Research and clinical experience have shown that stimulant medications are the most effective first-line treatment for ADD (ADHD). Currently, there are many new medications to treat ADD (ADHD). Although many parents and educators continue to voice concerns over the prescription of medication for children with ADD (ADHD), recent studies suggest that stimulant medication is the most effective treatment option for children with ADD (ADHD) and that, in some studies, medication alone has a positive treatment effect equal to medication in combination with cognitive/behavioral therapy.

STIMULANT MEDICATIONS

Methylphenidate based products (Ritalin, Ritalin LA, Concerta, Metadate )

For a number of years, methylphenidate was available only as Ritalin with a duration of action (the length of time its beneficial clinical effects can be observed) of approximately 3-4 hours. Because of this short half-life, methylphenidate required multiple daily doses to obtain clinical benefits throughout the day. Recently, a number of other methylphenidate products have become available (e.g., Concerta, Metadate CD, Ritalin LA) that require only once daily dosing to address ADD (ADHD) symptoms throughout the day. These products use different delivery systems that allow for a slow release of medication throughout the day and have been shown to have pharmacological and clinical profiles comparable to twice a day (b.i.d) or three times a day (t.i.d.) dosing with typically formulated methylphenidate. To date, there is little evidence to support the superiority of any one of the once-daily products over the others.

Long-acting Methylphenidate Medications

Products                    Concerta®             Metadate®             CD Ritalin® LA

Formulation                OROS®                 Diffucaps®                SODAS™

Technology

Dose Available      18/27/36/54 mg           20 mg                     20/30/40 mg

Immediate (%)               22%                     30%                              50%

1st release

(dose amt)                4/6/8/12 mg                6 mg                     10/15/20 mg

Sustained (%)                  78%                      70%                            50%

2nd release

(dose amt)             14/21/28/42 mg            14 mg                     10/15/20 mg

Amphetamine-Based Products (Dexedrine, Adderall, Adderall XR)

Both Dexedrine and Adderall are trade names for products whose active component is some form of amphetamine. Dexedrine, which has been available for a number of years,is equally effective as methylphenidate for a number of problems associated with ADD (ADHD), but is not prescribed as frequently.

Adderall is the trade name for a generic compound of mixed amphetamine salts (three forms of d-amphetamine and one of l-amphetamine). It has become available for treatment of ADD (ADHD) relatively recently compared with the other stimulants and is now available as a once daily formulation (Adderall XR). Adderall, which has been studied primarily in children, has been shown to be equally as effective as methylphenidate in reducing disruptive behaviors in a classroom setting, improving parent and teacher behavior ratings, and improving academic performance. It is recommended that the maximum daily dose not exceed 40 mg (PDR). It has been reported that the duration of behavioral effects or of Adderall is generally dose-dependent, with higher doses resulting in longer duration of action (e.g., 5 mg = 3.52 hours; 20 mg = 6.40 hours). This same study found similar results for the time of peak effects for Adderall with lower doses resulting in shorter times to peak effects (e.g., 5 mg = 1.5 hours; 20 mg = 3.0 hours). In general, both the duration of action and the time to peak effects is longer for Adderall compared to methylphenidate The half-life of Adderall has not been conclusively determined, but given its chemical composition, it would be expected to be similar to that for Dexedrine! (e.g., 6-7 hours). Adderall XR has a much longer duration of action (e.g. 10-12 hours).

The following table lists medications to treat ADD (ADHD) and duration of action

Immediate-release Drugs Description Duration

Ritalin methylphenidate (3-4 hours)

Focalin™: a refined form of Ritalin®, isolating

only the effective isomer (3-4 hours)

Dexedrine dextroamphetamine (4-5 hours)

Adderall mixed amphetamine salts (4-6 hours)

Long-acting Drugs Description Duration

Ritalin® LA (once-daily formulation of Ritalin® thatmimics BID dosing and duration and is designed to last the school day) (6-8 hours)

Adderall XR™ (extended-release formulation ofmixed amphetamines that mimics BID dosing ) (8-12 hours)

Metadate® CD (methylphenidate formulation designed to mimic BID) (4-8 hours)

Concerta® (methylphenidate formulated to mimicTID duration) (10-12 hours)

Dexedrine Spansules (longer-acting amphetamine) (8-10 hours)

Side Effects

The main side effects of stimulants are appetite suppression and insomnia. It appears, however, that these side effects are not as severe with the long-acting stimulants. In addition, long-acting stimulants are smoother and keep symptoms at bay for many hours on end without the feelings of medication effects starting and stopping throughout the day. This long-duration may help the student address not only symptoms causing academic difficulties but also those that can affect social and daily-living activities.

Newer Non-Stimulant Medication

Atomoxetine (Strattera)

Strattera is a selective norepinephrine re-uptake inhibitor, which is indicated for the treatment of ADHD in children, adolescents, and adults. To date, 1109 children and adolescents and 536 adults have been included in double-blind, controlled trials. Strattera is currently the only agent that has an FDA-approved indication for treatment of adult ADD (ADHD).

The mode of action of Strattera in the treatment of ADHD is currently not known. However, it is the only medication that affects the regulation of norepinephine by acting as a potent inhibitor of the presynaptic norepinerhrine transporter. It is not associated with an appreciable abuse potential and is not a controlled substance.

The response to treatment of ADD (ADHD) was dose-dependent and in open label trials it was suggested that Strattera was as effective as methylphenidate for the treatment of ADHD. Dosing of Strattera depends on body weight. Children and adolescents up to 70 kg body weight should begin with 0.5 mg/kg/day; the dose should be increased to 1.2 mg/kg/day after a minimum of 3 days on the initial dose. The maximum dose should be the lesser of 1.4mg/kg/day or 100 mg/day. Adults and children/adolescents over 70 kg body weight should begin with 40 mg/day; the dose should be increased to 80 mg/day after a minimum of 3 days on the initial dose. After 2 to 4 additional weeks, the dose may be increased to a maximum of 100 mg/day in patients who have not reached optimal response.

Strattera is recommended to be administered as a single daily dose in the am or pm. and with effects lasting until the next dose. It may be administered with or without food. Although, some evidence indicates that taking with food decreases gastrointestinal side effects. Side effects include initial weight loss, gastrointestinal distress, somnolence, and some dizziness.

What children with ADD (ADHD) say about their medication:

(the following are direct quotes from children in treatment for ADD (ADHD) with Patricia Quinn, M.D.)

• “When I take my medicine it’s like glue. Before, my brain was all in pieces but the medicine has stuck it all together.”
• “Before, I was looking through a door that had frosted glass but now it is all clear.”
• When I take my medicine for homework, it is like my teacher is in my head.”
• “I don’t feel any different when I take my medicine, but my report card sure looks different!”
• “On my medicine I feel calm, without it I’m in hyperspace.”
• “Why can’t I take my medicine all the time, not just for school?”

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