Wednesday, June 3, 2009

Attention Deficit Disorder part 6

This is the second to the last in a series on Attention Deficit Hyperactivity Disorder (ADHD). Today I would like to talk about the unique medication atomoxatine or Strattera. Next we will review some behavioral and psychosocial treatments.

Strattera is the only non stimulant medication that is FDA approved for the treatment of ADHD. It is a selective norepinephrine reuptake inhibitor that works by making available more of the neurotransmitter norepinephrine which is responsible for alertness and attention focusing. It is very similar to some antidepressant medications and unlike stimulants has no abuse potential. This makes it an ideal medication to use in those patients who have substance abuse problems as well as ADHD.

Unlike the stimulants Strattera does not carry a "black box warning" about abuse potential. Instead, like antidepressants it carries a black box warning of increased risk of suicidal ideation in children or adolescents which is the same for all
antidepressants. The black box indicates though that no suicides have been reported and recommends close monitoring. Like all medication it carries some risks and I will discuss these below.

Like the stimulants two of the major risks are cardiovascular and psychiatric. Strattera does increase the blood pressure to a small degree and should be used with caution in those who have hypertension, cerebral vascular disease or underlying cardiac disease. There have been reports of sudden death in those taking Strattera who have underlying cardiac disease and like the stimulants I strongly recommend a baseline electrocardiogram as well as a careful medical history. Unlike the stimulants it has no net effect on growth taken long term. The psychiatric risks of Strattera are the same as for the stimulants and include emergence of new manic or psychotic symptoms as well as increase in aggression or hostility. So the main difference between Strattera and the stimulants is the lack of abuse potential.

After reading of the possible risks of both the stimulants and Strattera you may be wondering why anyone would even take these medications? There are three factors to take into consideration. The first is that these risks are relatively small. The second is to realize that all medications of any type carry some possible serious risks. The third is that ADHD is very often severely disabling and affects psychological development, school and occupational functioning, and impairs interpersonal relationships to a great extent. I am bringing the problems with these medications to attention to emphasize that the use of ADHD medications should not be taken lightly, involve a thorough assessment and require close monitoring which is not the normal standard practice among many pediatricians, primary care physicians,and psychiatrists at this time. This leads to charges of overuse and inappropriate use which threaten the availability of these medications for those who very much need them.

Again I welcome any comments or questions.

Thought for the day

The same as yesterday. All medical treatments involve possible risks as well as benefits.

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