Stimulants and Other Medications Used to Treat ADHD

ADHD is a neurodevelopmental disorder in childhood and is characterized by a triad of impulsivity, hyperactivity, and inattention (Magnus et al., 2021). This disorder is twice more common in males than females, with age on onset typically below 12 years. In the US, the prevalence of ADHD is estimated at 5% (Magnus et al., 2021). According to the DSM-5, ADHD can be predominantly inattentive, predominantly hyperactive/impulsive, or a combination of the two. The etiology of this condition is multifactorial, while treatment involves a combination of both behavioral and pharmacological intervention. This piece of writing will explore methylphenidate as well as other pharmacological agents used to treat ADHD, in addition to providing a suggestion to a patient with truancy charges.

Methylphenidate

Methylphenidate is a stimulant FDA-approved medication for treating ADHD in children and adults and a second-line medication for the treatment of narcolepsy. Methylphenidate primarily acts by indirect and central sympathomimetic activity by increasing the release as well as blockage of the reuptake of norepinephrine and dopamine, resulting in their increased concentration on the synaptic cleft, particularly the prefrontal cortex (Verghese & Abdijadid, 2022). The resultant effect is increased mental performance manifesting as improved concentration, cognition, short-term memory, and fine motor skills. Similarly, methylphenidate possesses weak agonistic activity at 5HT1A receptors, an additional mechanism that contributes to increased dopamine levels.

Pharmacotherapy for ADHD

Pharmacological therapy is the principal treatment of ADHD. It is conventionally divided into stimulants and non-stimulants. Stimulants are further subdivided into methylphenidates and amphetamines. Stimulants are the first-line treatment of ADHD since they are effective in more than 70% of patients. According to Caye et al. (2019), stimulants effectively alleviate symptoms of ADHD, including distractibility, poor attention span, hyperactivity, impulsive behavior, and restlessness. Additionally, stimulants improve cognition. The efficacy and safety have been established in children aged 6 years and above. Excessive intake or very high dosages of stimulants cause dependence.

Second-line treatment of ADHD is majorly non-stimulant medications, particularly atomoxetine. Atomoxetine is a selective norepinephrine reuptake inhibitor that increases norepinephrine concentration in the synaptic cleft (Caye et al., 2019). It is mainly indicated as second-line therapy for patients with ADHD aged 6 years and above. Moreover, it is preferred in patients with substance abuse disorder or in whom stimulant addiction is a concern. Atomoxetine is a normal prescription drug with no potential for addiction. However, recent studies have revealed increased suicidal ideation in children and adolescents being treated with this drug (Caye et al., 2019).

What would you suggest?

A twelve-year-old ADHD patient effectively controlled on long-acting stimulants but with truancy charges necessitates further evaluation. Truancy is associated with poor academic performance, poor self-esteem, poor employment, and school dropout. Its prevalence increases with age. For this twelve-year-old, however, I would suggest a combination of behavioral interventions with the long-acting stimulants as the caregiver complains of the delayed onset of action of the stimulant. Alternatively, I can prescribe a short-acting stimulant to be used in conjunction with the long-acting stimulant.

Conclusion

ADHD is characterized by impulsivity, hyperactivity, and inattention. This prevalent childhood disorder can be treated effectively by a combination of both behavioral and pharmacologic interventions. Stimulants and non-stimulant (atomoxetine) are the first and second-line treatments for ADHD, respectively.

 

References

Caye, A., Swanson, J. M., Coghill, D., & Rohde, L. A. (2019). Treatment strategies for ADHD: an evidence-based guide to select optimal treatment. Molecular Psychiatry24(3), 390–408. https://doi.org/10.1038/s41380-018-0116-3

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2021). Attention Deficit Hyperactivity Disorder. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441838/

Verghese, C., & Abdijadid, S. (2022). Methylphenidate. https://pubmed.ncbi.nlm.nih.gov/29494058/

 

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