Drug holiday utilisation in ADHD-diagnosed children and adolescents in South Africa

Medication holidays in osteoporosis: evidence-based recommendations from the Italian guidelines on 'Diagnosis, risk stratification, and continuity of care of fragility fractures' based on a systematic literature review

Background

Noncommunicable, chronic diseases need pharmacological interventions for long periods or even throughout life. The temporary or permanent cessation of medication for a specific period, known as a 'medication holiday,' should be planned by healthcare professionals.

Objectives

We evaluated the association between continuity (adherence or persistence) of treatment and several outcomes in patients with fragility fractures in the context of the development of the Italian Guidelines.

Design

Systematic review.

Data Sources and Methods

We systematically searched PubMed, Embase, and the Cochrane Library up to November 2020 for randomized clinical trials (RCTs) and observational studies that analyzed medication holidays in patients with fragility fracture. Three authors independently extracted data and appraised the risk of bias of the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random effects models. Primary outcomes were refracture and quality of life; secondary outcomes were mortality and treatment-related adverse events.

Results

Six RCTs and nine observational studies met our inclusion criteria, ranging from very low to moderate quality. The adherence to antiosteoporotic drugs was associated with a lower risk of nonvertebral fracture [relative risk (RR) 0.42, 95% confidence interval (CI) 0.20-0.87; three studies] than nonadherence, whereas no difference was detected in the health-related quality of life. A reduction in refracture risk was observed when continuous treatment was compared to discontinuous therapy (RR 0.49, 95% CI 0.25-0.98; three studies). A lower mortality rate was detected for the adherence and persistence measures, while no significant differences were noted in gastrointestinal side effects in individuals undergoing continuous versus discontinuous treatment.

Conclusion

Our findings suggest that clinicians should promote adherence and persistence to antiosteoporotic treatment in patients with fragility fractures unless serious adverse effects occur.

A Randomized Controlled Trial of Interventions for Growth Suppression in Children With Attention-Deficit/Hyperactivity Disorder Treated With Central Nervous System Stimulants

OBJECTIVE

To examine the impact of central nervous system (CNS) stimulants on the growth of children with attention-deficit/hyperactivity disorder (ADHD), and to assess the efficacy and feasibility of weight recovery interventions on growth.

METHOD

A total of 230 children aged 5 to 12 years with ADHD with no history of chronic CNS stimulant use were randomly assigned to receive daily CNS stimulants (78%, primarily osmotic release oral system-methylphenidate [OROS-MPH]) or behavioral treatment (22%) for 30 months. After 6 months, children evidencing a decline in body mass index (BMI) of >0.5 z-units were randomized to 1 of 3 weight recovery treatments (WRTs): monthly monitoring of height/weight (MON) plus continued daily medication; drug holidays (DH) with medication limited to school days; or daily caloric supplementation (CS) with a 150-kcal supplement plus daily medication.

RESULTS

Before WRT assignment, medication was associated with significant reductions in standardized weight and height (p values <.01). Adherence to CS and DH during WRT was high, with significant increases in daily caloric intake and decreases in weekly medication exposure (p values <.05). Across all WRT participants (n = 71), weight velocity increased significantly after WRT randomization (β₂ = 0.271, SE = 0.027, p < .001).When analyzed by what parents did (versus what they were assigned to), CS (p < .01) and DH (p < .05) increased weight velocity more than MON. No increase in height velocity was seen after randomization to any WRT. Over the entire study, WRT participants declined in standardized weight (-0.44 z-units) and height (-0.20 z-units).

CONCLUSION

Drug holidays, caloric supplementation, and increased monitoring all led to increased weight velocity in children taking CNS stimulants, but none led to increased height velocity.

CLINICAL TRIAL REGISTRATION INFORMATION

Novel Approach to Stimulant Induced Weight Suppression and Its Impact on Growth; https://clinicaltrials.gov/; NCT01109849.

Consumption of methylphenidate and atomoxetine in the private healthcare sector in South Africa: a longitudinal study

Background Globally Attention-Deficit/Hyperactivity Disorder (ADHD) has been in the spotlight. Despite some controversies, treatment of ADHD remains the cornerstone of patient care. Objective To describe the consumption of methylphenidate and atomoxetine in the private healthcare sector in South Africa over a four-year period (2013-2016). Method Data were extracted from the Intercontinental Marketing Service (IMS) database for the drug utilisation study. Consumption patterns were expressed as number of Defined Daily Doses (DDDs)/1000 inhabitants/day and number of DDDs/1000 inhabitants/month. Results Methylphenidate (95.85%) was the medication of choice when compared to atomoxetine (4.15%) in 2013. The corresponding figures for 2016 were 96.40% and 3.60%. Consumption of ADHD medication showed slight changes over the 4-year period. If only the private healthcare sector population is considered, consumption of methylphenidate was 6.010 DDDs/1000 inhabitants/day in 2013, and 7.827 DDDs/1000 inhabitants/day in 2016. A previous study (1994-1996) reported 0.12 DDDs/1000 inhabitants/day for methylphenidate. Consumption of atomoxetine was 0.044 DDDs/1000 inhabitants/day in 2013 and 0.050 DDDs/1000 inhabitants/day in 2016. Conclusion Consumption showed an increase in use of methylphenidate in South Africa, with small changes observed over the study period. Further studies are required.