Continuity in Methylphenidate Treatment of Adults With Attention-Deficit/Hyperactivity Disorder

Abstract

ReseaRch Int he general adult population, the prevalence of attentiondeficit/hyperactivity disorder (ADHD) is approximately 2% to 4%. [1][2][3][4] Methylphenidate (MPH) effectively ameliorates many symptoms of adult ADHD. [5][6][7][8][9] In 1l arge 6-week randomized controlled trial of adults with ADHD,7 immediate-release methylphenidate (IR-MPH) was associated with a76% response rate, compared with a1 9% response rate for placebo. In a 6-week trial with the same response criteria, 66% of subjects treated with osmotic release oral system methylphenidate (OROS-MPH) responded, compared with 39% who received placebo. 9In both studies, response was defined as a3 0% symptom reduction and, at least, much overall improvement.Early discontinuation of treatment is common in the community careo fp atients initiating stimulant therapy. [10][11][12][13] In 1s tudy, BACKGROUND: Although stimulant therapyiscommonly discontinued early in adults with attention-deficit/hyperactivity disorder (ADHD), the factors that contribute to continuity of stimulant therapyremain largely unknown.OBJECTIVE: To (1) comparethe continuity of methylphenidate (MPH) therapy among adults who use immediate-release methylphenidate (IR-MPH) for ADHD with adults who use extended-release methylphenidate (ER-MPH) formulations, and (2) RESULTS: Less than one third(30.0%) of the adult patients who were prescribed MPH had 1ormoremedical claims with adiagnosis code for ADHD.For the adult MPH patients with at least 1medical claim with a diagnosis code for ADHD,the patients who initiated therapywith ER-MPH (N =2,833) weresignificantly younger,weremorelikely to be male,and were less likely to be treated by apsychiatrist than werethe patients who initiated therapywith IR-MPH (N =2,289). Only 50.5% (n =1,156) of IR-MPH patients and 61.4% (n =1,739) of ER-MPH patients had morethan 1pharmacyclaim for the indexMPH medication. Adults treated with ER-MPH also had a significantly longer median duration of treatment with the indexmedication (ER-MPH: 68 days, 95% confidence interval [CI], 65-71 days vs. IR-MPH 39 days, 95% CI, 33-52 days). Controlling for group differences in age,gender, treatment by apsychiatrist, recently prescribed psychotropic medications, treated mental disorders, emergencymental health treatment, and inpatient mental health care, ER-MPH initiation wasassociated with an average 27% longer duration of treatment than with IR-MPH (survival time ratio: 1.27, 95% CI, 1.20-1.35).CONCLUSION: In management of adult ADHD,use of ER-MPH formulations wasassociated with alonger median duration of the initially prescribed medication than wasuse of IR-MPH. It is unknown whether the observed absolute unadjusted difference of 29 days in median length of therapyis clinically important.

Predictive Factors for More Than 3 Years’ Duration of Central Stimulant Treatment in Adult Attention-Deficit/Hyperactivity Disorder

“…9,14 Few studies have investigated predictive factors for long CS treatment duration in adults, but some suggest there is an association between longer treatment duration and the use of extended-release (ER) formulations of CS. 15,19,20 Olfson and colleagues 15 also found that treatment by a psychiatrist was positively related to longer CS treatment duration. Mental health treatment in an emergency department during the 6 months before initiation of MPH treatment and younger age were related to shorter duration.…”

“…9,14 Few studies have investigated predictive factors for long CS treatment duration in adults, but some suggest there is an association between longer treatment duration and the use of extended-release (ER) formulations of CS. 15,19,20 Olfson and ORIGINAL CONTRIBUTION …”

“…15Y17 Lack of effect and intolerable adverse effects are common reasons for discontinuation of CS treatment, but cannot alone explain the large discontinuation rates in clinical studies 12,16,18 and community-based treatment. 15, 17 Bejerot and colleagues 11 found in their 2-year follow-up study of CS treatment in adult ADHD the most important discontinuation causes to be lack of efficacy (15.2%), adverse effects too bothersome (7.6%), anxiety and/or depression (16.7%), unknown or lost to follow-up (22.7%), and patient decision, not specified (12.1%). In total, more than 40% discontinued CS treatment because of unknown or unspecified causes.…”

ADD or ADHD or What Exactly?--GIGO Part II and Other Lessons in Research with Administrative Claims

“…This research informs us that less than one-third( 30%) of adult patients who received MPH had am edical claim for ADD or ADHD. 2 The authors' focus in this study was continuity or length of MPH therapy in adult ADD/ADHD patients, and the median duration of treatment with the index MPH medication was 68 Editorial days (95% confidence internal [CI], 65-71 days for ER-MPH versus 39 days [95% CI, 33-52 days] for IR-MPH). Although this difference of 29 days is statistically significant, the clinical and practical significance areunknown and no doubt small.…”

“…2 Code 314.01 accounted for 46% of the patients that received ER-MPH and 39% that received IR-MPH. Code 314.00 (without mention of hyperactivity) accounted for 48% of the patients that received ER-MPH and 53% of the patients that received IR-MPH.…”