This is the first in a series of upcoming pages discussing treatment of attention deficit hyperactivity disorder (ADD or ADHD) with medications.
The Four Decisions in Treating ADHD with Medications
The four big factors that determine the success of treatment with ADHD medications are: Which medication? Which preparation of that medication? What dose? At what times? Being skillful in choosing and managing all four of these is important, along with being able to manage adverse effects, of course.
1. Which medication?
There are two broad groups of ADHD medications: the methylphenidate group and the amphetamine group. There is no strong reason to always prefer a medication from one group or the other. So, how do we decide which group to pick the medication from?
If the person had benefit from a drug from one group drug in the past, it may be wise to stick with that group.
If there is a strong history of substance abuse, it may be wise to prescribe atomoxetine (Strattera), at least early in the course of treatment until you know the person better and the person has demonstrated abstinence from substance abuse. There are alternatives to atomoxetine like bupropion, tricyclics, clonidine/guanfacine, etc, but they should be third line because atomoxetine is much better established as a treatment for ADHD.
If abuse potential is a major concern but a stimulant is prescribed anyway, lisdexamfetamine (Vyvanse) does have lower abuse potential. This is because it is dextroamphetamine combined with the amino acid lysine. In the body, the lysine is gradually cleaved off and the dextroamphetamine is slowly released. Thus, the medication would not work if snorted or injected. Also, due to slow effect, it is less likely to produce a high.
2. Which preparation(s)?
The ADHD medications come in a variety of preparations with differing durations of action. With ADHD medications not only the choice of the medication but the choice of the preparation matters as well.
Longer-acting preparations have the advantage of convenience, not having to take the medication during the day (at school or at work), better adherence (due to not forgetting to take the midday dose), lower abuse potential,and less problem with worsening when the medication wears off.
However, short-acting (“plain”) preparations have some advantages as well including lower cost and ability to more precisely time the onset and wearing off of the effect. I have several patients who prefer the short-acting preparation and don’t mind taking the medication three or even four times a day.
3. What dose?
The benefit of ADHD medications is definitely related to dose. A very common reason for limited response is using too low a dose.
4. At what times?
Getting adequate coverage throughout the day plus higher levels at the right times requires skillful combination of preparations with different durations of action given at the right times.
I tell my patients to keep the medication on their nightstand with a cup of water and to take it the FIRST thing in the morning, “before you get out of bed, before you brush your teeth.” By doing this, the medication gets absorbed and starts to work by the time the person is up and about.
For persons who have great difficulty waking up in the morning, I ask the person to take the medication when he first wakes up even if he then falls back asleep. If needed, I ask a family member to go in and give the medication to the person at a fixed time and then let him go back to sleep. This often helps the person to wake up and to be somewhat more energetic upon waking up. This tip has helped me in treating persons with severe problems.
The following problems may occur when we prescribe ADHD medications:
The medication appears to not work
2. Duration of effect:
The medication wears off too early in the evening or stays around for too long, making it hard for the person to sleep
3. Adverse effects:
These will be discussed on a separate page in the future.
1. Are you sure it is not working?
Monitor the person systematically by noting several examples of ADHD symptoms specific to that person and then asking about these in follow up appointments. For example, “You had said when we first met that you lock yourself out of your house or car about once every two weeks. Has that happened in the last month?” Or, “Before starting this medication, you said that your coworkers will often comment that it seems that you are not listening. Has that happened in the last month?” Going through symptoms noted in the initial evaluation provides an individualized assessment of the person’s progress. I often find that the person says that there has been limited progress, but when we go through the symptoms in this way, we conclude that, in fact, there has been marked progress.
It is also helpful to use questionnaires and rating scales. One good one, the Adult ADHD Self-Rating Scale is short and is free.
2. Efficacy for what?
ADHD medications mainly work for problems with inattention, hyperactivity, and fatigue. They don’t work so well for Executive Dysfunction (planning, time management, etc). Therefore, when executive dysfunction persists, both patient and clinician may wrongly conclude that that ADHD medication is not working.
As noted above, the benefit of ADHD medications is definitely related to dose. A very common reason for limited response is using too low a dose. It is a good idea to individualize the dose based on systematic monitoring of the benefit and adverse effects.
4. Group effect
If medications from one group are not efficacious, an important principle is to try a medication from the other group. So, for example, if methylphenidate extended release (Concerta) at an adequate dose has produced little benefit, switch to a medication from the other group, like mixed amphetamine salts (Adderall) or lisdexamfetamine (Vyvanse). Note: here, not being efficacious is different from the duration of action being inadequate.
Duration of effect
1. What is the goal?
It is important to remember that the day does not end with work or school. The person with ADHD probably has stuff to do in the evenings as well. Almost always, aim to choose preparations or combine them in order to produce benefit till an hour or two prior to bedtime. You do want the medication to wear off prior to bedtime in order to not interfere with being able to fall asleep. Persons with ADHD have enough problems with falling asleep without medication making it worse!
2. Different preparations with different durations of effect
The duration of effect of commonly used stimulants is given below. We must keep in mind that these are averages and we should encourage the person to take note of how long the medication works for him.
About 4 hours: methylphenidate (Ritalin), dexmethylphenidate (Focalin), dextroamphetamine (Dexedrine)
About 6 hours: mixed amphetamine salts (Adderall), dextramphetamine spansules (Dexedrine spansule)
About 8 hours: methylphenidate sustained release (Ritalin SR), Metadate CD (contains both methylphenidate immediate and delayed release), Ritalin LA, Focalin XR (contains dexmethylphenidate)
About 12 hours: methylpheindate extended release (Concerta), Adderall XR, lisdexamfetamine (Vyvanse)
(More details about different stimulant preparations will be provided on a separate page in the near future.)
3. More than one way
A full day’s coverage can be achieved in several ways including:
a) very long-acting preparation
b) long-acting preparation given on waking up and then four hours later
c) long-acting preparation on waking up plus short-acting preparation eight hour later
…and so on.
4. Not an issue with atomoxetine (Strattera)
Atomoxetine has a long duration of action is provides coverage for the entire day (and more) even if given just once in the morning
One last thing
For all of these factors — efficacy, dose, duration, and timing — try many flavors before deciding. Because the benefits of ADHD medications (or lack of benefit) become apparent very quickly, before settling down with a medication, a preparation, a dose, and a schedule, it is usually a good idea to try varying the medication, preparation, timing, and dose. Why not? We should remember that once the best possible combination of these four factors.
Copyright 2015, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
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