Adult attention-deficit hyperactivity disorder.(Drug Update)

Adult attention-deficit hyperactivity disorder (ADHD) is the second most common neuropsychiatric disorder of adulthood, following depressive disorders; it affects about 8 million people, or 4% of the adult U.S. population. But experts estimate that about 80% are unaware that they have the disorder.

ADHD is often hard to recognize in adults. Patients may complain of chronic depression and low self-esteem. A good screening tool is the Adult Self-Report Scale, version 1.1, which is available at www.med.nyu.edu/psych/training/adhd.html.

ADHD is associated with a number of comorbid conditions, such as bipolar disorder, anxiety disorders, and substance abuse disorders. If these impair the patient, they should be treated first. ADHD is the primary target when associated conditions are mild.

Long-acting stimulants and atomoxetine are all first-line treatments. Atomoxetine is the only agent with Food and Drug Administration approval for ADHD in adults, but several methylphenidate formulations and long-acting amphetamine are considered equally good options by experts. Choosing among these for an individual patient depends on several factors including specific symptoms, patient preferences, a family history of response to certain drugs, and toleration of side effects. Sometimes a long-acting stimulant is paired with a short-acting agent for additional coverage. Timing is crucial, because symptoms tend to rebound as a stimulant wears off. It's important to review an agent's time course with the patient. Stimulants may show more of an effect early, but long term, both stimulant and nonstimulant treatments are well tolerated and effective. Some patients prefer the flexibility of short-acting stimulants.

Few data exist on use of these drugs during pregnancy or lactation. All have an FDA pregnancy rating of C. If possible, avoid the listed drugs during the first trimester. Many mothers with ADHD opt not to breast-feed so they can resume treatment as soon as possible.

For more information, visit www.help4adhd.org.

 
METHYLPHENIDATES 
 
Stimulant works quickly and robustly on attention and disinhibition, but 
no formulations specifically approved for adults. Classified as schedule 
II drug: has potential for abuse and diversion; short-acting 
formulations easier to divert. Most adult patients are treated with and 
prefer a long-acting formulation. Each marketed formulation works 
slightly differently, which means the best formulation has to be found 
for each patient. Start with the lowest dose and titrate up as needed. 
Methylphenidate is a pregnancy class C drug. Animal data suggest low 
risk, but human data are too limited to define the risk to the embryo 
and/or fetus. Probably excreted into milk. 
 
Drug                Cost/Day*   Dosage     What the Experts Say** 
 
EXTENDED-RELEASE FORMULATIONS 
methylphenidate     no generic  18 mg/day  Available in trade 
  [Concerta]        available              formulation only. Combines 
                    [$2.68]                immediate- and continuous- 
                                           release drug. Dosage of 
                                           immediate release less than 
                                           other formulations, so 
                                           patients don't feel much 
                                           right away. Some patients 
                                           prefer a more immediate 
                                           effect, but provides smooth 
                                           coverage and may be preferred 
                                           by some. Taken in the 
                                           morning; generally lasts 12 
                                           hours. Recommended starting 
                                           dosage is 18 mg/day; should 
                                           not exceed 54 mg/day 
                                           according to the label, but 
                                           higher dosages are used in 
                                           practice. 
methylphenidate     no generic  20 mg/day  Available in trade 
  [Metadate CD]     available              formulation only. Combines 
                    [$1.86]                immediate- and extended- 
                                           release drug. Larger 
                                           immediate effect than 
                                           Concerta, but duration of 
                                           effect not as long. May need 
                                           to supplement with a short- 
                                           acting formulation. 
                                           Recommended starting dosage 
                                           is 20 mg/day; should not 
                                           exceed 60 mg/day. Another 
                                           extended-release formulation 
                                           of Metadate, Metadate ER, 
                                           uses a different method for 
                                           delaying drug release. 
methylphenidate     no generic  20-30      Available in trade 
  [Methylin ER]     available   mg/day     formulation only. Pure 
                    [$1.12 (20             extended release. Taken once 
                    mg)]                   daily, released entirely at a 
                                           continuous rate, and lasts 
                                           about 8 hours so effect is 
                                           not as prolonged as with 
                                           Concerta. Some patients 
                                           prefer its smooth effect, 
                                           but some might need 
                                           supplementation with a 
                                           short-acting agent. 
methylphenidate     no generic  20 mg/day  Available in trade 
  [Ritalin LA]      available              formulation only. Lasts up to 
                    [$2.24]                8 hours. Largest immediate 
                                           effect of any extended- 
                                           release formulation and a 
                                           good choice for patients who 
                                           prefer a strong immediate 
                                           effect. Duration of effect 
                                           shorter than Concerta's; may 
                                           need supplementation later in 
                                           day with short-acting agent. 
                                   ...