ADHD Medication

1. General
   1. Medication is not a cure, only control
   2. Medication holiday is not needed
      1. Medication should be taken on weekends and holidays
      2. Summer use of medication is optional
         1. Restart medication well before school
         2. Do not trial off medication at onset of school year
   3. Myths (Stimulant non-causes)
      1. Stimulants do not cause Sedation
      2. Stimulants do not cause growth delay
         1. Weight does however need to be watched closely
      3. Stimulants do not cause drug addiction
         1. Drug Abuse occurs six times more commonly in Attention Deficit
         2. Stimulants do not increase that risk (and might decrease Substance Abuse risk)
         3. Diversion is a higher risk
2. Contraindications
   1. See Specific medications
   2. Age under 6 years old (may be used in ages 4-5 years old for severe refractory symptoms)
      1. If used in ages 4-5 years old, start with short-acting low dose Methylphenidate (slower metabolism in young children)
   3. Cardiovascular risks (relative)
      1. Stimulants are not associated with increased cardiovascular events
         1. (2012) Presc Lett 19(2): 12
      2. Monitor Blood Pressure and Heart Rate
      3. Reasons to avoid stimulants
         1. Uncontrolled Hypertension
         2. Serious arrhythmias
         3. Symptomatic heart disease
         4. Recent cardiovascular event
         5. Congenital heart defect (ask related PMH, Family History and screen on ADHD exam)
            1. Consider an EKG before prescribing
            2. Vetter (2008) Circulation 117(18):2407-23.
3. Management: Medication Protocol
   1. Start with short acting first-line stimulant (below)
   2. Advance dose to desired affect and per adverse affects
   3. Advance to combine long-acting with short-acting agents
   4. Consider rapid onset long-acting agents as single med
      1. Adderall
      2. Concerta
   5. Converting between stimulants
      1. Methylphenidate 1 mg is roughly equivalent to 0.5 mg Amphetamine salt, Dextroamphetamine or dexmethylphenidate
      2. Concerta 18 mg/day is roughly equivalent to Methylphenidate 15 mg/day
      3. Switching from Adderall to Dextroamphetamine or Methylphenidate
         1. Start with same total daily dose and titrate up for effect
      4. Switching from Methylphenidate to Adderall
         1. Start with one half of total daily dose and adjust based on effect and adverse effects
4. Management: First Line Medications (Stimulants)
   1. Rapid Onset agents with short duration
      1. Methylphenidate (Ritalin)
      2. Dextroamphetamine (Dexedrine)
   2. Rapid Onset agents with long duration
      1. Duration 8 hours
         1. Methylphenidate LA (Ritalin LA)
      2. Duration 10 hours
         1. Amphetamine-Dextroamphetamine (Adderall XR, Focalin XR)
      3. Duration 12 hours
         1. Methylphenidate (Concerta, Daytrana, Vyvanse)
   3. Agents to use if Substance Abuse is a concern (see myths above)
      1. Vyvanse
      2. Bupropion
      3. Strattera
   4. Slow Onset agents with long duration (not recommended)
      1. Methylphenidate (Ritalin-SR or Metadate ER)
      2. Dextroamphetamine (Dexedrine Spansules)
   5. Equivalent dosages
      1. Methylphenidate (Ritalin) 20 mg SR
      2. Dextroamphetamine (Dexedrine) 10 mg spansules
   6. Investigational Agents (Stimulant)
      1. Modafinil (Provigil)
   7. Agents avoided due to toxicity risk
      1. Pemoline (Cylert): Liver toxicity risks
5. Management: Second-Line Medications
   1. Atomoxetine (Strattera) - Non-stimulant agent
6. Management: Third Line Medications
   1. Newer Antidepressants
      1. Indications
         1. Comorbid Major Depression
         2. Hyper-focused on activity (e.g. computer games)
         3. Obsessive-Compulsive type unproductive behavior
      2. Agents
         1. Bupropion (Wellbutrin)
         2. Venlafaxine (Effexor)
   2. Tricyclic Antidepressants
      1. Indications
         1. Insomnia
         2. Poor appetite
         3. Enuresis
      2. Agents
         1. Imipramine (Preferred of tricyclics)
            1. Start 10 mg PO qhs (Up to 150 mg/day divided bid)
         2. Desipramine (Risk of sudden CV death)
            1. Start 10 mg PO qhs (Up to 150 mg/day divided bid)
7. Management: Adjunctive medications for modulating emotions
   1. Indications
      1. Impulsivity
      2. Hyperactivity
      3. Conduct problems
      4. Tics (Tourette's)
   2. Agents
      1. Clonidine 0.05 mg PO qhs to 0.4 mg/day divided tid
      2. Guanfacine (Tenex)
      3. Beta Blocker
      4. Carbamazepine (Tegretol)
      5. Divalproex (Depakote)
   3. Other specific agents
      1. Risperidone (Risperdal)
         1. Indicated for severe Oppositional Defiant Disorder
      2. Wellbutrin (Bupropion)
         1. Indicated for aggression
8. References
   1. (2011) Prescr Lett 18(12): 68
   2. (1996) Pediatrics 98:301-4
   3. Andesman (1999) Pediatr Clin North Am 46:945-63
   4. Bennett (1999) Pediatr Clin North Am 46:929-44
   5. Challman (2000) Mayo Clin Proc 75:711-21
   6. Silver (1999) Pediatr Clin North Am 46:965-75
   7. Syzmanski (2001) Am Fam Physician 64(8):1355