bupropion, along with close monitoring.
Collapse
Affiliation(s)
- Julie A Dopheide
- Titus Family Department of Clinical Pharmacy and Pharmaceutical Economics and Policy, School of Pharmacy, University of Southern California, Los Angeles, California 90033, USA
| | | |
Collapse
|
34
|
Brinkman WB, Sherman SN, Zmitrovich AR, Visscher MO, Crosby LE, Phelan KJ, Donovan EF. Parental angst making and revisiting decisions about treatment of attention-deficit/hyperactivity disorder. Pediatrics 2009; 124:580-9. [PMID: 19651580 DOI: 10.1542/peds.2008-2569] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral conditions of childhood and adolescence. Despite availability of effective treatment options, initiation of treatment is variable and persistence with therapeutic regimens is poor. OBJECTIVE We sought to better understand how parents make decisions about treatment for their child or adolescent with ADHD. METHODS We conducted a qualitative study among parents of children and adolescents; 52 parents participated in 1 of 12 focus groups. Parents answered questions about decision-making, information sharing, and sources of conflict and uncertainty. Sessions were audiotaped and transcribed verbatim. Themes were coded independently by 4 of the investigators, who then agreed on common themes. RESULTS Parents in our study made decisions about treatment for their child with ADHD in the midst of experiencing a variety of emotions as they witnessed child functional impairments at home and at school. In addition, parents felt stress as a result of their daily efforts to manage their child's struggles. Multiple factors influenced the decision to initiate medication. Subsequently, revisiting the decision to give their child medicine for ADHD was common. Many parents contrasted time on and off medicine to help inform management decisions. Trials stopping medication were almost always parent- or child-initiated. CONCLUSIONS Decisions about medication use for children and adolescents with ADHD are made and frequently revisited by their parents. Choices are often made under stressful conditions and influenced by a variety of factors. Striking a balance between benefits and concerns is an ongoing process that is often informed by contrasting time on and off medication. Development of strategies to support families across the continuum of decisions faced while managing ADHD is warranted.
Collapse
Affiliation(s)
- William B Brinkman
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
| | | | | | | | | | | | | |
Collapse
|
35
|
Hammerness P, Wilens T, Mick E, Spencer T, Doyle R, McCreary M, Becker J, Biederman J. Cardiovascular effects of longer-term, high-dose OROS methylphenidate in adolescents with attention deficit hyperactivity disorder. J Pediatr 2009; 155:84-9, 89.e1. [PMID: 19394037 DOI: 10.1016/j.jpeds.2009.02.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 12/17/2008] [Accepted: 02/03/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To examine the effects of high doses of extended-release methylphenidate (OROS MPH) on cardiovascular variables in adolescents with attention deficit hyperactivity disorder (ADHD). STUDY DESIGN ECG indices plus systolic blood pressure (SBP), diastolic BP (DBP) and heart rate (HR) were assessed during an open-label study of OROS MPH in 114 adolescents with ADHD (doses up to 1.5 mg/kg/d). Cardiovascular parameters were assessed at 6 weeks and 6 months. RESULTS Small but statistically significant changes in DBP and HR were observed at 6 weeks, without further increases up to 6 months' follow-up. A small but statistically significant increase in SBP was observed over time. Twenty-nine percent of patients had isolated elevations in BP readings prior to study entry, and 14% had >3 consecutive visits at which elevated BP were observed during OROS MPH treatment. No clinically significant changes in ECG parameters were observed. No serious cardiovascular adverse events occurred. CONCLUSIONS Treatment with relatively high doses of OROS MPH was associated with small but statistically significant mean increases in BP and HR, primarily during the first 6 weeks of treatment, without clinically meaningful changes in ECG. These observations are consistent with previous reports using lower doses.
Collapse
Affiliation(s)
- Paul Hammerness
- Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02138, USA.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Lan Y, Zhang LL, Luo R. Attention Deficit Hyperactivity Disorder in Children: Comparative Efficacy of Traditional Chinese Medicine and Methylphenidate. J Int Med Res 2009; 37:939-48. [PMID: 19589280 DOI: 10.1177/147323000903700340] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Traditional Chinese medicine (TCM) is frequently used to treat attention deficit hyperactivity disorders (ADHD) in children in China. However, until now there has been no strong evidence to prove that TCM has better efficacy than western medicine. In this systematic study of 34 studies published in the Chinese literature, the effectiveness of TCM in treating ADHD in children was examined and compared with methylphenidate (MPH), which is widely used to treat ADHD. It was found that TCM may have equal or better effectiveness than MPH. However, the lack of high-quality clinical trials to support this conclusion means that it is not currently possible to recommend any particular kind of TCM preparation for treating ADHD in children.
Collapse
Affiliation(s)
- Y Lan
- Pharmaceutical Department, West China Second Hospital of Sichuan University, Chengdu, China
| | - L-L Zhang
- Pharmaceutical Department, West China Second Hospital of Sichuan University, Chengdu, China
| | - R Luo
- Children Nerves and Digestion Department, West China Second Hospital of Sichuan University, Chengdu, China
| |
Collapse
|
37
|
Newcorn JH, Donnelly C. Cardiovascular safety of medication treatments for attention-deficit/hyperactivity disorder. ACTA ACUST UNITED AC 2009; 76:198-203. [DOI: 10.1002/msj.20096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
38
|
McGregor A. A case that is not for the faint of heart. Semin Pediatr Neurol 2008; 15:167-72; discussion 172-3. [PMID: 19073320 DOI: 10.1016/j.spen.2008.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 5-year-old was admitted after an episode of loss of consciousness and an episode of convulsive activity. Information that aids in differentiating seizures and syncope is discussed.
Collapse
Affiliation(s)
- Amy McGregor
- University of Tennessee Health Science Center, LeBonheur Comprehensive Epilepsy Program, Neuroscience Institute, LeBonheur Children's Medical Center, Memphis, TN, USA.
| |
Collapse
|
39
|
Bhat V, Grizenko N, Sanche S, Joober R. No Relation between Therapeutic Response to Methylphenidate and its Cardiovascular Side Effects in Children with Attention-Deficit/Hyperactivity Disorder. CLINICAL MEDICINE. PEDIATRICS 2008. [DOI: 10.4137/cmped.s1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective The aim of this study was to examine the relation between therapeutic response to methylphenidate (MPH) and its associated short term cardiovascular side effects (Systolic Blood Pressure-SBP, Diastolic Blood Pressure-DBP and Heart Rate-HR changes) in children with ADHD, based on the hypothesis that these parameters share common underlying mechanisms. Method A double-blind placebo-controlled crossover clinical trial of children 6 to 12 years old diagnosed with ADHD was done. The children were given one week of 0.5 mg/kg MPH and one week of placebo (divided into two equal doses, given twice every day). On the morning of the third day of each week, Blood Pressure (BP) and HR were recorded immediately before (at time 0) and after (at time 10 and 45 minutes) administration of MPH. Children were grouped into 4 categories according to their therapeutic response (large, moderate, mild or no response) to MPH. A mixed model analysis of variance was performed to determine whether response groups were different with regard to cardiovascular side effects. Results All variables were comparable among the four groups 10 min after treatment with MPH and with placebo. Small but significant (p < 0.001) increases were seen in SBP (3.65 mm of Hg) and DBP (3.99 mm of Hg) 45 minutes after administration of MPH. A small but significant decrease in HR (3.3 beats per minute) was observed 45 min after administration of placebo. No significant differences in SBP, DBP and HR were found between response groups. Conclusions MPH causes a small but significant change in BP at 45 minutes after administration. No changes in HR were observed with MPH at 45 minutes. Responders to MPH treatment do not differ from non-responders in occurrence of BP and HR changes, at least within 45 minutes after administration and with the MPH dosage used in the study.
Collapse
Affiliation(s)
| | | | - Steven Sanche
- Douglas Mental Health University Institute, Montreal, Canada
| | - Ridha Joober
- Douglas Mental Health University Institute, Montreal, Canada
| |
Collapse
|
40
|
Daly MW, Custer G, McLeay PD. Cardiac Arrest with Pulseless Electrical Activity Associated with Methylphenidate in an Adolescent with a Normal Baseline Echocardiogram. Pharmacotherapy 2008; 28:1408-12. [DOI: 10.1592/phco.28.11.1408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
41
|
Abstract
There are several important issues regarding the manner in which medications are tested prior to their release and monitored after approval that must be appreciated in considering issues related to cardiovascular safety of medication treatments for attention-deficit/hyperactivity disorder (ADHD) in adults. First, patients treated in clinical trials are not necessarily representative of those seen in practice settings, as specific inclusion/exclusion criteria in studies limit a variety of psychiatric, medical, and social factors that could potentially introduce confounds related to the collection and/or interpretation of efficacy, tolerability, and safety data. However, many of these factors are present in patients treated in clinical practice. In addition, the manner in which medications are administered in clinical trials does not necessarily replicate the way they are used in the community. Often, there are differences in titration schemes and dosing options. Also, in clinical trials, drugs are rarely studied in combination, although they are often used in this manner in practice settings. Further, Phase III clinical trials (at least in psychiatry) often do not enroll a large enough sample to evaluate infrequently occurring adverse events. Rather, the predominance of information regarding rare side effects is derived from voluntary reports made after a drug comes to market—and therefore likely under-reports the phenomenon. Finally, information regarding drug safety that comes to practitioners in the form of medication warnings or advisories may reflect concerns that extend beyond the strict interpretation of clinical trials data. These and other issues represent major obstacles in attempting to fully understand issues related to safety and tolerability of medication in “real world” settings.
Collapse
|
42
|
Cormier E. Attention deficit/hyperactivity disorder: a review and update. J Pediatr Nurs 2008; 23:345-57. [PMID: 18804015 DOI: 10.1016/j.pedn.2008.01.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 01/08/2008] [Accepted: 01/09/2008] [Indexed: 11/24/2022]
Abstract
Attention deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and pervasive childhood disorder characterized by developmentally inappropriate activity level, impulsivity, and inability to sustain attention and concentration. Core symptoms of the disorder are associated with impairment in multiple domains of functioning and often coexist with other psychiatric disorders, the most prevalent being oppositional defiant disorder, conduct disorder, depression, and anxiety disorders. Concerns have been expressed about the overdiagnosis of ADHD, an upsurge in prescription of stimulant medication, and wide variations in practice patterns related to diagnosis and treatment of children with ADHD among primary care providers. Clinical research and expert consensus guidelines over the past decade have increasingly clarified the most effective approaches to diagnosis and treatment of the disorder. Hence, the purpose of this article was to provide primary care providers with the most current, evidence-based information on the assessment and treatment of children with ADHD.
Collapse
Affiliation(s)
- Eileen Cormier
- Florida State University College of Nursing, 421 Vivian M. Duxbury Hall, Tallahassee, FL 32306-4310, USA.
| |
Collapse
|
43
|
Conway J, Wong KK, O'Connell C, Warren AE. Cardiovascular risk screening before starting stimulant medications and prescribing practices of canadian physicians: impact of the Health Canada advisory. Pediatrics 2008; 122:e828-34. [PMID: 18829780 DOI: 10.1542/peds.2008-0276] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In May 2006, Health Canada released a statement advising against the use of stimulant medications for patients with cardiac disease after isolated reports of sudden death. The objectives of this study were to determine whether the Health Canada advisory has had an impact on cardiovascular screening of all children with attention-deficit/hyperactivity disorder before stimulants and the medical treatment of children with attention-deficit/hyperactivity disorder and real or potential cardiac problems. METHODS Two questionnaires were developed and mailed to a sample of noncardiologist physicians and pediatric cardiologists in Canada. The difference in the proportion of noncardiologist-responders who performed a "full screen" before and after the announcement of the Health Canada advisory was analyzed. Willingness to prescribe stimulant medications to children was assessed by using a series of clinical scenarios. RESULTS A total of 2326 questionnaires were distributed, 717 (31%) of which were returned. The proportion who performed a full screen increased for both noncardiologists and cardiologists after the advisory. There was also a dramatic increase in the use of the "modified screen" by the noncardiologist group and the pediatrician subgroup. There was a considerable decrease in the proportion of noncardiologists who were willing to prescribe stimulant medications to children with potential or actual cardiac issues after the advisory. CONCLUSIONS The Health Canada advisory has had an impact on clinical practice. It has resulted in an increase in the use of cardiovascular assessment tools before starting stimulants and a decrease in noncardiologists' willingness to prescribe stimulants to those with real or potential cardiac disease. These changes have occurred despite the lack of studies to address the cardiac risks of these medications. Because it will be difficult to assess the true cardiac risks of stimulants, consensus recommendations are needed to determine whether screening is required, what constitutes an appropriate screen, and which children can be treated cautiously with stimulant medications.
Collapse
Affiliation(s)
- Jennifer Conway
- Division of Pediatric Cardiology and Perinatal Epidemiology Research Unit, Department of Pediatrics, IWK Children's Heart Centre, Halifax, Nova Scotia, Canada.
| | | | | | | |
Collapse
|
44
|
Paying attention to stimulants: height, weight, and cardiovascular monitoring in clinical practice. J Am Acad Child Adolesc Psychiatry 2008; 47:977-80. [PMID: 18580503 DOI: 10.1097/chi.0b013e31817e0eb9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
45
|
Effects of methylphenidate on the catecholaminergic system in attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 2008; 28:S46-53. [PMID: 18480677 DOI: 10.1097/jcp.0b013e318173312f] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Stimulants are part of the standard-of-care treatment for attention-deficit/hyperactivity disorder (ADHD). Methylphenidate, with a history of use spanning approximately 5 decades, is a first-line stimulant treatment for ADHD. Methylphenidate chiefly affects the prefrontal cortex and striatum, the mechanism of action being modulation of catecholaminergic tone. Methylphenidate treatment produces an increase in dopamine (DA) signaling through multiple actions, including blockade of the DA reuptake transporter and amplification of DA response duration, disinhibition of DA D2 autoreceptors and amplification of DA tone, and activation of D1 receptors on the postsynaptic neuron. The actions of methylphenidate may also be mediated by stimulation of the noradrenergic alpha2 receptor and DA D1 receptor in the cortex. The role of other neurotransmitters such as histamine, acetylcholine, serotonin, and alpha-agonists in modulating catecholamine pathophysiology in ADHD and ADHD treatment needs to be elucidated. Overall, the changes in catecholaminergic tone clinically manifest as improvements in attention deficit, distractibility, and motor hyperactivity in patients with ADHD.
Collapse
|
46
|
Vetter VL, Elia J, Erickson C, Berger S, Blum N, Uzark K, Webb CL. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder [corrected]: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation 2008; 117:2407-23. [PMID: 18427125 DOI: 10.1161/circulationaha.107.189473] [Citation(s) in RCA: 229] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
47
|
Vitiello B. Understanding the Risk of Using Medications for ADHD with Respect to Physical Growth and Cardiovascular Function. Child Adolesc Psychiatr Clin N Am 2008; 17:459-74, xi. [PMID: 18295156 PMCID: PMC2408826 DOI: 10.1016/j.chc.2007.11.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The effects of stimulant medications and atomoxetine on physical growth and on cardiovascular function are reviewed in light of the most recent data, with attention to clinical implications and research needs. Although these medications have a favorable benefit/risk profile and do not induce clinically significant changes in growth or cardiovascular function in the majority of cases, careful patient monitoring is needed to identify individuals at risk for negative outcomes. More research is needed to elucidate the mechanism of growth suppression to estimate better the risk for rare but life-threatening events and test the effectiveness of monitoring procedures.
Collapse
Affiliation(s)
- Benedetto Vitiello
- National Institute of Mental Health, Room 7147, 6001 Executive Boulevard, Bethesda, MD 20892-9633, telephone: 301-443-4283, fax 301-443-4045,
| |
Collapse
|
48
|
Supraventricular tachycardia in an adolescent with attention-deficit/hyperactivity disorder (ADHD). J Am Acad Child Adolesc Psychiatry 2008; 47:219-220. [PMID: 18216716 DOI: 10.1097/chi.0b013e31815d7485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
49
|
Winterstein AG, Gerhard T, Shuster J, Johnson M, Zito JM, Saidi A. Cardiac safety of central nervous system stimulants in children and adolescents with attention-deficit/hyperactivity disorder. Pediatrics 2007; 120:e1494-501. [PMID: 18055666 DOI: 10.1542/peds.2007-0675] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Case reports have raised concerns about the risk of cardiac events associated with central nervous system stimulants for the treatment of attention-deficit/hyperactivity disorder. PATIENTS AND METHODS This was a retrospective cohort study that used 10 years (July 1994 to June 2004) of Florida Medicaid claims data cross-linked to Vital Statistics Death Registry data. The cohort was composed of all youth 3 to 20 years old who were newly diagnosed with attention-deficit/hyperactivity disorder. Each month of follow-up was classified according to stimulant claims (methylphenidate, amphetamines, and pemoline) as current use (active stimulant claim), former use (time after periods of current use), or nonuse (time preceding the first stimulant claim, including follow-up of youth who were never exposed to stimulants). The study's end points were (1) cardiac death, (2) first hospital admission for cardiac causes or (3) first emergency department visit for cardiac causes. Risks were compared with time-dependent Cox regression analysis adjusting for various cardiac risk factors. RESULTS During 124,932 person-years of observation (n = 55,383), 73 youth died, 5 because of cardiac causes. No cardiac death occurred during 42,612 person-years of stimulant use. Hospital admissions for cardiac cause occurred for 27 children (8 during stimulant use, 11 during 35,671 person-years of former use, and 8 during 46,649 person-years of nonuse); and 1091 children visited the emergency department for cardiac causes (8.7 per 1000 person-years). Current stimulant use was associated with a 20% increase in the hazard for emergency department visits when compared with nonuse. No increased risk was found for periods of former use when compared with nonuse. CONCLUSIONS Incidence rates of cardiac events requiring hospitalization were small and similar to national background rates. Stimulants were associated with an increase in cardiac emergency department visits. More evidence is needed that addresses the long-term risk/benefit of the various treatment options and the effect of other cardiac risk factors and comedications.
Collapse
Affiliation(s)
- Almut G Winterstein
- Department of Healthcare Administration, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Newcorn JH, Ivanov I. Psychopharmacologic treatment of attention-deficit/hyperactivity disorder and disruptive behavior disorders. Pediatr Ann 2007; 36:564-74. [PMID: 17910204 DOI: 10.3928/0090-4481-20070901-08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|