Lyn Billington June 2006 Treatment of Attention Deficit/Hyperactivity Disorder Lyn Billington Deputy...

Lyn Billington June 2006

Treatment of Attention Treatment of Attention Deficit/Hyperactivity Deficit/Hyperactivity

DisorderDisorder

Treatment of Attention Treatment of Attention Deficit/Hyperactivity Deficit/Hyperactivity

DisorderDisorderLyn BillingtonLyn Billington

Deputy Pharmacy ManagerDeputy Pharmacy ManagerLatrobe Regional HospitalLatrobe Regional Hospital


ADHD

• Symptoms are • Persistent inattention-becomes a

problem at school• Hyperactivity - often the most

prominent feature• Impulsivity• Accurate diagnosis essential before

commencing treatment


Course of the condition• In most cases - spontaneous

remission• Late adolescence about 50% still

show the full syndrome• This falls to about 1/3 by early 20’s• Late 20’s 10% still fully affected.


Complications• Academic failure• Truancy• Misconduct• In adult years - more likely to have

antisocial personality disorder & substance misuse


Etiology• Some studies show genetic causes• Most appear idiopathic• Small number may be related to

lead encephalopathy or rare, inherited resistance to thyroid hormones


Differential diagnosis• Chaotic upbringing• Foetal alcohol syndrome• Mental retardation• Autism• Children with mania• Children with agitated depression ( however

have other symptoms not typical of ADHD)• Children with schizophrenia ( Have other

symptoms which rules out ADHD)• Difficult to diagnose in adults


Treatment• Medication is not the only

treatment.• Parent education & school support

are of major importance• Psychostimulants can reduce

symptoms


Rationale for drug use• Symptom relief• To reduce function impairment in

daily life (home, school, peer)• Minimise long term adverse effects

on academic performance• Minimise impact on social and

emotional development


Medication used• Short acting psychostimulants

– Dexamphetamine– MethylphenidateUp to 90 % will respond ( to one or the

other)Effect is often immediate improvement

in impulsive behaviour and task completion


Mode of action and Childrens doses

• Thought to enhance dopaminergic and noradrenergic transmission

• Dose - dexamphetamine2.5-10mg daily increasing by 2.5-5mg/day each week to a maximum of 30mg per day

• Dose - methylphenidate 5-10mg/day in two doses increasing by 5-10mg/day each week to a maximum of 40mg /day


Short acting stimulants– Rapid absorption – peak response 1-3

hours– Dose titrated according to response– Need to be given more than once

daily.– Should not be given after early

afternoon to minimise sleep disturbance


• Methylphenidate also available as• Ritalin LA ®20mg,30mg & 40mg• Concerta®18mg, 36mg & 54mg• Use conventional tables first to

establish dose then swap to the long acting formulation

• Advantage - once daily dose


Adverse effects• Headache• Abdominal discomfort• Appetite suppression• Insomnia• Minor effect on growth – but need

to monitor weight and height


Atomoxetine (Strattera ®)

• May be a useful alternative for children who do not respond to stimulants

• Indicated for children > 6 years old• May be useful where diversion of

medication is a problem• Monitor liver function


Mode of action and dose

• Selectively inhibits presynaptic noradrenaline reuptake in the CNS

• Dose: < 70 kg Initially 0.5mg/kg/day for 3 days, increasing to 1.2mg/kg/day


Adverse effects• Nausea• Vomiting• abdominal pain• decreased appetite• irritability• temper tantrums• Rare- suicidal thoughts and behaviors -

monitor


Other therapies• Tricyclic antidepressants – not

approved for ADHD in Australia.• If used start low - go slow• ECG before commencement

(cardiotoxicity)• Consider Imipramine or Nortriptylline


• Clonidine• No reliable evidence of

effectiveness in ADHD• May be useful in children with

ADHD who are aggressive and where sleep disturbance is a problem


Disadvantages of clonidine

• Several weeks for clinical effect• Does not seem to affect inattention

symptoms• Risk of causing depression• Monitor BP and pulse during

therapy• Avoid sudden cessation


Note• Pharmacological treatment for

children and adolescents difficult because of the lack of clinical trials in this age group.

• Most information extrapolated from adult trials

• Care is needed.


References• Therapeutic Guidelines - Psychotropic

2003• The Maudsley 2005-2006 Prescribing

Guidelines• Moore & Jefferson Handbook of Medical

Psychiatry, 2nd ed• AMH 2006• Jacobson: Psychiatric Secrets, 2nd ed

Lyn Billington June 2006 Treatment of Attention Deficit/Hyperactivity Disorder Lyn Billington Deputy...

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