Combination pharmacotherapy for adult ADHD

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent neuropsychiatric disorders of adulthood. Although clinical guidelines recommend monotherapy with stimulants or atomoxetine, combination pharmacotherapy is a common practice among clinicians. There are four main situations in which combination medications may be necessary: partial response, dose-limiting side effects, associated disorders, and comorbid diagnoses. We present data from two chart reviews that support existing research on combination pharmacotherapy. Adjunct treatment of d-methylphenidate to stimulant medications extended the duration of therapeutic effect. Adjunct treatment of mirtazapine to stimulant medications reduced associated insomnia. These data support previous research that validates the use of combination pharmacotherapy for adults with ADHD.

Evaluation of a Potential Metabolism-Mediated Drug-Drug Interaction Between Atomoxetine and Bupropion in Healthy Volunteers

“…These pharmacological agents are not only linked to the same isoenzyme, as atomoxetine is a substrate (6), while bupropion is an enzymatic inhibitor of CYP2D6 (13), but, equally important, their association in clinical circumstances can be taken into consideration. Adler et al emphasized that the practice of prescribing a combination of medications is common in adult ADHD and is especially required in cases of partial response, dose-limiting side effects, preexisting or treatment-induced disorders and comorbid diagnoses (21). ADHD is particularly associated with significant lifetime psychiatric comorbidity (22).…”

Updates on combination pharmacotherapy for adult ADHD

“…Additionally, nine patients received daily concomitant treatment with atomoxetine. All but one patient reported clinical improvement with suffi cient and extended relief of ADHD symptoms later in the day [17]. The supplemental dose of d-MPH was well tolerated, with only two patients reporting dose-limiting side effects (agitation, early insomnia) [17].…”

“…Adler et al [17] conducted a chart review of 27 children, adolescents, and adults who were being treated for ADHD and receiving a supplemental dose of d-MPH to augment the effect or extend the duration of effect of sustained-release stimulant medications. Most of the sample (n = 19) received one supplemental dose of d-MPH in the afternoon, with the remaining sample (n = 8) receiving a supplemental dose of d-MPH in the morning and afternoon.…”

“…The most commonly reported stimulant side effects are decreased appetite, stomachache, headache, jitteriness or restlessness, mood disturbances, fatigue, and sleep diffi culties (including delay of onset and insomnia) [6,17]. Additionally, stimulants have been found to increase blood pressure and heart rate, and in rare cases, lead to the development of motor tics [6,21].…”

“…Adler et al [17] conducted a chart review of 16 children, adolescents, and adults with ADHD who received mirtazapine for 4 to 6 weeks to treat early insomnia, which was exacerbated by or co-occurred with the initiation of stimulant therapy. Additionally, fi ve patients were also being treated with stable doses of antidepressants for comorbid dysthymia prior to initiation of stimulant and mirtazapine treatment.…”