Tuesday, June 2, 2009

Attention Deficit Hyperactivity Disorder part 5

Yesterday I discussed the medications that are used to treat Attention Deficit Hyperactivity Disorder (ADHD). Today I want to talk a bit about the potential side effects and risks of the medications. I will take the stimulants first as the possible problems are basically the same for all of them and secondly to review Strattera.

Adderall and the other stimulants all carry a "black box warning". This refers to the FDA instruction to manufacturers requiring them to outline a particular drug risk, put in in a box with the warning highlighted as the first piece of prescribing information that any clinician will review. The stimulants all carry the warning of the possibility of misuse and drug dependence as well as the risk for serious cardiovascular complications if misused. Although it appears that almost any medication can occasionally cause almost any side effects the main risks are the cardiovascular events, psychiatric events, drug dependency, and growth retardation.

Stimulants can increase the heart rate, blood pressure, put more demands upon the heart, and in people with underlying structural cardiac defects or other serious heart problems there have been reports of sudden death. For this reason the American Heart Association has recommended that all patients being placed on stimulants be prescreened with a baseline electrocardiogram or EKG. Because this raises the cost of providing treatment this stance is somewhat controversial as the history, family history, and physical exam are likely to pick up any heart problems.The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have not yet adopted this position but it is one that I very much agree with and I will not start a patient on stimulant medication without having a baseline EKG.

The second group of potential complications are psychiatric problems. Although these medications are used to treat a psychiatric disorder they can occasionally cause exacerbation of symptoms of patients with an underlying psychotic disorder, induce mania in patients with bipolar disorder, cause treatment emergent new onset of manic or psychotic symptoms, and aggressive behavior or hostility.

Careful followup studies have shown that persistent use of the medications seven days per week can result in growth suppression between the ages 5 to 10 or 13 of an average of 2 centimeters of height and 2.7 kilograms of weight with no growth rebound after cessation of the medication. Two centimeters average in itself is not a huge issue but this average means that some children have significantly more growth retardation therefore growth rates need to be monitored.

The issue of drug dependency is a difficult one. Most patients on stimulants for ADHD do not develop a drug dependency, need for higher and higher doses of the medication or misuse the medication but the possibility exists. The complicated thing however is that substance abuse is a risk of untreated AHHD so many with this disorder have co occurring substance abuse problems. In many cases the problems can be avoided by treating ADHD with Strattera instead of stimulants but what about the many patients who do benefit from or cannot tolerate Strattera? The decision of whether or not to use stimulants in patients with any kind of substance abuse disorder needs to be individualized but I will not use these medications in anyone with a history of stimulant, cocaine, or methamphetamine abuse. For others risk can be decreased by using one of the stimulant formulations that are slow release and compounded in a way unlikely to give the high that people are seeking. These are methylphenidate in the form of Concerta and amphetamine in the form of Vyvanse but both are expensive medications with no generic substitutions available.

I will talk about the problems of Strattera tomorrow. I welcome any questions or comments.

Thought for the day

All medical treatments involve both potential benefits as well as risks.

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