Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient’s age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient’s needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

First-Time Users of ADHD Medication Among Children and Adolescents in Germany: An Evaluation of Adherence to Prescribing Guidelines Based on Claims Data

“…Regarding potential reasons for starting ADHD treatment with second-line medication, prescribing based on trial data ahead of formal licensing might be a potential cause. Nevertheless, clinical data on efficacy do not support the superiority of LDX, DEX, or GUA (i.e., second-line drugs in this study) over MPH or ATX (i.e., first-line drugs in this study) for patients with the above-mentioned conditions (16). Considering data from randomized controlled trials on tolerability, amphetamines (including LDX and DEX) and GUA-but not MPH-were inferior to placebo in children and adolescents (17).…”

“…However, second-line drugs should not be preferably prescribed-particularly to preschool children-as long as superiority over first-line drugs is not proven by sound evidence. Currently, MPH is considered the treatment of first choice for preschool children, if pharmacotherapy is indicated, as it is the ADHD drug with the strongest evidence for efficacy and safety in this population (16,20). Surprisingly-even when adjusted for age and characteristics indicating the complexity of ADHD cases-patients were more likely to receive a second-line drug as the first ADHD medication when the prescription was made by a pediatrician.…”

Effects of methylphenidate on blood pressure, QT-interval, and cardiac output in ADHD diagnosed children: A three months’ follow-up study

“…Psychosocial therapy combined with pharmacotherapy, with methylphenidate is the first-choice medication for ADHD in school-aged children [34] , [35] . Although first-line drugs for ADHD are considered safe, cardiovascular based personal and familial history alongside with complete physical examination including baseline height, weight, blood pressure, and heart rate should be acquired before the initiation of the treatment [36] .…”

A clinician’s guide for navigating the world of attention deficit hyperactivity disorder medications

“…Studies by Sallee, Whalen, Mattingly, and others have shown that clinicians primarily focus on consequences of ADHD during school and work while overlooking impairments that occur at the beginning and end of the day. [35][36][37] Sallee et al found that 79% of ADHD caregivers have discussed early morning functional impairments such as getting out of bed, getting dressed, self-hygiene, eating breakfast, packing their backpack, and being able to catch the bus as being some of the most impairing issues for their children with ADHD.…”

“…These symptoms can present in childhood as difficulty waiting, impatience with delays, or excessive frustration when asked to shift from a preferred to a nonpreferred task. 36 Such frustration often leads to a sequence of escalating emotional and behavioral dyscontrol, "meltdowns" out of proportion to the task at hand, and emotional fragmentation. 37,38 Oppositional thoughts and behaviors can trouble ADHD individuals of any age.…”