Michael Shuman, PharmD, BCPP, Staff Pharmacist
Central State Hospital, Lousiville, KY
At CPNP 2021, longstanding member Dr. Julie Dopheide provided an informative discussion on utilization of stimulants for attention deficit/hyperactivity disorder (ADHD) treatment across the lifespan. She started the presentation by pointing out that 5-10% of children carry a diagnosis of ADHD, with as many as 75% display symptoms that persist into adolescence and 50% into adulthood.1-2 Furthermore, a subset may meet criteria for what is known as complex ADHD (slide 10).
As a result, it is crucially important to understand unique variables that would influence the risk and benefit of pharmacotherapy in each stage of life. For example, as many as 50% of persons diagnosed with ADHD have a comorbid conduct disorder or oppositional defiant disorder.3-4 In such cases, once optimizing a stimulant dose, there may be additional benefit from augmentation with alpha2 agonist or risperidone.
The first case discussed by Dr. Dopheide was that of Max, a four-year-old boy who was recently asked to not come back to his preschool program due to his hyperactive and oppositional behavior (again recall the high co-occurrence of these two conditions). Given his current age, she explains that methylphenidate would be the best option for starting pharmacologic treatment (assuming behavioral interventions were trialed initially and insufficient), with lisdexamfetamine a second-line option.5-6 While mixed amphetamine salts are also available, there is literature which indicates that children do not tolerate these products as well and experience more side effects (i.e, headaches, anorexia, insomnia, and weight loss) when compared to methylphenidate.7
The second case discussed Angel, a 14 year old girl with history of autism spectrum disorder (ASD) and a mild intellectual disability (ID) who was recently diagnosed with complex ADHD. Audience members were advised that up to 25% of individuals with ASD also meet criteria for an ADHD diagnosis and that some may also demonstrate intellectual disability (ID).3 But how do these factors affect treatment decisions? Dr. Dopheide states that methylphenidate remains a first-line option for individuals with ASD and ADHD; however, response rates are lower in those with ASD compared to ADHD on its own.3,8-9 Furthermore, side effects are more commonly reported, which results in higher discontinuation rates. Similar to patients with ASD and ADHD, methylphenidate also has the best evidence supporting its use among those with ID.10 In both ID and comorbid ASD, Alpha 2 agonists and guanfacine are second line options, with less evidence to support use of other stimulants besides methylphenidate.3,8-10
The third case discussed Cassie, a 32 year old woman who was first diagnosed with ADHD at age 18. Past medical history also included cannabis use disorder and morbid obesity; after bariatric surgery at age 22, she was noted to have lost 200 pounds. Family history included a mother with depression and anxiety and an uncle with ADHD who died by suicide. Dr. Dopheide used the case to compare and contrast ADHD symptoms in children and adults. She reminded the audience that among adults, symptoms such as inattention, impulsivity, and emotional dysregulation are more common with lower prevalence of hyperactivity.11 Cassie’s case was also used to discuss examples of specific medical and psychiatric conditions which may increase risk of complex ADHD (slide 37).
Unlike in children, amphetamine formulations are associated with greater efficacy among adults and as a result are considered first line rather over methylphenidate products.12-13 Of these, lisdexamfetamine was mentioned as the lone agent with approval for both Binge Eating Disorder and ADHD. Dr. Dopheide concluded Cassie’s case by discussing interactions between substance use, stimulants, and cardiovascular side effects. She notes that early recognition and treatment of ADHD may actually lower future rates of substance abuse.14-16 One study found higher rate of cardiac events among individuals prescribed stimulants.17 Cannabis use may further increase blood pressure and heart rate.18