Dec. 5th, 2013 09:11 pm
What's a good med for ADHD?
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nightengaleskndA non-clinical colleague asked me that recently, “What are some good meds for ADHD?” Her child was taking one and had some improvement in symptoms but also some side effects. She was wondering if they should consider a switch.
I answered, “They’re all good. And they’re all lousy.”
That isn’t quite true. There are some less-good medications out there, or that used to be out there. I wouldn’t prescribe Cylert, for example. It worked for ADHD OK but it also caused liver damage. I think it’s off the market now so I couldn’t prescribe it even if I wanted to. I can still name my two students from the late 90s who took Cylert. It came up recently in a talk I attended about pharmacology, much to my surprise. And there are some medications out there that are occasionally used for ADHD that are less-good for ADHD than the ones typically used, such as Wellbutrin and the ‘triptyline family. That’s why they are only used occasionally, when all else has failed or when everything else is contraindicated for some reason. There are also poor medication decisions. I’ve seen children who can’t swallow pills prescribed medications that must be swallowed whole, or prescribed halves of medications that can’t be swallowed whole.
But overall, the medications which are on-label for use with ADHD are well studied, are effective against placebo in sufficiently large studies, and are safe for use in recommended dosages.
There are a lot of medications out there approved for ADHD. There’s the methylphenidate family, which includes, Ritalin and its generic methylphenidate, Concerta, Metadate and Ritalin LA, which are long-acting preparations, Daytrana, which is methylphenidate in a skin patch, Methyln and Quillivant, which are short and long-acting liquid preparations respectively, and Focalin (regular and XR) which is basically a right handed Ritalin molecule, on the somewhat substantiated theory that right handed Ritalin causes all the improvement and left handed Ritalin causes all the side effects. Then there’s the amphetamine family, which includes Adderall and its generic, mixed amphetamine salts, both of which come in short and long acting forms, Dexedrine, in long and short acting forms, which is the right handed half of the mixed salts, and Vyvanse, which converts to a long-acting Adderall in the body. There are also two blood pressure medicines approved for ADHD, either alone or in conjunction with a stimulant, guanfacine and clonidine, that mainly help with hyperactivity and impulsivity rather than focus. Guanfacine comes in short acting and long acting versions called Tenex and Intuniv. Clonidine comes in a short acting generic, long acting Kapvay, and a skin patch. And last, there’s Strattera, a non-stimulant which is built a lot like an antidepressant or antianxiety molecule, and mainly works on inattentive ADHD.
I’ve prescribed all of them except Methlyn and Quillivant, and I’ve only prescribed Kapvay once, too recently to have feedback.
With that exception, there is no medication for ADHD that I have prescribed that hasn’t worked for some of my patients. This includes kids with just ADHD, kids with ADHD and anxiety, kids with ADHD and autism, kids with hyperkinesis and developmental delays and other kids who have symptoms of hyperactivity, impulsivity or inattention. I have kids who are no longer being sent regularly to the principal’s office or being suspended. I have kids who are no longer hitting on the playground. I have kids who were able to return to aftercare, or resume speech or occupational therapy. I have kids who are able to go to regular ed classrooms for part of the day who couldn’t before due to behavior. I have kids whose therapists asked their mother “did you give him smart pills this morning?” before being told anything had changed. I have kids who sat and watched a movie for 30 minutes, which is 6x longer than they previously would sit and watch a movie. I have kids whose grades went from Fs to Bs. I have kids whose parents greet my “how did the [whatever] go?” question with “We love it!”
There are also a lot of kids who have had more subtle improvement, but who report better focus in class, whose parents and teachers report some improved attention or reduced impulsivity. Kids who no longer get badly side tracked getting dressed in the morning. Kids who don’t struggle with homework for nearly as long.
However, there is no medication for ADHD that I have prescribed for which I have not seen a child have a spectacularly poor response. I’ve had kids who never hit before take one dose and smack their teacher. This includes kids on Tenex, which isn’t reported to do such things, as well as Ritalin, which is. I’ve had kids get so sleepy they called the on-call doctor and needed a blood pressure check. I’ve had kids get way too sad, withdrawn, hide under the tables. I’ve had kids get much more anxious and bite the skin around their nails or pick at their arms. I’ve had kids get significantly more hyper. One mother descriptively told me the medicine “Vice Versa-ed.” These reactions are more likely in kids who also have autism or other brain differences, but I have seen them in otherwise typically developing kids with ADHD as well.
There are also kids who have had less striking side effects that still led to discontinuation, such as poor appetite, whinyness, sleepiness, sadness or stomachaches. And there are some kids who didn’t seem to show any improvement after increasing to the maximum recommended dose.
So they’re all good. And they’re all lousy.
And having a bad side effect to a medication, even a really really bad side effect to a medication, doesn’t mean the medication is bad, objectively, or even that the medication had been a bad choice for that particular patient in the first place.
Someday, perhaps someday soon, we will likely have a blood test that can predict who would do well with what medication. There are studies already looking for biomarkers that seem to correlate with response to stimulants, antidepressants, atypical antipsychotics.
But right now, the best we have when making a decision are our studies, the FDA approval list, insurance coverage, family preference and clinical judgment. In other words, informed, joint decision making and a best guess.
There are reasons to start with an alpha agonist, clonidine or guanfacine. The side effect profile is reassuring. Some feel they are less likely to cause side effects in children who are younger, and/or autistic. They may be less likely to worsen mood or behavior, although I’ve had more patients than would be expected start Tenex and start hitting. They can be used in the afternoon without affecting sleep, for kids who are just as hyperactive and impulsive after school as they were in school. They can even be given at night, in slightly higher doses, to help with sleep in children with sleep problems, so we can sometimes get away with one medication instead of two. They are less likely to increase heart rate or blood pressure, in children with known heart problems. There isn’t abuse potential, for children living in a household where there may be a high risk of diversion of a stimulant. They can be called-in, and written for 3 months at a time. There is less need for lunch-time dosing at school, although that is less of a concern now with the advent of long-acting stimulants. They also don’t have the bad reputation that sometimes comes along with Ritalin. Sometimes I use Tenex as a “starter medication,” knowing that a stimulant is likely in the future but hoping to buy a year or so of brain development so the stimulant is more likely to work.
There are even a few times I’ve started with Strattera. For an older kid who is mostly inattentive and has some anxiety, and who has symptoms at home as well as school, it makes sense to try a once-daily medication that gives 24 hour coverage. Sometimes it's worked.
Mostly, I start with a stimulant. They are better studied, over decades in some cases. They work better, when they work, especially on focus. They are less likely to cause sleepiness. They work quickly. They can be taken some days and not other days, for example not taken on weekends, without the risk of withdrawal or rebound symptoms if a dose is missed.
And usually the stimulant I try first is methylphenidate, absent compelling reasons to the contrary. Compelling reasons to the contrary include, but are not limited to, insurance coverage, attending telling me otherwise, parent requesting not to use “Ritalin” for whatever reason, or a close relative with a history of doing poorly on a methylphenidate product and well on an amphetamine product. We don’t have that blood test yet, but there does seem to be some medical folklore to support this practice. I routinely use short acting Ritalin in younger kids, longer acting Concerta in older kids who can swallow pills whole, a longer acting Ritalin that can be opened up and sprinkled onto food in older kids who can’t swallow pills. Sometimes I start with Focalin in an anxious kid, since Focalin isn’t supposed to make anxiety worse, even though it sometimes does.
And I give my new-medication spiel. I give administration directions that Strattera, Intuniv, Kapvay and Concerta HAVE to be swallowed whole and can’t be cut in half or crushed. I recommend giving the first dose on a weekend rather than a school day, even if ultimately the family is not going to use the medication on weekends. I give titration directions for starting at a low dose, often so low that my psychiatrist colleagues would call homeopathic, and increasing over the next few weeks. I explain the state and federal laws about stimulants, so that I can’t call in a prescription if they run out, and about watching appetite. I reassure that the media coverage of dangerous heart symptoms were found to not be a risk in large studies of children without heart problems or family history of certain heart problems. We make plans to bring the child back for a weight and blood pressure check. I explain about the risk of rebound hypertension if an alpha agonist is stopped suddenly, and warn about daytime sleepiness. We make plans to bring the child back for a blood pressure check. I talk about side effects of stomachache for Strattera, as well as the rare but dangerous liver damage symptoms, and make plans for a recheck. Strattera rechecks are usually 6-8 weeks out, rather than a month out, because it can take time to build up levels and take effect.
And then, whatever the medication, I tell them, “any medicine that can affect the brain in ways we like has the potential to affect the brain in ways we don’t like.” There may be an increase in aggression or anxiety, exactly the symptoms we are trying to avoid. If that’s the case, try giving it a few days because anyone can have one bad day. But if, even after one dose, you are thinking, “that’s not my kid,” stop the medicine and call us. I’m not expecting a bad reaction, but they do happen and I want my families to call me if they do, rather than either stop the medication or keep giving it and not let us know until the follow-up visit. Because sometimes the kid who went bezerk on Ritalin would do great if I mail them a substitute prescription for Adderall instead. Having a bad response means you had bad luck, not a bad med.
A psychiatrist I know tells families that they will run out of patience before she runs out of meds.
Because they all work, often enough to get through the studies, and often enough for us to have positive clinical experiences.
They’re all good. And they’re all lousy.
Is that why we call it practicing medicine?
I answered, “They’re all good. And they’re all lousy.”
That isn’t quite true. There are some less-good medications out there, or that used to be out there. I wouldn’t prescribe Cylert, for example. It worked for ADHD OK but it also caused liver damage. I think it’s off the market now so I couldn’t prescribe it even if I wanted to. I can still name my two students from the late 90s who took Cylert. It came up recently in a talk I attended about pharmacology, much to my surprise. And there are some medications out there that are occasionally used for ADHD that are less-good for ADHD than the ones typically used, such as Wellbutrin and the ‘triptyline family. That’s why they are only used occasionally, when all else has failed or when everything else is contraindicated for some reason. There are also poor medication decisions. I’ve seen children who can’t swallow pills prescribed medications that must be swallowed whole, or prescribed halves of medications that can’t be swallowed whole.
But overall, the medications which are on-label for use with ADHD are well studied, are effective against placebo in sufficiently large studies, and are safe for use in recommended dosages.
There are a lot of medications out there approved for ADHD. There’s the methylphenidate family, which includes, Ritalin and its generic methylphenidate, Concerta, Metadate and Ritalin LA, which are long-acting preparations, Daytrana, which is methylphenidate in a skin patch, Methyln and Quillivant, which are short and long-acting liquid preparations respectively, and Focalin (regular and XR) which is basically a right handed Ritalin molecule, on the somewhat substantiated theory that right handed Ritalin causes all the improvement and left handed Ritalin causes all the side effects. Then there’s the amphetamine family, which includes Adderall and its generic, mixed amphetamine salts, both of which come in short and long acting forms, Dexedrine, in long and short acting forms, which is the right handed half of the mixed salts, and Vyvanse, which converts to a long-acting Adderall in the body. There are also two blood pressure medicines approved for ADHD, either alone or in conjunction with a stimulant, guanfacine and clonidine, that mainly help with hyperactivity and impulsivity rather than focus. Guanfacine comes in short acting and long acting versions called Tenex and Intuniv. Clonidine comes in a short acting generic, long acting Kapvay, and a skin patch. And last, there’s Strattera, a non-stimulant which is built a lot like an antidepressant or antianxiety molecule, and mainly works on inattentive ADHD.
I’ve prescribed all of them except Methlyn and Quillivant, and I’ve only prescribed Kapvay once, too recently to have feedback.
With that exception, there is no medication for ADHD that I have prescribed that hasn’t worked for some of my patients. This includes kids with just ADHD, kids with ADHD and anxiety, kids with ADHD and autism, kids with hyperkinesis and developmental delays and other kids who have symptoms of hyperactivity, impulsivity or inattention. I have kids who are no longer being sent regularly to the principal’s office or being suspended. I have kids who are no longer hitting on the playground. I have kids who were able to return to aftercare, or resume speech or occupational therapy. I have kids who are able to go to regular ed classrooms for part of the day who couldn’t before due to behavior. I have kids whose therapists asked their mother “did you give him smart pills this morning?” before being told anything had changed. I have kids who sat and watched a movie for 30 minutes, which is 6x longer than they previously would sit and watch a movie. I have kids whose grades went from Fs to Bs. I have kids whose parents greet my “how did the [whatever] go?” question with “We love it!”
There are also a lot of kids who have had more subtle improvement, but who report better focus in class, whose parents and teachers report some improved attention or reduced impulsivity. Kids who no longer get badly side tracked getting dressed in the morning. Kids who don’t struggle with homework for nearly as long.
However, there is no medication for ADHD that I have prescribed for which I have not seen a child have a spectacularly poor response. I’ve had kids who never hit before take one dose and smack their teacher. This includes kids on Tenex, which isn’t reported to do such things, as well as Ritalin, which is. I’ve had kids get so sleepy they called the on-call doctor and needed a blood pressure check. I’ve had kids get way too sad, withdrawn, hide under the tables. I’ve had kids get much more anxious and bite the skin around their nails or pick at their arms. I’ve had kids get significantly more hyper. One mother descriptively told me the medicine “Vice Versa-ed.” These reactions are more likely in kids who also have autism or other brain differences, but I have seen them in otherwise typically developing kids with ADHD as well.
There are also kids who have had less striking side effects that still led to discontinuation, such as poor appetite, whinyness, sleepiness, sadness or stomachaches. And there are some kids who didn’t seem to show any improvement after increasing to the maximum recommended dose.
So they’re all good. And they’re all lousy.
And having a bad side effect to a medication, even a really really bad side effect to a medication, doesn’t mean the medication is bad, objectively, or even that the medication had been a bad choice for that particular patient in the first place.
Someday, perhaps someday soon, we will likely have a blood test that can predict who would do well with what medication. There are studies already looking for biomarkers that seem to correlate with response to stimulants, antidepressants, atypical antipsychotics.
But right now, the best we have when making a decision are our studies, the FDA approval list, insurance coverage, family preference and clinical judgment. In other words, informed, joint decision making and a best guess.
There are reasons to start with an alpha agonist, clonidine or guanfacine. The side effect profile is reassuring. Some feel they are less likely to cause side effects in children who are younger, and/or autistic. They may be less likely to worsen mood or behavior, although I’ve had more patients than would be expected start Tenex and start hitting. They can be used in the afternoon without affecting sleep, for kids who are just as hyperactive and impulsive after school as they were in school. They can even be given at night, in slightly higher doses, to help with sleep in children with sleep problems, so we can sometimes get away with one medication instead of two. They are less likely to increase heart rate or blood pressure, in children with known heart problems. There isn’t abuse potential, for children living in a household where there may be a high risk of diversion of a stimulant. They can be called-in, and written for 3 months at a time. There is less need for lunch-time dosing at school, although that is less of a concern now with the advent of long-acting stimulants. They also don’t have the bad reputation that sometimes comes along with Ritalin. Sometimes I use Tenex as a “starter medication,” knowing that a stimulant is likely in the future but hoping to buy a year or so of brain development so the stimulant is more likely to work.
There are even a few times I’ve started with Strattera. For an older kid who is mostly inattentive and has some anxiety, and who has symptoms at home as well as school, it makes sense to try a once-daily medication that gives 24 hour coverage. Sometimes it's worked.
Mostly, I start with a stimulant. They are better studied, over decades in some cases. They work better, when they work, especially on focus. They are less likely to cause sleepiness. They work quickly. They can be taken some days and not other days, for example not taken on weekends, without the risk of withdrawal or rebound symptoms if a dose is missed.
And usually the stimulant I try first is methylphenidate, absent compelling reasons to the contrary. Compelling reasons to the contrary include, but are not limited to, insurance coverage, attending telling me otherwise, parent requesting not to use “Ritalin” for whatever reason, or a close relative with a history of doing poorly on a methylphenidate product and well on an amphetamine product. We don’t have that blood test yet, but there does seem to be some medical folklore to support this practice. I routinely use short acting Ritalin in younger kids, longer acting Concerta in older kids who can swallow pills whole, a longer acting Ritalin that can be opened up and sprinkled onto food in older kids who can’t swallow pills. Sometimes I start with Focalin in an anxious kid, since Focalin isn’t supposed to make anxiety worse, even though it sometimes does.
And I give my new-medication spiel. I give administration directions that Strattera, Intuniv, Kapvay and Concerta HAVE to be swallowed whole and can’t be cut in half or crushed. I recommend giving the first dose on a weekend rather than a school day, even if ultimately the family is not going to use the medication on weekends. I give titration directions for starting at a low dose, often so low that my psychiatrist colleagues would call homeopathic, and increasing over the next few weeks. I explain the state and federal laws about stimulants, so that I can’t call in a prescription if they run out, and about watching appetite. I reassure that the media coverage of dangerous heart symptoms were found to not be a risk in large studies of children without heart problems or family history of certain heart problems. We make plans to bring the child back for a weight and blood pressure check. I explain about the risk of rebound hypertension if an alpha agonist is stopped suddenly, and warn about daytime sleepiness. We make plans to bring the child back for a blood pressure check. I talk about side effects of stomachache for Strattera, as well as the rare but dangerous liver damage symptoms, and make plans for a recheck. Strattera rechecks are usually 6-8 weeks out, rather than a month out, because it can take time to build up levels and take effect.
And then, whatever the medication, I tell them, “any medicine that can affect the brain in ways we like has the potential to affect the brain in ways we don’t like.” There may be an increase in aggression or anxiety, exactly the symptoms we are trying to avoid. If that’s the case, try giving it a few days because anyone can have one bad day. But if, even after one dose, you are thinking, “that’s not my kid,” stop the medicine and call us. I’m not expecting a bad reaction, but they do happen and I want my families to call me if they do, rather than either stop the medication or keep giving it and not let us know until the follow-up visit. Because sometimes the kid who went bezerk on Ritalin would do great if I mail them a substitute prescription for Adderall instead. Having a bad response means you had bad luck, not a bad med.
A psychiatrist I know tells families that they will run out of patience before she runs out of meds.
Because they all work, often enough to get through the studies, and often enough for us to have positive clinical experiences.
They’re all good. And they’re all lousy.
Is that why we call it practicing medicine?