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Abellán Alemán J, Sabaris RC, Pardo DE, García Donaire JA, Romanos FG, Iriso JI, Penagos LM, Iglesias LJN, de Salinas APM, Pérez-Monteoliva NRR, Lezcano PSR, Saborido MT, Roca FV. Documento de consenso sobre tabaquismo y riesgo vascular. HIPERTENSION Y RIESGO VASCULAR 2024; 41 Suppl 1:S1-S85. [PMID: 38729667 DOI: 10.1016/s1889-1837(24)00075-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.
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Affiliation(s)
- José Abellán Alemán
- Sociedad Murciana de Hipertensión Arterial y Riesgo Cardiovascular, Cátedra de Riesgo Cardiovascular, Universidad Católica de Murcia, Murcia, España.
| | - Rafael Crespo Sabaris
- Sociedad Riojana de Hipertensión y Riesgo Vascular, Centro de Salud de Entrena, La Rioja, España
| | - Daniel Escribano Pardo
- Sociedad Aragonesa de Hipertensión y Riesgo Vascular, Centro de Salud Oliver, Zaragoza, España
| | - José Antonio García Donaire
- Sociedad Española de Hipertensión, Unidad de Hipertensión, Servicio de Medicina Interna, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Fernando García Romanos
- Sociedad de Hipertensión y Riesgo Vascular de las Illes Balears, Centro de Salud Santa Catalina, Palma de Mallorca, España
| | - Jesús Iturralde Iriso
- Sociedad Vasca de Hipertensión y Riesgo Vascular, Centro de Salud la Habana-Cuba, Vitoria-Gasteiz, España
| | - Luis Martín Penagos
- Sociedad Cántabra de Hipertensión y Riesgo Vascular, Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - L Javier Nieto Iglesias
- Sociedad Castilla-La Mancha de Hipertensión y Riesgo Vascular, Unidad de Hipertensión y Riesgo Vascular, Servicio de Nefrología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Alfonso Pobes Martínez de Salinas
- Sociedad Asturiana de Hipertensión y Riesgo Vascular, Área de Gestión Clínica, Interáreas de Nefrología VII y VIII del SESPA, Asturias, España
| | | | - Pablo Sánchez-Rubio Lezcano
- Sociedad Aragonesa de Hipertensión y Riesgo Vascular, Servicio de Medicina Interna, Hospital General Universitario San Jorge, Huesca, España
| | - Maribel Troya Saborido
- Sociedad Catalana de Hipertensión y Riesgo Vascular, Servicio de Nefrología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - Francisco Valls Roca
- Sociedad Valenciana de Hipertensión y Riesgo Vascular, Centro de Salud de Beniganim, Valencia, España
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Anbarasan D, Safyer G, Adler LA. Updates in Pharmacologic Strategies in Adult Attention-Deficit/Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am 2022; 31:553-568. [PMID: 35697401 DOI: 10.1016/j.chc.2022.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) significantly worsens quality of life and long-term functional outcomes in adults. Individual impairments in adults with ADHD can be further contextualized within considerable costs to society at large. Food and Drug Administration (FDA) approved stimulants and nonstimulant medications can significantly improve ADHD symptoms in adults. In the past 2 decades, the United States FDA has expanded approval of pharmacotherapeutic options for adult ADHD. However, limitations still persist in available psychotropics for certain patient populations such as those with comorbid substance use or cardiovascular illness. Clinicians therefore must appreciate several ongoing investigations into medications with unique mechanisms of action. This article reviews the current FDA approved and emerging medication options while providing guidelines for pharmacologic management of adult ADHD.
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Affiliation(s)
- Deepti Anbarasan
- Department of Neurology, NYU Grossman School of Medicine, One Park Avenue, 8th Floor, New York, NY 10016, USA; Department of Psychiatry, NYU Grossman School of Medicine, One Park Avenue, 8th Floor, New York, NY 10016, USA.
| | - Gabriella Safyer
- Department of Psychiatry, NYU Grossman School of Medicine, One Park Avenue, 8th Floor, New York, NY 10016, USA
| | - Lenard A Adler
- Department of Psychiatry, NYU Grossman School of Medicine, One Park Avenue, 8th Floor, New York, NY 10016, USA; Department of Child & Adolescent Psychiatry, NYU Grossman School of Medicine, One Park Avenue, 8th Floor, New York, NY 10016, USA
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Swainson J, Klassen LJ, Brennan S, Chokka P, Katzman MA, Tanguay RL, Khullar A. Non-parenteral Ketamine for Depression: A Practical Discussion on Addiction Potential and Recommendations for Judicious Prescribing. CNS Drugs 2022; 36:239-251. [PMID: 35165841 PMCID: PMC8853036 DOI: 10.1007/s40263-022-00897-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/12/2022]
Abstract
Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.
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Affiliation(s)
- Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada. .,Misericordia Community Hospital, Edmonton, AB, Canada.
| | | | - Stefan Brennan
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK Canada
| | - Pratap Chokka
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Chokka Center for Integrative Health, Edmonton, AB Canada
| | - Martin A. Katzman
- START Clinic for Mood and Anxiety Disorders, Toronto, ON Canada ,Department of Psychiatry, Northern Ontario School of Medicine, Thunder Bay, ON Canada ,Department of Psychology, Lakehead University, Thunder Bay, ON Canada ,Department of Psychology, Adler Graduate Professional School, Toronto, ON Canada
| | - Robert L. Tanguay
- Department of Psychiatry and Department of Surgery, University of Calgary, Calgary, AB Canada ,The Newly Institute, Calgary, AB Canada ,Hotchkiss Brain Institute and Mathison Centre for Mental Health, Calgary, AB Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB Canada ,Grey Nuns Community Hospital, Edmonton, AB Canada ,Northern Alberta Sleep Clinic, Edmonton, AB Canada
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Abstract
PURPOSE OF REVIEW We reviewed most current medical literature in order to describe the epidemiology, clinical manifestation, outcome, and management of hypertension in athletes. RECENT FINDINGS An estimated quarter of the world's population is suffering from hypertension and this prevalence is also reflected in athletes and in individuals involved in leisure time sport activities. Several studies found an inverse relationship between physical activity and blood pressure. Therefore, physical exercise is recommended to prevent, manage, and treat hypertension. On the other hand, the prevalence of hypertension may vary by sport and in some cases may even be higher in athletes competing in certain disciplines than in the general population. Hypertension is the most common medical condition in athletes and may raise concerns about its management and the individual's eligibility for competitive sports. A thorough clinical evaluation should be performed to correctly diagnose or rule out hypertension in athletes, describe the individual's risk profile, rule out secondary causes, and detect possible hypertension-mediated organ damage caused by hypertension at an early stage. Based on most recent clinical research and international consensus documents, we propose a diagnostic algorithm as well the non-pharmacological and pharmacological management of hypertension in athletes. Although elevated blood pressure levels are less common in the active population, athletes are not protected from hypertension. A thorough diagnostic approach may help to identify individual at risk for adverse cardiovascular events and to address the optimal treatment as well as sport recommendations.
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Affiliation(s)
- Victor Schweiger
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - David Niederseer
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Christian Schmied
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Christine Attenhofer-Jost
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Cardiovascular Center Zurich, Hirslanden Klinik im Park, Zurich, Switzerland
| | - Stefano Caselli
- Cardiovascular Center Zurich, Hirslanden Klinik im Park, Zurich, Switzerland
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Abstract
Bupropion hydrochloride is a norepinephrine-dopamine reuptake inhibitor approved for the treatment of depression and smoking cessation. Although cardiovascular and hematological side effects are common with bupropion along with weight loss and headache, hematological side effects are rarely reported other than few post marketing studies. Here we present the case of a 47-year-old white female who presented with significant leukocytosis after bupropion overdose.
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Mental Health Issues and Psychological Factors in Athletes: Detection, Management, Effect on Performance, and Prevention: American Medical Society for Sports Medicine Position Statement. Clin J Sport Med 2020; 30:e61-e87. [PMID: 32000169 DOI: 10.1097/jsm.0000000000000817] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The American Medical Society for Sports Medicine convened a panel of experts to provide an evidence-based, best practices document to assist sports medicine physicians and other members of the athletic care network with the detection, treatment, and prevention of mental health issues in competitive athletes. This statement discusses how members of the sports medicine team, including team physicians, athletic trainers, and mental health providers, work together in providing comprehensive psychological care to athletes. It specifically addresses psychological factors in athletes including personality issues and the psychological response to injury and illness. The statement also examines the athletic culture and environmental factors that commonly impact mental health, including sexuality and gender issues, hazing, bullying, sexual misconduct, and transition from sport. Specific mental health disorders in athletes, such as eating disorders/disordered eating, depression and suicide, anxiety and stress, overtraining, sleep disorders, and attention-deficit/hyperactivity disorder, are reviewed with a focus on detection, management, the effect on performance, and prevention. This document uses the Strength of Recommendation Taxonomy (SORT) to grade level of evidence.
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Gan J, Galer P, Ma D, Chen C, Xiong T. The Effect of Vitamin D Supplementation on Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Child Adolesc Psychopharmacol 2019; 29:670-687. [PMID: 31368773 DOI: 10.1089/cap.2019.0059] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective: A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to assess the benefits and harms of vitamin D supplementation for attention-deficit/hyperactivity disorder (ADHD) patients. Methods: We followed the standard methodological procedures of the Cochrane Handbook for Systematic Reviews of Intervention. PubMed, Embase, the Cochrane Central Register of Controlled Trials, Science and Conference Proceedings Citation Index-Social Science and Humanities (Web of Science), ClincalTrials.gov, and World Health Organization's International Clinical Trials Registry Platform were searched for RCTs in January 2019. Independently, two authors (J.G., T.X.) extracted data, assessed the risk of bias, combined the data, and graded evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation approach. Our primary outcomes were assessed through rating scales of ADHD severity. Secondary outcomes measured were the possible adverse effects of vitamin D supplementation and vitamin D status after supplementation for ADHD. Results: We included four RCTs with 256 children addressing vitamin D supplementation as adjunctive therapy to methylphenidate on ADHD symptoms. Vitamin D supplementation demonstrated a small but statistically significant improvement in ADHD total scores, inattention scores, hyperactivity scores, and behavior scores. The improvement was likely limited due to the low to very low quality of evidence in the literature. There was no statistically significant improvement in oppositional scores. Reported adverse events in the vitamin D group were mild and not significantly different from the control group. Vitamin D supplementation increased serum vitamin D levels and the ratio of patients with sufficient vitamin D levels. Conclusions: Vitamin D supplementation as adjunctive therapy to methylphenidate appeared to reduce ADHD symptoms without serious adverse events, associated with improved vitamin D status. However, considering the generally low strength of evidence, well-designed RCTs are needed to determine the efficacy and safety of vitamin D supplementation for both children and adults with ADHD, especially in the setting of a combination of vitamin D and other ADHD treatments.
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Affiliation(s)
- Jing Gan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Peter Galer
- Department of Biomedical and Health Informatics (DBHI), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dan Ma
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chao Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,Deep Underground Space Medical Center, West China Hospital, Sichuan University, Chengdu, China
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Bali V, Kamble PS, Aparasu RR. Cardiovascular Safety of Concomitant Use of Atypical Antipsychotics and Long-Acting Stimulants in Children and Adolescents With ADHD. J Atten Disord 2019; 23:163-172. [PMID: 26494504 DOI: 10.1177/1087054715608443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study examined cardiovascular safety of concomitant use of long-acting stimulants (LAS) and atypical antipsychotics (AAP) in children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD). METHOD The study used 2004-2007 IMS LifeLink™ claims data involving 6- to 16-year-old children with ADHD and at least one LAS prescription from July 2004 to December 2006. Time-dependent Cox regression analysis was performed to evaluate the risk of cardiovascular disease (CVD) events due to concomitant use of LAS and AAP. RESULTS The analytical cohort consisted of 37,903 children: 538 (1.9%) used LAS and AAP concurrently and the rest used LAS monotherapy. Time-dependent Cox regression analysis revealed no difference in CVD risk among concomitant users of LAS and AAP (hazard ratio = 1.19; 95% confidence interval = [0.60, 2.53]) when compared with users of LAS monotherapy. CONCLUSION Concomitant use of LAS and AAP was not associated with risk of CVD events in ADHD patients when compared with LAS monotherapy.
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Affiliation(s)
- Vishal Bali
- 1 Health Advocate, Westlake Village, CA, USA
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Cardiovascular Effects of Drugs Used to Treat Attention-Deficit/Hyperactivity Disorder: Part 1: Epidemiology, Pharmacology, and Impact on Hemodynamics and Ventricular Repolarization. Cardiol Rev 2018; 27:113-121. [PMID: 30365404 DOI: 10.1097/crd.0000000000000233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a clinical syndrome characterized by persistent inattention, impulsivity, and hyperactivity. It is most commonly encountered in children and adolescents but may persist into adulthood. A variety of psychostimulant and nonpsychostimulant medications have proven to be successful in reducing inattention, impulsivity, and hyperactivity in those with ADHD. Psychostimulants used to treat ADHD include methylphenidate and related drugs and various amphetamine preparations. Non-psychostimulant medications used to treat ADHD include atomoxetine and two alpha-2 adrenergic agonists: guanfacine extended-release and clonidine extended-release. The psychostimulants and atomoxetine have been shown, on average, to increase heart rate by 3-10 beats/min, systolic blood pressure by 3-8 mm Hg, and diastolic blood pressure by 2-14 mm Hg. These drugs may also delay ventricular repolarization. The alpha-2 adrenergic agonists may reduce heart rate and blood pressure. For these reasons, there is concern about the safety of psychostimulant and nonpsychostimulant medications in patients with ADHD. In part 1 of this review, we discuss the epidemiology and natural history of ADHD, describe the pharmacology of drugs used to treat ADHD, and discuss in detail studies assessing the effects of ADHD drugs on blood pressure, heart or pulse rate, and electrocardiographic indices of ventricular repolarization.
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Castells X, Blanco‐Silvente L, Cunill R. Amphetamines for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev 2018; 8:CD007813. [PMID: 30091808 PMCID: PMC6513464 DOI: 10.1002/14651858.cd007813.pub3] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is a childhood-onset disorder characterised by inattention, hyperactivity, and impulsivity. ADHD can persist into adulthood and can affects individuals' social and occupational functioning, as well as their quality of life and health. ADHD is frequently associated with other mental disorders such as substance use disorders and anxiety and affective disorders. Amphetamines are used to treat adults with ADHD, but uncertainties about their efficacy and safety remain. OBJECTIVES To examine the efficacy and safety of amphetamines for adults with ADHD. SEARCH METHODS In August 2017, we searched CENTRAL, MEDLINE, Embase, PsycINFO, 10 other databases, and two trials registers, and we ran citation searches for included studies. We also contacted the corresponding authors of all included studies, other experts in the field, and the pharmaceutical company, Shire, and we searched the reference lists of retrieved studies and reviews for other published, unpublished, or ongoing studies. For each included study, we performed a citation search in Web of Science to identify any later studies that may have cited it. SELECTION CRITERIA We searched for randomised controlled trials comparing the efficacy of amphetamines (at any dose) for ADHD in adults aged 18 years and over against placebo or an active intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data from each included study. We used the standardised mean difference (SMD) and the risk ratio (RR) to assess continuous and dichotomous outcomes, respectively. We conducted a stratified analysis to determine the influence of moderating variables. We assessed trials for risk of bias and drew a funnel plot to investigate the possibility of publication bias. We rated the quality of the evidence using the GRADE approach, which yielded high, moderate, low, or very low quality ratings based on evaluation of within-trial risk of bias, directness of evidence, heterogeneity of data; precision of effect estimates, and risk of publication bias. MAIN RESULTS We included 19 studies that investigated three types of amphetamines: dexamphetamine (10.2 mg/d to 21.8 mg/d), lisdexamfetamine (30 mg/d to 70 mg/d), and mixed amphetamine salts (MAS; 12.5 mg/d to 80 mg/d). These studies enrolled 2521 participants; most were middle-aged (35.3 years), Caucasian males (57.2%), with a combined type of ADHD (78.8%). Eighteen studies were conducted in the USA, and one study was conducted in both Canada and the USA. Ten were multi-site studies. All studies were placebo-controlled, and three also included an active comparator: guanfacine, modafinil, or paroxetine. Most studies had short-term follow-up and a mean study length of 5.3 weeks.We found no studies that had low risk of bias in all domains of the Cochrane 'Risk of bias' tool, mainly because amphetamines have powerful subjective effects that may reveal the assigned treatment, but also because we noted attrition bias, and because we could not rule out the possibility of a carry-over effect in studies that used a cross-over design.Sixteen studies were funded by the pharmaceutical industry, one study was publicly funded, and two studies did not report their funding sources.Amphetamines versus placeboSeverity of ADHD symptoms: we found low- to very low-quality evidence suggesting that amphetamines reduced the severity of ADHD symptoms as rated by clinicians (SMD -0.90, 95% confidence interval (CI) -1.04 to -0.75; 13 studies, 2028 participants) and patients (SMD -0.51, 95% CI -0.75 to -0.28; six studies, 120 participants).Retention: overall, we found low-quality evidence suggesting that amphetamines did not improve retention in treatment (risk ratio (RR) 1.06, 95% CI 0.99 to 1.13; 17 studies, 2323 participants).Adverse events: we found that amphetamines were associated with an increased proportion of patients who withdrew because of adverse events (RR 2.69, 95% CI 1.63 to 4.45; 17 studies, 2409 participants).Type of amphetamine: we found differences between amphetamines for the severity of ADHD symptoms as rated by clinicians. Both lisdexamfetamine (SMD -1.06, 95% CI -1.26 to -0.85; seven studies, 896 participants; low-quality evidence) and MAS (SMD -0.80, 95% CI -0.93 to -0.66; five studies, 1083 participants; low-quality evidence) reduced the severity of ADHD symptoms. In contrast, we found no evidence to suggest that dexamphetamine reduced the severity of ADHD symptoms (SMD -0.24, 95% CI -0.80 to 0.32; one study, 49 participants; very low-quality evidence). In addition, all amphetamines were efficacious in reducing the severity of ADHD symptoms as rated by patients (dexamphetamine: SMD -0.77, 95% CI -1.14 to -0.40; two studies, 35 participants; low-quality evidence; lisdexamfetamine: SMD -0.33, 95% CI -0.65 to -0.01; three studies, 67 participants; low-quality evidence; MAS: SMD -0.45, 95% CI -1.02 to 0.12; one study, 18 participants; very low-quality evidence).Dose at study completion: different doses of amphetamines did not appear to be associated with differences in efficacy.Type of drug-release formulation: we investigated immediate- and sustained-release formulations but found no differences between them for any outcome.Amphetamines versus other drugsWe found no evidence that amphetamines improved ADHD symptom severity compared to other drug interventions. AUTHORS' CONCLUSIONS Amphetamines improved the severity of ADHD symptoms, as assessed by clinicians or patients, in the short term but did not improve retention to treatment. Amphetamines were associated with higher attrition due to adverse events. The short duration of studies coupled with their restrictive inclusion criteria limits the external validity of these findings. Furthermore, none of the included studies had an overall low risk of bias. Overall, the evidence generated by this review is of low or very low quality.
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Affiliation(s)
- Xavier Castells
- Universitat de GironaUnit of Clinical Pharmacology, TransLab Research Group, Department of Medical SciencesEmili Grahit, 77GironaCataloniaSpain17071
| | - Lídia Blanco‐Silvente
- Universitat de GironaUnit of Clinical Pharmacology, TransLab Research Group, Department of Medical SciencesEmili Grahit, 77GironaCataloniaSpain17071
| | - Ruth Cunill
- Parc Sanitari Sant Joan de DéuParc Sanitari Sant Joan de Déu ‐ NumanciaBarcelonaCatalunyaSpain08735
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Bosco A, Lopez R, Barateau L, Chenini S, Pesenti C, Pépin JL, Jaussent I, Dauvilliers Y. Effect of psychostimulants on blood pressure profile and endothelial function in narcolepsy. Neurology 2018; 90:e479-e491. [DOI: 10.1212/wnl.0000000000004911] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 10/27/2017] [Indexed: 01/05/2023] Open
Abstract
ObjectiveTo assess the effect of psychostimulant treatments on the 24-hour blood pressure (BP) profile of patients with narcolepsy type 1 (NT1).MethodsHeart rate (HR) and BP were monitored for 24 hours and morning endothelial function was evaluated in 160 consecutive patients with NT1: 68 untreated (41 male, median age 34.9 years), 54 treated (32 male, median age 40.9 years), and 38 evaluated twice (21 male, median age 32 years), before and during treatment.ResultsPatients treated for NT1 showed higher 24-hour, daytime, and nighttime diastolic BP and HR values compared with the untreated group. Similarly, HR as well as 24-hour and daytime systolic BP were increased during treatment in the group evaluated twice. The combination of stimulant and anticataplectic drugs showed a synergistic effect on BP, without differences among stimulant categories. Based on 24-hour BP monitoring, hypertension was diagnosed in 58% of treated patients and in 40.6% of untreated patients. After adjustments for age, sex, and body mass index, the percentage of REM sleep remained associated with 24-hour hypertension in untreated and treated patients. Endothelial function was comparable in treated and untreated patients.ConclusionsThe finding that patients with NT1 treated with psychostimulants have higher diastolic BP and HR than untreated patients suggests an increased long-term risk of cardiovascular diseases that requires careful follow-up and specific management.
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Demir Gündoğmuş P, Gündoğmuş İ, Karagöz A, Kıyançiçek M, Yaşar AB, Algül A. Treatment of ADHD in a patient with Brugada syndrome: a case report and a brief review. PSYCHIAT CLIN PSYCH 2017. [DOI: 10.1080/24750573.2017.1412607] [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: 10/18/2022] Open
Affiliation(s)
- Pınar Demir Gündoğmuş
- Department of Psychiatry, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
| | - İbrahim Gündoğmuş
- Department of Psychiatry, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
| | - Abdulkadir Karagöz
- Department of Psychiatry, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
| | - Murat Kıyançiçek
- Department of Psychiatry, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
| | | | - Ayhan Algül
- Department of Psychiatry, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
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Abstract
Heart failure is a chronic, progressive illness that is increasing in prevalence in the USA. Patients with advanced heart failure experience a high symptom burden that is comparable to patients with advanced cancer. Palliative care, however, is underutilized in patients with heart failure, and symptoms may go untreated as the disease progresses. A combination of pharmacologic and non-pharmacologic interventions should be used to address symptoms and maintain quality of life. While there have been significant advances in evidence-based heart failure treatments in recent years, selection of appropriate palliative medications as symptoms progress is challenging due to limited clinical studies in this patient population. Medications that are commonly used for symptom management in other life-limiting illnesses may have little to no evidence in heart failure, or have undesirable cardiac effects that preclude use. Clinicians must extrapolate available clinical evidence and prescribing considerations relevant to heart failure to palliate symptoms as well as possible. The objectives of this paper are to review the most common and distressing symptoms in heart failure, analyze evidence, or lack thereof, for pharmacologic management of symptoms, and provide prescribing considerations based on side effect profiles and comorbid conditions.
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Affiliation(s)
- Diana Stewart
- MedStar Washington Hospital Center, Washington, DC, 20010, USA.
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Indave BI, Sordo L, Bravo MJ, Sarasa-Renedo A, Fernández-Balbuena S, De la Fuente L, Sonego M, Barrio G. Risk of stroke in prescription and other amphetamine-type stimulants use: A systematic review. Drug Alcohol Rev 2017; 37:56-69. [DOI: 10.1111/dar.12559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 03/15/2017] [Accepted: 03/20/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Blanca Iciar Indave
- National Center for Epidemiology; Carlos III Institute of Health; Madrid Spain
| | - Luis Sordo
- National Center for Epidemiology; Carlos III Institute of Health; Madrid Spain
- Consortium for Biomedical Research in Epidemiology and Public Health Madrid; Madrid Spain
- Department of Preventive Medicine and Public Health, Faculty of Medicine; Complutense University; Madrid Spain
| | - María José Bravo
- National Center for Epidemiology; Carlos III Institute of Health; Madrid Spain
- Consortium for Biomedical Research in Epidemiology and Public Health Madrid; Madrid Spain
| | - Ana Sarasa-Renedo
- National Center for Epidemiology; Carlos III Institute of Health; Madrid Spain
- Consortium for Biomedical Research in Epidemiology and Public Health Madrid; Madrid Spain
| | - Sonia Fernández-Balbuena
- National Center for Epidemiology; Carlos III Institute of Health; Madrid Spain
- Consortium for Biomedical Research in Epidemiology and Public Health Madrid; Madrid Spain
| | - Luis De la Fuente
- National Center for Epidemiology; Carlos III Institute of Health; Madrid Spain
- Consortium for Biomedical Research in Epidemiology and Public Health Madrid; Madrid Spain
| | - Michela Sonego
- Consortium for Biomedical Research in Epidemiology and Public Health Madrid; Madrid Spain
| | - Gregorio Barrio
- National School of Public Health; Carlos III Institute of Health; Madrid Spain
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Abstract
Hypertension continues to be the most common cardiovascular disorder in the USA and worldwide. While generally considered a disorder of aging individuals, hypertension is more prevalent in athletes and the active population than is generally appreciated. The timely detection, diagnosis, and appropriate treatment of hypertension in athletes must focus on both adequately managing the disorder and ensuring safe participation in sport while not compromising exercise capacity. This publication focuses on appropriately diagnosing hypertension, treating hypertension in the athletic population, and suggesting follow-up and participation guidelines for athletes.
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Affiliation(s)
- Kevin T Schleich
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.,Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
| | - M Kyle Smoot
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA
| | - Michael E Ernst
- Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA. .,Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, IA, USA.
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Adult ADHD Medications and Their Cardiovascular Implications. Case Rep Cardiol 2016; 2016:2343691. [PMID: 27579185 PMCID: PMC4992783 DOI: 10.1155/2016/2343691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/11/2016] [Indexed: 12/18/2022] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobiological disorder exhibited by difficulty maintaining attention, as well as hyperactivity and impulsive behavior. Central nervous system (CNS) stimulants are the first line of treatment for ADHD. With the increase in number of adults on CNS stimulants, the question that arises is how well do we understand the long-term cardiovascular effects of these drugs. There has been increasing concern that adults with ADHD are at greater risk for developing adverse cardiovascular events such as sudden death, myocardial infarction, and stroke as compared to pediatric population. Cardiovascular response attributed to ADHD medication has mainly been observed in heart rate and blood pressure elevations, while less is known about the etiology of rare cardiovascular events like acute myocardial infarction (AMI), arrhythmia, and cardiomyopathy and its long-term sequelae. We present a unique case of AMI in an adult taking Adderall (mixed amphetamine salts) and briefly discuss the literature relevant to the cardiovascular safety of CNS stimulants for adult ADHD.
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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.
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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
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Connell C, Gellatly R, Dooley M, Shaw J. A case of ST elevation myocardial infarction precipitated by methylphenidate therapy for gait freeze. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/jppr.1077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Cia Connell
- Department of Pharmacy; Alfred Hospital; Melbourne Australia
| | - Rochelle Gellatly
- Department of Pharmacy; Alfred Hospital; Melbourne Australia
- Postgraduate Studies & Professional Development Unit; The Faculty of Pharmacy & Pharmaceutical Sciences, Monash University; Melbourne Australia
| | - Michael Dooley
- Department of Pharmacy; Alfred Hospital; Melbourne Australia
- Centre for Medicine Use and Safety; Monash University; Melbourne Australia
| | - James Shaw
- Department of Cardiovascular Medicine Services; Alfred Hospital; Melbourne Australia
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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.
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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,
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22
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Freudenmann RW, Freudenmann N, Zurowski B, Schönfeldt-Lecuona C, Connemann BJ, Gahr M, Freudenmann R. Better risk assessment for individual substances. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:120. [PMID: 25780871 PMCID: PMC4353870 DOI: 10.3238/arztebl.2015.0120a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Roland W Freudenmann
- *On behalf of the authors:Universitätsklinikum Ulm, Klinik für Psychiatrie und Psychotherapie III,
| | - Ninja Freudenmann
- *On behalf of the authors:Universitätsklinikum Ulm, Klinik für Psychiatrie und Psychotherapie III,
| | - Bartosz Zurowski
- *On behalf of the authors:Universitätsklinikum Ulm, Klinik für Psychiatrie und Psychotherapie III,
| | | | - Bernhard J Connemann
- *On behalf of the authors:Universitätsklinikum Ulm, Klinik für Psychiatrie und Psychotherapie III,
| | - Maximilian Gahr
- *On behalf of the authors:Universitätsklinikum Ulm, Klinik für Psychiatrie und Psychotherapie III,
| | - Roland Freudenmann
- *On behalf of the authors:Universitätsklinikum Ulm, Klinik für Psychiatrie und Psychotherapie III,
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Liver Transplant in a Patient under Methylphenidate Therapy: A Case Report and Review of the Literature. Case Rep Pediatr 2015; 2015:437298. [PMID: 25688317 PMCID: PMC4320912 DOI: 10.1155/2015/437298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/09/2014] [Indexed: 12/18/2022] Open
Abstract
Background. Methylphenidate (MPH) is widely used in treating children with attention-deficit-hyperactivity disorder. Hepatotoxicity is a rare phenomenon; only few cases are described with no liver failure. Case. We report on the case of a 12-year-old boy who received MPH for attention-deficit-hyperactivity disorder. Two months later the patient presented with signs and symptoms of hepatitis and MPH was discontinued, showing progressive worsening and developing liver failure and a liver transplantation was required. Other causes of liver failure were ruled out and the liver biopsy was suggestive of drug toxicity. Discussion. One rare adverse reaction of MPH is hepatotoxicity. The review of the literature shows few cases of liver injury attributed to MPH; all of them recovered after withdrawing the treatment. The probable mechanism of liver injury was MPH direct toxicity to hepatocytes. In order to establish the diagnosis of MPH-induced liver injury, we used CIOMS/RUCAM scale that led to an assessment of “possible” relationship. This report provides the first published case of acute MPH-induced liver failure with successful hepatic transplantation. Conclusions. It is important to know that hepatotoxicity can occur in patients with MPH treatment and monitoring the liver's function is highly recommended.
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Manor I, Rubin J, Daniely Y, Adler LA. Attention benefits after a single dose of metadoxine extended release in adults with predominantly inattentive ADHD. Postgrad Med 2014; 126:7-16. [PMID: 25295645 DOI: 10.3810/pgm.2014.09.2795] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the first-dose effectiveness and tolerability of metadoxine extended release (MDX) in adults with predominantly inattentive attention-deficit/hyperactivity disorder (ADHD-PI). METHODS In this double-blind, placebo-controlled, crossover study, adults with ADHD-PI were randomized 1:1:1 to receive a single dose of MDX 1400 mg, MDX 700 mg, and placebo (ClinicalTrials.gov identifier: NCT01685281). The primary efficacy end point was the mean change in the Test of Variables of Attention (TOVA) ADHD score from baseline to 3 to 5 hours after drug administration. Secondary assessments included TOVA subscores, TOVA response rates (defined as an increase of 0.8 points in the TOVA ADHD score), and the Cambridge Neuropsychological Automated Test Battery. Safety assessments included adverse events and vital signs. RESULTS The intention-to-treat population included 36 patients (52.8% men; mean age, 32 years). The efficacy of MDX 1400 mg was demonstrated by a statistically significant difference in the mean (± SD) change in the TOVA ADHD score at baseline to 3 to 5 hours after drug administration compared with placebo (2.0 [4.2]; P = 0.009). The TOVA response time variability subscore was significantly different between MDX 1400 mg and placebo (mean difference, 7.9 [19.2] points; P = 0.022). Significantly more adults responded to single-dose MDX 1400 mg versus placebo (97.1% vs 71.4%, P = 0.006). There were no statistically significant differences between MDX 700 mg and placebo on any measures. Exploratory analyses of the Cambridge Neuropsychological Automated Test Battery did not yield significant findings. Fatigue and headache were the 2 most frequently reported adverse events. There were no clinically significant abnormalities in laboratory values, vital signs measurements, Columbia-Suicide Severity Rating Scale scores, or electrocardiographic parameters. CONCLUSIONS Single-dose MDX 1400 mg significantly improved sustained and selective attention in adults with ADHD-PI as measured by the TOVA ADHD score 3 to 5 hours after drug administration. Single doses of MDX 700 and 1400 mg were well tolerated.
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Affiliation(s)
- Iris Manor
- Associate Professor of Psychiatry, Geha Mental Health Center, Petah Tikva, Israel
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Maintenance of wakefulness with lisdexamfetamine dimesylate, compared with placebo and armodafinil in healthy adult males undergoing acute sleep loss. J Clin Psychopharmacol 2014; 34:690-6. [PMID: 25159886 DOI: 10.1097/jcp.0000000000000202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study evaluated daytime alertness and performance with lisdexamfetamine dimesylate during acute sleep loss. In a randomized, double-blind study in healthy adult men (n = 135) undergoing 24-hour sleep loss, the alerting effects of single oral lisdexamfetamine dimesylate doses (20, 50, or 70 mg) were compared with a placebo and an active control (armodafinil 250 mg). Primary end point was mean unequivocal sleep latency on the 30-minute maintenance of wakefulness test taken every 2 hours from midnight to 8:00 A.M. Secondary end points included the Karolinska sleepiness scale and psychomotor vigilance task. Safety assessments included treatment-emergent adverse events (TEAEs) and vital signs. Least squares mean (SE) maintenance of wakefulness test unequivocal sleep latency (in minutes) was longer with lisdexamfetamine dimesylate 20, 50, and 70 mg, or armodafinil 250 mg (23.3 [1.10], 27.9 [0.64], 29.3 [0.44], or 27.6 [0.63], respectively) versus placebo (15.3 [1.00]; P < 0.0001). Longer mean unequivocal sleep latency was seen with lisdexamfetamine dimesylate 70 mg versus armodafinil (P = 0.0351) and armodafinil versus lisdexamfetamine dimesylate 20 mg (P = 0.0014). On Karolinska sleepiness scale, lisdexamfetamine dimesylate 50 and 70 mg improved estimated sleepiness versus placebo (P ≤ 0.0002) and armodafinil (P ≤ 0.03). Active treatments improved psychomotor vigilance task performance versus placebo (P < 0.0001). The TEAEs were mild/moderate. No serious adverse events occurred. The most common TEAE was headache with lisdexamfetamine dimesylate and armodafinil (7.4% each) versus placebo (3.7%). Small mean increases in vital signs were observed with lisdexamfetamine dimesylate and armodafinil. In sleep-deprived healthy men, alertness was greater with lisdexamfetamine dimesylate and armodafinil versus placebo on the primary end point. Studies are needed in clinical populations and using longer durations of administration.
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Kelly AS, Rudser KD, Dengel DR, Kaufman CL, Reiff MI, Norris AL, Metzig AM, Steinberger J. Cardiac autonomic dysfunction and arterial stiffness among children and adolescents with attention deficit hyperactivity disorder treated with stimulants. J Pediatr 2014; 165:755-9. [PMID: 25015574 PMCID: PMC5880029 DOI: 10.1016/j.jpeds.2014.05.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 04/09/2014] [Accepted: 05/27/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare markers of cardiovascular health in youth diagnosed with attention deficit hyperactivity disorder (ADHD) by the use of stimulant medication with healthy controls. STUDY DESIGN Children and adolescents (n = 85; mean age 11.2 ± 2.8 years; 66 boys) diagnosed with ADHD using a stimulant and 53 siblings without ADHD (mean age 11.1 ± 3.8 years; 28 boys) were included in this cross-sectional study. Measured variables included blood pressure, heart rate (HR), HR variability: SD of the RR interval and low frequency to high frequency ratio, carotid-radial pulse wave velocity, carotid artery augmentation index (AIx), radial artery AIx, brachial artery flow-mediated dilation, and digital reactive hyperemic index. RESULTS Compared with control patients, participants with ADHD had greater resting systolic blood pressure (3.9 mm Hg, 95% CI [1.2-6.7], P = .005), diastolic blood pressure (5.5 mm Hg, 95% CI [3.2-7.8], P < .001), HR (9.2 beats/min, 95% CI [6.0-12.3], P < .001), low frequency to high frequency ratio (0.55, 95% CI [0.22-0.89], P = .001), carotid AIx (7.2%, 95% CI [1.9-12.5], P = .008), and pulse wave velocity (0.36 m/s, 95% CI [-0.05, 0.78], P = .089), and lower SD of the RR interval (-33.7 milliseconds, 95% CI [-46.1, -21.3], P < .001). Neither flow-mediated dilation nor reactive hyperemic index was significantly different. CONCLUSIONS Children and adolescents being treated with a stimulant medication for ADHD exhibited signs of altered cardiac autonomic function, characterized by increased sympathetic tone, and showed evidence of arterial stiffening.
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Affiliation(s)
- Aaron S. Kelly
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Kyle D. Rudser
- Division of Biostatistics, School of Public Health and Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN
| | | | | | - Michael I. Reiff
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
| | - Anne L. Norris
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
| | - Andrea M. Metzig
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
| | - Julia Steinberger
- Department of Pediatrics, University of Minnesota Medical School, and University of Minnesota Children’s Hospital, Minneapolis, MN
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Blankfield RP, Iftikhar IH. Food and Drug Administration Regulation of Drugs That Raise Blood Pressure. J Cardiovasc Pharmacol Ther 2014; 20:5-8. [DOI: 10.1177/1074248414531852] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although it is recognized that a systolic blood pressure (SBP) increase ≥2 mm Hg or a diastolic blood pressure (DBP) increase ≥1 mm Hg increases the risk of heart attacks and strokes in middle-aged adults, the Food and Drug Administration (FDA) lacks an adequate policy for regulating medications that increase blood pressure (BP). Some FDA reviewers consider a clinically significant increase in BP to occur only if a drug raises SBP ≥20 mm Hg or if a drug raises DBP ≥10 to 15 mm Hg. In recent years, numerous drugs have been regulated or taken off the market due to cardiovascular safety concerns. The list includes rofecoxib (Vioxx), valdecoxib (Bextra), nonselective nonsteroidal anti-inflammatory drugs, sibutramine (Meridia), and phenylpropanolamine. It is probable that the hypertensive effect of these drugs explains why they increase the risk of adverse cardiovascular events. Other drugs, notably serotonin–norepinephrine reuptake inhibitors and drugs used to treat attention deficit hyperactivity disorder, were approved without cardiovascular safety data despite the fact that they raise BP comparable to valdecoxib and sibutramine. It is the responsibility of the FDA to ensure that drugs are properly labeled regarding risk. Even if a drug raises BP only modestly, FDA guidelines for new drug approvals should include a requirement for cardiovascular safety data. However, such guidelines will not address the problem of how to obtain cardiovascular safety data for the many already approved drugs that increase BP. The FDA should play a role in obtaining cardiovascular safety data for such drugs.
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Affiliation(s)
- Robert P. Blankfield
- Department of Family Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Imran H. Iftikhar
- Department of Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
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Attention deficit hyperactivity disorder screening electrocardiograms: a community-based perspective. Pediatr Cardiol 2014; 35:485-9. [PMID: 24141829 DOI: 10.1007/s00246-013-0810-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 09/24/2013] [Indexed: 10/26/2022]
Abstract
Screening electrocardiograms (EKGs) for attention deficit hyperactivity disorder (ADHD) medication administration is controversial. We reviewed our experience as a community-based cardiology group. We reviewed all ADHD screening EKGs during a 2-year period. We evaluated whether screening EKGs resulted in further consultation and if management was altered. We also evaluated differences between patients on ADHD medications and those starting ADHD medications and further stratified the patients into stimulant versus nonstimulant groups. A total of 691 screening EKGs met our criteria. Forty-two patients (6.1%) were recommended for further consultation. EKG findings requiring consultation included the following: left-ventricular hypertrophy, right atrial enlargement, arrhythmia, prolonged QT, and axis deviation. Studies performed during consultation included 39 echocardiograms, 2 stress tests, 2 Holter monitors, and 1 heart card. Five patients (0.72%) were identified to have cardiac disease, one of whom decided against starting ADHD medications due to an arrhythmia, resulting in a change in management (0.14%). Results comparing mean age, heart rate, and corrected QT interval between patients on medication and patients starting medications were as follows: 10.06 years, 82.87, bpm and 405.24 ms compared with 9.99 years, 80.05 bpm, and 405.82 ms, respectively (p = not significant [NS], p = 0.013 [NS], respectively). Results comparing mean age, heart rate, and corrected QT interval between patients on stimulant versus nonstimulant medications were as follows: 9.68 years, 83.10 bpm, and 403.04 ms compared with 9.81 years, 80.10 bpm, and 407.08 ms, respectively (p = NS for all). In our population, screening EKGs rarely resulted in management changes for patients taking or starting ADHD medications.
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Arnold VK, Feifel D, Earl CQ, Yang R, Adler LA. A 9-week, randomized, double-blind, placebo-controlled, parallel-group, dose-finding study to evaluate the efficacy and safety of modafinil as treatment for adults with ADHD. J Atten Disord 2014; 18:133-44. [PMID: 22617860 DOI: 10.1177/1087054712441969] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study evaluated the efficacy and tolerability of modafinil at a range of doses, versus placebo, in alleviating symptoms of ADHD in adults. METHOD Adult patients with ADHD were randomized in 1:1:1:1:1 fashion to double-blind treatment with modafinil 255, 340, 425, or 510 mg daily or placebo for 9 weeks. The primary efficacy outcome was the change from baseline at final visit in the Adult ADHD Investigator Symptom Rating Scale (AISRS) total score. RESULTS A total of 338 patients were enrolled, of whom 330 received at least 1 dose of study medication (modafinil or placebo). No statistically significant difference in the AISRS total score was observed at final visit between any modafinil group and placebo; however, some observations among patients who completed the trial may warrant further investigation. CONCLUSION Modafinil was reasonably tolerated but did not demonstrate a benefit on ADHD symptoms in adults.
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Poulton A. Long-term outcomes of stimulant medication in attention-deficit hyperactivity disorder. Expert Rev Neurother 2014; 6:551-61. [PMID: 16623654 DOI: 10.1586/14737175.6.4.551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The rate of prescribing of stimulant medication for the treatment of attention-deficit hyperactivity disorder (ADHD) has been progressively increasing in countries such as the USA and Australia. In the short term, stimulant medication is effective in reducing the symptoms of ADHD and appears well tolerated with relatively minor side effects. In the long term, much of the benefit of stimulant medication disappears after medication is ceased. Studies have demonstrated only marginal improvements in adult outcomes following a period of treatment in childhood. This may be owing to the beneficial effects being masked by the variability of the condition, the developmental changes in symptomatology that happen with maturation and the substantial influence of social and environmental factors. Stimulant medication may give some protection against later substance abuse. Stimulant medication may slightly elevate the blood pressure and possibly increase susceptibility to seizures and to tics and Tourette syndrome. Starting treatment with stimulant medication is usually associated with weight loss and a transient slowing of the height velocity, although it is believed that most children catch up during puberty. No studies were found that listed strokes or heart attacks as potential or actual complications, although one individual from a group of normal controls died suddenly of cardiac arrest in adolescence. It would appear that the medical complications associated with amphetamine addiction are not relevant to the therapeutic use of stimulant medication in the treatment of ADHD, although there is limited information on extended periods of treatment lasting 10 years or more.
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Affiliation(s)
- Alison Poulton
- Western Clinical School, Nepean Campus, University of Sydney, Australia.
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Rucklidge JJ, Johnstone J, Kaplan BJ. Nutrient supplementation approaches in the treatment of ADHD. Expert Rev Neurother 2014; 9:461-76. [DOI: 10.1586/ern.09.7] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Haavik J, Halmøy A, Lundervold AJ, Fasmer OB. Clinical assessment and diagnosis of adults with attention-deficit/hyperactivity disorder. Expert Rev Neurother 2014; 10:1569-80. [DOI: 10.1586/ern.10.149] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rustad JK, Stern TA, Hebert KA, Musselman DL. Diagnosis and treatment of depression in patients with congestive heart failure: a review of the literature. Prim Care Companion CNS Disord 2013; 15:13r01511. [PMID: 24392265 DOI: 10.4088/pcc.13r01511] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 04/12/2013] [Indexed: 01/02/2023] Open
Abstract
CONTEXT Major depressive disorder (MDD) can be challenging to diagnose in patients with congestive heart failure, who often suffer from fatigue, insomnia, weight changes, and other neurovegetative symptoms that overlap with those of depression. Pathophysiologic mechanisms (eg, inflammation, autonomic nervous system dysfunction, cardiac arrhythmias, and altered platelet function) connect depression and congestive heart failure. OBJECTIVE We sought to review the prevalence, diagnosis, neurobiology, and treatment of depression associated with congestive heart failure. DATA SOURCES A search of all English-language articles between January 2003 and January 2013 was conducted using the search terms congestive heart failure and depression. STUDY SELECTION We found 1,498 article abstracts and 19 articles (meta-analyses, systematic reviews, and original research articles) that were selected for inclusion, as they contained information about our focus on diagnosis, treatment, and pathophysiology of depression associated with congestive heart failure. The search was augmented with manual review of reference lists of articles from the initial search. Articles selected for review were determined by author consensus. DATA EXTRACTION The prevalence, diagnosis, neurobiology, and treatment of depression associated with congestive heart failure were reviewed. Particular attention was paid to the safety, efficacy, and tolerability of antidepressant medications commonly used to treat depression and how their side-effect profiles impact the pathophysiology of congestive heart failure. Drug-drug interactions between antidepressant medications and medications used to treat congestive heart failure were examined. RESULTS MDD is highly prevalent in patients with congestive heart failure. Moreover, the prevalence and severity of depression correlate with the degree of cardiac dysfunction and development of congestive heart failure. Depression increases the risk of congestive heart failure, particularly in those patients with coronary artery disease , and is associated with a poorer quality of life, increased use of health care resources, more frequent adverse clinical events and hospitalizations, and twice the risk of mortality. CONCLUSIONS At present, limited empirical data exist with regard to treatment of depression in the increasingly large population of patients with congestive heart failure. Evidence reveals that both psychotherapeutic treatment (eg, cognitive-behavioral therapy) and pharmacologic treatment (eg, use of the selective serotonin reuptake inhibitor sertraline) are safe and effective in reducing depression severity in patients with cardiovascular disease. Collaborative care programs featuring interventions that work to improve adherence to medical and psychiatric treatments improve both cardiovascular disease and depression outcomes. Depression rating scales such as the 9-item Patient Health Questionnaire should be used to monitor therapeutic efficacy.
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Affiliation(s)
- James K Rustad
- Department of Psychiatry and Behavioral Medicine, Morsani College of Medicine, University of South Florida, Tampa, and Department of Psychiatry, University of Central Florida College of Medicine, Orlando (Dr Rustad); Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston (Dr Stern); Departments of Medicine (Ms Hebert) and Psychiatry (Dr Musselman), University of Miami/Miller School of Medicine, Miami, Florida
| | - Theodore A Stern
- Department of Psychiatry and Behavioral Medicine, Morsani College of Medicine, University of South Florida, Tampa, and Department of Psychiatry, University of Central Florida College of Medicine, Orlando (Dr Rustad); Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston (Dr Stern); Departments of Medicine (Ms Hebert) and Psychiatry (Dr Musselman), University of Miami/Miller School of Medicine, Miami, Florida
| | - Kathy A Hebert
- Department of Psychiatry and Behavioral Medicine, Morsani College of Medicine, University of South Florida, Tampa, and Department of Psychiatry, University of Central Florida College of Medicine, Orlando (Dr Rustad); Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston (Dr Stern); Departments of Medicine (Ms Hebert) and Psychiatry (Dr Musselman), University of Miami/Miller School of Medicine, Miami, Florida
| | - Dominique L Musselman
- Department of Psychiatry and Behavioral Medicine, Morsani College of Medicine, University of South Florida, Tampa, and Department of Psychiatry, University of Central Florida College of Medicine, Orlando (Dr Rustad); Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston (Dr Stern); Departments of Medicine (Ms Hebert) and Psychiatry (Dr Musselman), University of Miami/Miller School of Medicine, Miami, Florida
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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.
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Affiliation(s)
- Paul Hammerness
- Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital (MGH), Cambridge, MA 02138, USA.
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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.
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Kornfield R, Watson S, Higashi AS, Conti RM, Dusetzina SB, Garfield CF, Dorsey ER, Huskamp HA, Alexander GC. Effects of FDA advisories on the pharmacologic treatment of ADHD, 2004-2008. Psychiatr Serv 2013; 64:339-46. [PMID: 23318985 PMCID: PMC4023684 DOI: 10.1176/appi.ps.201200147] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study assessed the effect of public health advisories issued between 2005 and 2007 by the U.S. Food and Drug Administration (FDA) on treatments of attention-deficit hyperactivity disorder (ADHD) and physician prescribing practices. METHODS Data obtained from the IMS Health National Disease and Therapeutic Index, a nationally representative audit of ambulatory physicians, were used to examine trends in office visits by children and adolescents (under age 18) during which ADHD was treated with Adderall, other psychostimulants, or atomoxetine. Segmented time series regressions were conducted to determine changes in use associated with three advisories issued between 2005 and 2007. RESULTS In 2004, before the first FDA advisory, Adderall accounted for 36% of ADHD pharmacotherapy treatment visits. Other stimulants accounted for 46%, and atomoxetine accounted for 19%. Overall pharmacotherapy treatment rates were stable over the study period, but by 2008 the treatment visits accounted for by Adderall (that is, market share) declined to 24%, and the market share for atomoxetine declined to 8%. The market share for substitute therapies-clonidine, guanfacine, and bupropion-was stable over this period, ranging from 5% to 7%. Despite the declines in the use of Adderall and atomoxetine over the study period, results from the regression models suggest that the advisories did not have a statistically significant effect on ADHD medication prescribing. CONCLUSIONS FDA advisories regarding potential cardiovascular and other risks of ADHD medications had little discernible incremental effect on the use of these medicines in this nationally representative ambulatory audit.
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Affiliation(s)
- Rachel Kornfield
- Institute for Health Research and Policy, University of Illinois at Chicago, Westside Research Office Bldg., 1747 West Roosevelt Rd., Chicago, IL 60608, USA.
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Martinez-Raga J, Knecht C, Szerman N, Martinez MI. Risk of serious cardiovascular problems with medications for attention-deficit hyperactivity disorder. CNS Drugs 2013; 27:15-30. [PMID: 23160939 DOI: 10.1007/s40263-012-0019-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity and/or impulsivity. The proportion of patients diagnosed with ADHD receiving pharmacological treatments has increased enormously in recent years. Despite the well established efficacy and the good safety and tolerability profile, there is concern about the potential for rare but serious cardiovascular adverse events, as well as sudden cardiac death, with pharmacotherapies used for treating ADHD in children, adolescents and adults. The present paper aims to comprehensively and critically review the published evidence on the controversial association between medications approved for treating patients with ADHD and the risk of serious cardiovascular problems, specifically the risk of corrected QT interval (QTc) prolongation, and the risk of sudden cardiac death. A comprehensive search of relevant databases (PubMed, EMBASE and PsychINFO) was conducted to identify studies published in peer-reviewed journals until 21 July 2012. Clinical reports, as well as retrospective or prospective population-based studies with children, adolescents or adults as participants, of pharmacotherapies for ADHD reporting cardiovascular adverse events were included. Stimulant medications for ADHD, including methylphenidate and amphetamine derivatives, are generally safe and well tolerated. Small but statistically significant increases in blood pressure (BP) and heart rate (HR) are among the adverse events of stimulant treatment in all age groups. Similarly, the non-stimulant medication atomoxetine has also been associated with increased HR and BP, although as is the case with stimulants, these are generally minor, time limited and of minor clinical significance in children, adolescents or adults. Growing evidence suggests that these medications do not cause sudden and unexpected cardiac death or serious cardiovascular problems including statistically or clinically significant increases in QTc, at therapeutic doses in ADHD patients across the lifespan. Small decreases in mean systolic BP, diastolic BP and HR have been observed in studies with guanfacine-extended release (-XR) or clonidine-XR, two α(2)-adrenergic receptor agonists, administered alone or in combination with psychostimulants to children and adolescents with ADHD. There are also no statistically or clinically significant increases in QTc associated with clonidine or guanfacine. There are no reports of torsades de pointes clearly and directly related to medications used for treating ADHD in patients of all age groups. The risk for serious cardiovascular adverse events, including statistically or clinically significant increases in QTc, and sudden cardiac death associated with stimulants, atomoxetine or α(2)-adrenergic agonists prescribed for ADHD is extremely low and the benefits of treating individual patients with ADHD, after an adequate assessment, outweigh the risks. However, great caution is advised when considering stimulant and non-stimulant medications for patients of any age with a diagnosis of ADHD and a personal or family history or other known risk factors for cardiovascular disease.
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Affiliation(s)
- Jose Martinez-Raga
- Teaching Unit of Psychiatry and Psychological Medicine, Medicine Department, University of Valencia, Valencia, Spain.
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Westover AN, Nakonezny PA, Winhusen T, Adinoff B, Vongpatanasin W. Risk of methylphenidate-induced prehypertension in normotensive adult smokers with attention deficit hyperactivity disorder. J Clin Hypertens (Greenwich) 2012; 15:124-32. [PMID: 23339731 DOI: 10.1111/jch.12039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The authors studied predictors of methylphenidate-induced increases in blood pressure (BP). In this secondary analysis of a randomized, double-blind, placebo-controlled smoking cessation trial, nonhypertensive adult smokers with attention deficit hyperactivity disorder randomized to osmotic-release oral system methylphenidate (OROS-MPH) (n=115) were matched one-to-one on baseline systolic BP (SBP) (±5 mm Hg) with participants randomized to placebo (n=115) and followed for 10 weeks. In adjusted mixed linear models of SBP and diastolic BP (DBP), baseline normal SBP (P<.0001) and DBP (P<.0001) were associated with significant OROS-MPH-induced increases compared with placebo, whereas significant increases were not observed in participants with baseline prehypertensive SBP (P=.27) and DBP (P=.79). Participants randomized to OROS-MPH with baseline normal BP had increased odds of developing either systolic (odds ratio [OR], 3.32; 95% confidence interval [CI], 1.41-8.37; P=.006) or diastolic prehypertension (OR, 4.32; 95% CI, 1.56-14.0; P=.004) compared with placebo using simple logistic regression. The authors demonstrated an augmented OROS-MPH-induced BP elevation and risk of prehypertension in adults with baseline normal BP. Significantly increased BP was not observed in adults with baseline prehypertension.
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Affiliation(s)
- Arthur N Westover
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390-8828, USA.
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Psychological and physiological effects of bupropion compared to methylphenidate after prolonged administration in healthy volunteers (NCT00285155). Eur J Clin Pharmacol 2012; 69:779-87. [DOI: 10.1007/s00228-012-1418-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 09/21/2012] [Indexed: 10/27/2022]
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40
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Shaw I, Rucklidge JJ, Hughes RN. A Possible Biological Mechanism for the B Vitamins Altering Behaviour in Attention-Deficit/Hyperactivity Disorder. Pharmaceut Med 2012. [DOI: 10.1007/bf03256827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Westover AN, Halm EA. Do prescription stimulants increase the risk of adverse cardiovascular events?: A systematic review. BMC Cardiovasc Disord 2012; 12:41. [PMID: 22682429 PMCID: PMC3405448 DOI: 10.1186/1471-2261-12-41] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 06/09/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is increasing concern that prescription stimulants may be associated with adverse cardiovascular events such as stroke, myocardial infarction, and sudden death. Public health concerns are amplified by increasing use of prescription stimulants among adults. METHODS The objective of this study was to conduct a systematic review of the evidence of an association between prescription stimulant use and adverse cardiovascular outcomes. PUBMED, MEDLINE, EMBASE and Google Scholar searches were conducted using key words related to these topics (MESH): ADHD; Adults; Amphetamine; Amphetamines; Arrhythmias, Cardiac; Cardiovascular Diseases; Cardiovascular System; Central Nervous Stimulants; Cerebrovascular; Cohort Studies; Case-control Studies; Death; Death, Sudden, Cardiac; Dextroamphetamine; Drug Toxicity; Methamphetamine; Methylphenidate; Myocardial Infarction; Stimulant; Stroke; Safety. Eligible studies were population-based studies of children, adolescents, or adults using prescription stimulant use as the independent variable and a hard cardiovascular outcome as the dependent variable. RESULTS Ten population-based observational studies which evaluated prescription stimulant use with cardiovascular outcomes were reviewed. Six out of seven studies in children and adolescents did not show an association between stimulant use and adverse cardiovascular outcomes. In contrast, two out of three studies in adults found an association. CONCLUSIONS Findings of an association between prescription stimulant use and adverse cardiovascular outcomes are mixed. Studies of children and adolescents suggest that statistical power is limited in available study populations, and the absolute risk of an event is low. More suggestive of a safety signal, studies of adults found an increased risk for transient ischemic attack and sudden death/ventricular arrhythmia. Interpretation was limited due to differences in population, cardiovascular outcome selection/ascertainment, and methodology. Accounting for confounding and selection biases in these studies is of particular concern. Future studies should address this and other methodological issues.
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Affiliation(s)
- Arthur N Westover
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ethan A Halm
- Division of Outcomes and Health Services Research, Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Cho SC, Kim BN, Cummins TDR, Kim JW, Bellgrove MA. Norepinephrine transporter -3081(A/T) and alpha-2A-adrenergic receptor MspI polymorphisms are associated with cardiovascular side effects of OROS-methylphenidate treatment. J Psychopharmacol 2012; 26:380-9. [PMID: 21628343 DOI: 10.1177/0269881111405356] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to investigate a possible association between norepinephrine genes and cardiovascular side effects of the Osmotic Controlled-Release Oral Delivery System-methylphenidate (OROS-MPH) in Korean children with attention-deficit/hyperactivity disorder (ADHD). One hundred and one children with ADHD (8.7 ± 1.7 years) were recruited from child psychiatric centers at six university hospitals in South Korea. All participants were drug-naive ADHD children treated with OROS-MPH for 12 weeks. During the treatment period the investigators titrated the OROS-MPH dosage on the basis of symptom severity and side effects. Resting heart rate (HR), diastolic blood pressure (DBP), and systolic blood pressure (SBP) were examined before and after treatment. The percentage change score (post-treatment - pretreatment/pretreatment × 100) of each parameter was calculated. Genotyping of SLC6A2 -3081(A/T) and G1287A, and alpha-2A-adrenergic receptor (ADRA2A) MspI and DraI polymorphisms was performed. Clinically significant changes were not found in cardiovascular monitoring during the course of treatment. An increase of HR after OROS-MPH treatment was found to be statistically significant (t = 3.54, p = 0.001). Changes in SBP and DBP were not significant and no specific change was found in the ECGs. However, an additive regression analysis demonstrated a significant association between SLC6A2 -3081(A/T) and percentage change in HR post-treatment (p = 0.01) after controlling for age, gender, dosage of MPH and response and baseline pulse rate. Children with ADHD having the T/T genotype of SLC6A2 showed a 12.5% increase in HR compared to baseline, whereas children with the A/T or A/A genotype showed a 3.5% and 2.5% increase after OROS-MPH treatment, respectively. There was also a significant association between the ADRA2A MspI genotype and percentage change of DBP post-treatment after controlling for age, gender, dosage of MPH and response and baseline DBP (p = 0.009). Children with ADHD having the C/C genotype of ADRA2A MspI showed an 18.5% increase in DBP compared to baseline, but children with the G/G or G/C genotype showed a 0.2% decrease after OROS-MPH treatment. The overall cardiovascular effects of OROS-MPH were modest. However, our findings show a positive association between norepinephrine-related gene polymorphisms and cardiovascular response induced by MPH in Korean children with ADHD. Consideration must be given to such children or adults with specific norepinephrine-related genotypes, especially if they show significant changes in HR or DBP after OROS-MPH administration.
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Affiliation(s)
- Soo-Churl Cho
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University, College of Medicine, Seoul, South Korea
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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.
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Affiliation(s)
- Timothy E Wilens
- Clinical Research Program in Pediatric Psychopharmacology, Child Psychiatry Service, Massachusetts General Hospital, Boston, MA, USA.
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Hammerness PG, Surman CBH, Chilton A. Adult attention-deficit/hyperactivity disorder treatment and cardiovascular implications. Curr Psychiatry Rep 2011; 13:357-63. [PMID: 21698412 DOI: 10.1007/s11920-011-0213-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder afflicting adults worldwide. This article is an update on the evidence supporting medications for adult ADHD, with particular emphasis on cardiovascular implications. Relevant clinical literature was sought using PubMed searches, with an emphasis on new reports from April 2009 to April 2011. This review describes the efficacy and general tolerability of stimulant and nonstimulant medications for adults with ADHD as seen in contemporary clinical trials. Cardiovascular response to medications for ADHD is primarily seen in heart rate and blood pressure elevations, while less is known about the etiology of rare cardiovascular events or long-term sequelae. Further research is indicated to delineate clinical and functional outcomes for adults with ADHD, as well as long-term safety of medication treatment.
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Affiliation(s)
- Paul G Hammerness
- Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital and Harvard University Medical School, Cambridge, MA 02138, USA.
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Attention deficit hyperactivity disorder and the athlete: an American Medical Society for Sports Medicine position statement. Clin J Sport Med 2011; 21:392-401. [PMID: 21892014 DOI: 10.1097/jsm.0b013e3182262eb1] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Attention deficit hyperactivity disorder (ADHD) is an important issue for the physician taking care of athletes since ADHD is common in the athletic population, and comorbid issues affect athletes of all ages. The health care provider taking care of athletes should be familiar with making the diagnosis of ADHD, the management of ADHD, and how treatment medications impact exercise and performance. In this statement, the term "Team Physician" is used in reference to all healthcare providers that take care of athletes. These providers should understand the side effects of medications, regulatory issues regarding stimulant medications, and indications for additional testing. This position statement is not intended to be a comprehensive review of ADHD, but rather a directed review of the core issues related to the athlete with ADHD.
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Castells X, Ramos-Quiroga JA, Bosch R, Nogueira M, Casas M. Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in adults. Cochrane Database Syst Rev 2011:CD007813. [PMID: 21678370 DOI: 10.1002/14651858.cd007813.pub2] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Attention Deficit Hyperactivity Disorder (ADHD) is a childhood onset disorder that can persist into adulthood. Amphetamines are used to treat adult ADHD, but uncertainties persist about their efficacy and safety. OBJECTIVES To examine the efficacy and safety of amphetamines for adults with ADHD, as well as the influence of dose, drug type and release formulation type. SEARCH STRATEGY We searched CENTRAL, PubMed, EMBASE, CINAHL, PsycINFO, clinicaltrials.gov, UK Clinical Trials Gateway and references obtained from articles and experts in the field. We conducted the electronic searches on 25 February 2010. SELECTION CRITERIA Randomized controlled trials comparing the efficacy of amphetamine derivatives against placebo or an active intervention. DATA COLLECTION AND ANALYSIS Two authors extracted data from each included study. We used the standardized mean difference (SMD) and the risk ratio (RR) to assess continuous and dichotomous outcomes, respectively. We conducted a stratified analysis to determine the influence of moderating variables. We assessed the trials for risk of bias and drew a funnel plot to investigate the possibility of publication bias. MAIN RESULTS We included seven studies, which enrolled 1091 participants. All studies were placebo-controlled and three included an active comparator: guanfacine, modafinil and paroxetine. Most studies had short-term follow-up, with a mean study length of 8.1 weeks. Amphetamines improved ADHD symptom severity (SMD = -0.72; 95% CI -0.87 to -0.57) but did not improve retention in treatment overall and were associated with increased dropout due to adverse events (RR 3.03; 95% CI 1.52 to 6.05). The three amphetamine derivatives investigated (dextroamphetamine, lisdexamphetamine and mixed amphetamine salts (MAS)) were all efficacious for reducing ADHD symptoms, but MAS also increased retention in treatment. Different doses did not appear associated with differences in efficacy. We investigated immediate and sustained drug release formulations but found no difference between them on any outcome. When amphetamines were compared to other drug interventions, no differences were found. We did not find any study to be at low risk of bias overall, mainly because amphetamines have powerful subjective effects that may reveal the assigned treatment. AUTHORS' CONCLUSIONS Amphetamines improved short-term ADHD symptom severity. MAS also increased retention in treatment. Amphetamines were associated with higher attrition due to adverse events. The short study length and the restrictive inclusion criteria limit the external validity of these findings. Furthermore, the possibility that the results of the included studies were biased was high, which could have led to an overestimation of amphetamine efficacy.
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Affiliation(s)
- Xavier Castells
- Unit of Clinical Pharmacology, Department of Medical Sciences, Faculty of Medicine, Universitat de Girona, Girona, Catalonia, Spain
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Findling RL, Childress AC, Cutler AJ, Gasior M, Hamdani M, Ferreira-Cornwell MC, Squires L. Efficacy and safety of lisdexamfetamine dimesylate in adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2011; 50:395-405. [PMID: 21421179 DOI: 10.1016/j.jaac.2011.01.007] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 01/07/2011] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine lisdexamfetamine dimesylate (LDX) efficacy and safety versus placebo in adolescents with attention-deficit/hyperactivity disorder (ADHD). METHOD Adolescents (13 through 17) with at least moderately symptomatic ADHD (ADHD Rating Scale IV: Clinician Version [ADHD-RS-IV] score ≥28) were randomized to placebo or LDX (30, 50, or 70 mg/d) in a 4-week, forced-dose titration, double-blind study. Primary and secondary efficacy measures were the ADHD-RS-IV, Clinical Global Impressions-Improvement (CGI-I), and Youth QOL-Research Version (YQOL-R). Safety assessments included treatment-emergent adverse events (TEAEs), vital signs, laboratory findings, physical examinations, and ECG. RESULTS Overall, 314 participants were randomized; 309 were in efficacy analyses and 49 withdrew (11 due to TEAEs). Least squares mean (SE) change from baseline at endpoint in ADHD-RS-IV total scores were -18.3 (1.25), -21.1 (1.28), -20.7 (1.25) for 30, 50, and 70 mg/d LDX, respectively; -12.8 (1.25) for placebo (p ≤ .0056 versus placebo for each). Differences in ADHD-RS-IV total scores favored all LDX doses versus placebo at all weeks (p ≤ .0076). On the CGI-I, 69.1% of participants were rated very much/much improved at endpoint with LDX all doses versus placebo (39.5%) (p < .0001). YQOL-R changes at endpoint scores for LDX groups versus placebo were not significant. Commonly reported LDX (all doses combined) TEAEs (≥5%) were decreased appetite, headache, insomnia, decreased weight, and irritability. Small mean increases in pulse and blood pressure and no clinically meaningful trends in ECG changes were noted with LDX. CONCLUSIONS LDX at all doses was effective versus placebo in treating adolescent ADHD and demonstrated a safety profile consistent with previous LDX studies. CLINICAL TRIALS REGISTRY INFORMATION: Efficacy and Safety of Lisdexamfetamine Dimesylate (LDX) in Adolescents With Attention-Deficit/Hyperactivity Disorder (ADHD); http://www.clinicaltrials.gov; NCT00735371.
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Affiliation(s)
- Robert L Findling
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA.
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Merkel RL. Safety of stimulant treatment in attention deficit hyperactivity disorder: part II. Expert Opin Drug Saf 2011; 9:917-35. [PMID: 20615078 DOI: 10.1517/14740338.2010.503238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Attention deficit hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder and in at least 50% of cases persists into adulthood. Treatment of ADHD with stimulants is one of the oldest and most effective pharmacological treatments in psychiatry. Yet, there continues to be controversy over the safety of stimulant medications in the treatment of ADHD. AREAS COVERED IN THIS REVIEW This paper is a continuation of an earlier paper that reviewed the safety profile of newer stimulant agents, especially in relation to special populations. This part II reviews, through essentially an organ-system approach, the various clinical concerns that have been raised over the safety of stimulant medications. This includes neuropsychiatric, cardiovascular effects on growth and development, and a number of other less common concerns. WHAT THE READER WILL GAIN A thorough review of safety concerns in stimulants that emphasizes clinical information, case reports, open series or controlled trials relating to stimulant use in the treatment of ADHD. TAKE HOME MESSAGE While many safety concerns have been raised in the use of stimulants, the vast majority of treatment complications are either quickly reversible or easily manageable with appropriate clinical care. The negative consequences of untreated ADHD clearly outweigh the risks of the stimulant medicines when used in an appropriate and careful manner.
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Affiliation(s)
- Richard Lawrence Merkel
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA 22908, USA.
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Dell'Osso B, Palazzo MC, Oldani L, Altamura AC. The noradrenergic action in antidepressant treatments: pharmacological and clinical aspects. CNS Neurosci Ther 2010; 17:723-32. [PMID: 21155988 DOI: 10.1111/j.1755-5949.2010.00217.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Even though noradrenaline has been recognized as one of the key neurotransmitters in the pathophysiology of major depression (MD), noradrenergic compounds have been less extensively utilized in clinical practice, compared to selective serotonin reuptake inhibitors (SSRIs). The development of the first selective noradrenergic reuptake inhibitor (NRI), Reboxetine, has not substantially changed the state of the art. In addition, Atomoxetine, a relatively pure NRI used for the treatment of ADHD, has shown mixed results when administered in augmentation to depressed subjects. Through a Medline search from 2000 to 2010, the present article provides an updated overview of the main pharmacological and clinical aspects of antidepressant classes that, partially or selectively, act on the noradrenergic systems. The noradrenergic action plays an important clinical effect in different antidepressant classes, as confirmed by the efficacy of dual action antidepressants such as the serotonin noradrenaline reuptake inhibitors (SNRIs), the noradrenergic and dopaminergic reuptake inhibitor (NDRI) Bupropion, and other compounds (e.g., Mianserin, Mirtazapine), which enhance the noradrenergic transmission. In addition, many tricyclics, such as Desipramine and Nortriptyline, have prevalent noradrenergic effect. Monoamine oxidase inhibitors (MAOIs), moreover, block the breakdown of serotonin, noradrenaline, dopamine and increase the availability of these monoamines. A novel class of antidepressants--the triple reuptake inhibitors--is under development to selectively act on serotonin, noradrenaline, and dopamine. Finally, the antidepressant effect of the atypical antipsychotic Quetiapine, indicated for the treatment of bipolar depression, is likely to be related to the noradrenergic action of its metabolite Norquetiapine. Even though a pure noradrenergic action might not be sufficient to obtain a full antidepressant effect, a pronoradrenergic action represents an important element for increasing the efficacy of mixed action antidepressants. In particular, the noradrenergic action seemed to be related to the motor activity, attention, and arousal.
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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.
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Affiliation(s)
- Raul R Silva
- New York University Langone Medical Center, New York, NY, USA.
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