PRESCRIPTION DRUGS FOR ADHD
A Controversial Issue
As a rule, discussions about prescription medications are not especially emotional. For example, there is nothing particularly controversial about treating chronic constipation. Dosages of diuretics can be, well, rather dull. But when it comes to medications for treating ADHD in children (or adults) things sometimes become rather tense. Over-prescribing has been a matter for serious debate and sincere concern. Some question the validity of calling this a "disease/disorder" and prefer to think of it as a social and emotional condition.
This article is not about those debates. This article is written for the benefit of patients and/or parents who have struggled through these issues, have considered their options, and are thoughtfully ready to consider medication therapy. For you, and other inquiring minds, I would like to provide a brief overview of the major medication classes used to treat ADHD today. Within each class I will identify all of the specific drugs currently being prescribed in the U.S for ADHD. Additionally, I will provide a few "counseling" points for each category to give patients and parents some advice on these drugs.
ADHD is Attention-Deficit Hyperactivity Disorder. The CDC has a nice summary of the symptoms required to make a diagnosis of this condition. These symptoms involve various degrees of innattention, hyperactivity and impulsiveness all of which must in some way be causing an impairment at home, school or work.
Prescription drugs used to treat ADHD can be divided into basically 2 categories: Stimulants and Non-Stimulants (rather brilliant don't ya think?). The "stimulants" can then be divided into 2 more categories: Amphetamines and Non-amphetamines (also known as "methylphenidates"). So then, our discussion will be broken down by looking at these 3 groups:
- STIMULANTS: Amphetamines
- STIMULANTS: Non-amphetamines (primarily methylphenidates)
ALL prescriptions currently used specifically to treat ADHD fall into 1 of these 3 groups.
Note: It may sound strange that we used medications classified as "stimulants" to help treat ADHD. Isn't the problem that such patients are TOO STIMULATED already? Well...these are "special" stimulants. They stimulate very specific areas in the brain that appear to help us focus.
1. STIMULANTS: AMPHETAMINES
The word "amphetamine" may be a bit scary. It is sometimes thought of as a "performance enhancing" drug, and has sometimes been misused in this way. We may associate the word "amphetamine" with a drug that is "strong" "addictive" and "dangerous." However, it should be pointed out that an 'amphetamine' is simply a stimulant, not entirely unlike some very often consumed stimulants...such as caffeine for example. In fact, a 2002 study in the Journal of Neuroscience confirmed that caffeine appears to stimulate one of the very same neurotransmitters (dopamine) that amphetamines effect.
The 3 primary neurotransmitters (little "chemical" messengers in our body) impacted by amphetamines are:
I mentioned caffeine stimulates dopamine release. Chocoloate has been cited as a possible stimulant of serotonin release. And "nuts" contain tyramine...the natural precursor to norepinephrine production. So...."amphetamines" are really just like a cup of coffee along with a Hershey bar with Almonds in a convenient little capsule! Well...okay...maybe that is just too much of a stretch. But there is a little truth in this, and hopefully you are getting my point that "amphetamines" may not be quite as scary as they are sometimes made out to be.
Amphetamine is a "nickname" by the way. The full name for this type of drug is alpha-methylphenethylamine (bold and underlined shows where they pulled the word 'amphetamine' from).
One of the key differences between prescriptions in this family is the "length" of their activity. Short-acting amphetamines lose their effectiveness after 4-6 hours and may require a second dose. Long-acting amphetamines can typically be taken once daily.
Another important factor to many patients and parents is the availability of a GENERIC for the specific medication. Generics are typically less expensive and will often be the lowest copay on your prescription plan. For that reason, I have indicated if a generic is currently available for each of the drugs below.
SHORT ACTING AMPHETAMINES:
- Adderall (available generically)
- Dexedrine (available generically)
- Dextrostat (available generically)
- Procentra Liquid (NOT available generically) - NOTE: Procentra is the ONLY liquid amphetamine currently available. It has an interesting history, which I won't go into here, but it began 'life' under the trade name "Liquadd" and has been 'reborn' under the name Procentra, and is currently marked by FSC Labs.
LONG ACTING AMPHETAMINES:
- Dexedrine Spansules (available generically)
- Adderall XR (available generically)
- Vyvanse (lisdexamphetamine - NOT available generically) - Click the drug name for more information! Vyvanse is approved for children ages 6-12, and for adults with ADHD.
Side Effects: Possible side effects include loss of appetite, weight loss, irritability, and sleep disturbances. If these become a problem, particularly the weight loss, notify your physician.
2. STIMULANTS: NON-AMPHETAMINES
The other category of "stimulants" for the treatment of ADHD are the "non-amphetamines." These include all of the "methylphenidate" type drugs.
Methylphenidate and other similar compounds (e.g. dexmethylphenidate) are stimulants which cause an increase in 2 key neurotransmitters: dopamine and norepinephrine. Therefore, though they are "chemically" different than amphetamines, they function in essentially the same way. Methylphenidate has been around for some time. It was being used to treat childhood symptoms of ADHD back in the 1960s. This fact alone should be of some comfort to those worried about the long term safety of these drugs.
Like amphetamines, "methylphenidate" type drugs differ in their "length" of activity. Unlike amphetamines, these are usually divided into 3 categories of "short," "intermediate," and "long" acting.
SHORT ACTING METHYLPHENIDATES (usually effective for 3-6 hours):
- Focalin (available generically)
- Methylin (available generically)
- Ritalin (available generically)
INTERMEDIATE ACTING METHYLPHENIDATES (usually effective from 4 to 10 hours):
- Metadate ER (available generically)
- Methylin ER (available generically)
- Ritalin SR (available generically)
- Metadate CD (NO generic available)
- Ritalin LA (NO generic available)
LONG ACTING METHYLPHENIDATES (usually 6-12 hours):
- Concerta (NO generic available)
- Focalin XR (NO generic available)
- Daytrana Patch (NO generic available) - The ONLY topical formulation of an ADHD medication. It is applied as a patch to the hip and left on for up to 9 hours. It is approved for treating children (ages 6-12) and adolescents (ages 13-17).
A note about Cylert (pemoline): Since you may come across this drug name while "surfing" the web for ADHD information, I just thought I should mention that it was discontinued in May of 2005 due to an FDA decision based on the fact that liver damage was becoming a significant risk.
3. NON-STIMULANTS FOR ADHD
There are currently 2 prescription medications for ADHD which fall into the "non-stimulant" category. A non-stimulant might be used if side-effects from a stimulant medication become intollerable, or stimulants are inneffective.
1. STRATTERA (atomoxetine) is a unique medication, unlike the stimulants. It works specifically on norepinephrine. It is known, in "clinical" language as a norepinephrine reuptake inhibitor. Due to this unique mechanism, it has virtually no potential for abuse or addiction. Strattera is LONG acting, with an effectiveness of about 24 hours. This makes once daily dosing very convenient. It is indicated for the treatment of ADHD in children ages 6 and older, as well as teens and adults. Generally side effects are mild and limited. Upset stomach, drowsiness, decreased appetite and slowing of growth have been reported. Liver damage is rare, but will usually be monitored for. Suicidal thoughts were reported in clinical studies.
Strattera may take up to 6 weeks to begin working. Be patient and consistent. Strattera is a capsule, comes in a variety of strengths and will be dosed based upon a patient's weight. Strattera does NOT come generically at this time.
An extensive "Patient Guide" is published by Lilly, the manufacturer, and available by CLICKING HERE.
2. INTUNIV: INTUNIV (guanfacine): Intuniv is sort of an OLD drug...with a NEW name and formulation. The ingredient in Intuniv has been previously used for many years to treat high blood pressure. It stimulates receptors in the brain which tell blood vessels to relax. Researches do not know exactly how this works at improving attention in ADHD. Intuniv comes in an extended release tablet, in either 1mg, 2mg, 3mg or 4mg strengths. It is taken once daily, and has been approved for treating ADHD in ages 6-17. Intuniv is considered an alternative when therapy with stimulant medications are not effective. Intuniv is NOT available generically.
Side effects of Intuniv include drowsiness, dizziness, upset stomach, decreased blood pressure, dry mouth and constipation.
A FEW PHARMACIST POINTS
Here are a few things to bear in mind about prescription drugs for ADHD:
Understand that the "stimulants" are typically the "first" line in terms of medication approaches. Whether you doctor chooses to try an "amphetamine" stimulant or a "non-amphetamine" stimulant is probably going to depend a little on the experience of the doctor using these drugs. There is no "best" choice to start with. About 70%-80% of patients will see some improvement in symptoms of ADHD with stimulants...but which one to use first can be a "trial and error" effort. Be prepared to possibly have to switch to a different stimulant due to side effects or a lack of effectiveness.
Be aware that ALL stimulants are currently designated as "Schedule 2 Controlled Substances." What does that mean? Well...it means that there are additional restrictions on these prescriptions. They cannot be refilled, and you must obtain a new written prescription every time you run out. State laws will determine if you can obtain 1 or 2 months (or more) at a time. The non-stimulants are not controlled substancs.
Ask if your prescription is available generically. This will be the lowest cost alternative for you.
Keep a close watch on these medications and be sure they are taken exactly as directed. If these medications, particularly the "stimulants," are "lost" it may be particularly difficult to get them refilled.
If weight loss becomes an issue, try using nutritional drinks which you can buy in most pharmacies or grocery stores. These would include products like Ensure or Boost. They come in many "kid friendly" flavors and can be used to supplement meals for added calories.
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