Methylphenidate–risperidone combination in child psychiatry: A retrospective analysis of 44 cases

Current nonstimulant medications for adults with attention-deficit/hyperactivity disorder

INTRODUCTION

Stimulants, including methylphenidate and amphetamines, are the first-line pharmacological treatment of ADHD in adults. However, in patients who do not respond or poorly tolerate stimulants, non-stimulant medications are usually recommended.

AREAS COVERED

The authors provide a narrative review of the literature on non-stimulant treatments for adult ADHD, including controlled and observational clinical studies conducted on adult samples. Atomoxetine has been extensively studied and showed significant efficacy in treating adult ADHD. Issues related to dosing, treatment duration, safety, and use in the case of psychiatric comorbidity are summarized. Among other compounds indicated for ADHD in adults, antidepressants sharing at least a noradrenergic or dopaminergic component, including tricyclic compounds, bupropion, and viloxazine, have shown demonstratable efficacy. Evidence is also available for antihypertensives, particularly guanfacine, as well as memantine, metadoxine, and mood stabilizers, while negative findings have emerged for galantamine, antipsychotics, and cannabinoids.

EXPERT OPINION

While according to clinical guidelines, atomoxetine may serve as the only second-line option in adults with ADHD, several other nonstimulant compounds may be effectively used in order to personalize treatment based on comorbid conditions and ADHD features. Nevertheless, further research is needed to identify and test more personalized treatment strategies for adults with ADHD.

The Use of Brexpiprazole Combined With a Stimulant in Adults With Treatment-Resistant Attention-Deficit/Hyperactivity Disorder

BACKGROUND

This is the first controlled pharmacologic study in either adults or children with uncomplicated, treatment-resistant attention-deficit/hyperactivity disorder (ADHD). This study augmented stimulant therapy with the atypical antipsychotic brexpiprazole. The Food and Drug Administration preapproved primary outcome measure (Conners' Adult ADHD Rating Scale [CAARS]) showed no drug-placebo differences. Often studies showing no efficacy on the prestudy, defined primary outcome variable go unpublished. While this is decried, publishing studies with equivocal results remains rare. This reanalysis highlights trends in secondary measures having implications for treatment and research regarding treatment resistant ADHD.

METHODS

Initially, 559 stimulant-naive and 174 prior stimulant nonresponders received methylphenidate osmotic-release oral system, dexmethylphenidate hydrochloride, lisdexamfetamine, or mixed amphetamine salts. After 5 weeks, 168 stimulant-naive patients and 68 prior stimulant nonresponders who failed treatment were randomized to brexpiprazole or placebo in a 2:1 ratio while the remaining were on the stimulant. Outcome was measured with the CAARS, Montgomery-Asberg Depression Rating Scale, Beck Depression Inventory, Clinical Global Impression, and the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). The WRAADDS contains 2 factors: attention and emotional dysregulation.

RESULTS

Stimulant-naive patients showed no improvement with adjunctive brexpiprazole. Prior stimulant nonresponders displayed no brexpiprazole effect on the CAARS, Montgomery-Asberg Depression Rating Scale, or Beck Depression Inventory. In contrast, the WRAADDS detected a trend in treatment benefit, primarily through emotional dysregulation symptoms. Adverse effects on brexpiprazole and placebo were equivalent.

CONCLUSIONS

Brexpiprazole might be effective in ADHD adults who are nonresponders to 2 or more stimulants. Future trials in treatment-resistant ADHD should use a 1:1 randomization and use a measure of ADHD symptoms that includes emotional dysregulation.

Children with ADHD and symptoms of oppositional defiant disorder improved in behavior when treated with methylphenidate and adjuvant risperidone, though weight gain was also observed - Results from a randomized, double-blind, placebo-controlled clinical trial

Children with ADHD often show symptoms of oppositional defiant disorders (ODD). We investigated the impact of adjuvant risperidone (RISP) to a standard treatment with methylphenidate (MPH) in children with ADHD and symptoms of ODD. Eighty-four children with ADHD and ODD (age: M=8.55; range: 7.28-9.95 years; 73.8% males) took part in a double-blind, randomized, placebo-controlled, clinical trial lasting eight weeks. Participants were randomly assigned either to the MPH+RISP (1mg/kg/d+0.5mg/d) or to the MPH+PLCO (1mg/kg/d+placebo) condition. Symptoms of ADHD, weight, height, and blood pressure were assessed at baseline, and at weeks 2, 4, 6 and 8. Symptoms of ADHD decreased over time, but more so in the MPH+RISP than in the MPH only condition. In the MPH+RISP condition weight, waist circumference and prolactine levels increased over time. Data suggest that adjuvant RISP improved symptoms in children with ADHD and ODD, but weight gain and higher prolactine levels were also observed, which are two alarming side effects. This may become an issue, once children become adolescents, a period of life in which body shape and body self-image are closely linked to self-confidence and peer acceptance. Health care professionals should carefully balance the short-term and long-term costs and benefits of administration of RISP.

Dystonia with MPH/Risperidone Combined Therapy for ADHD

Investigators from Child Neurology and Pediatrics, University of Texas Health Science Center, Houston, report extrapyramidal symptoms in a 13-year-old boy with a psychiatric history of schizophrenia, bipolar disorder, ADHD, and autism, responsive to combination risperidone, oxcarbazepine, and MPH.

Comparison of the effects of methylphenidate and the combination of methylphenidate and risperidone in preschool children with attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder among preschool children but the number of controlled clinical trials regarding psychopharmacological treatment in this age group is limited. The aim of this study was to compare methylphenidate with the combination of methylphenidate and risperidone in preschool children with ADHD. Forty-two preschool children, aged 3–6 years, diagnosed with ADHD by a child and adolescent psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Text Revision criteria, were enrolled in a 6-week, single-blind clinical trial and administered with methylphenidate (5–30 mg/dl) or the combination of methylphenidate and risperidone (0.25–2 mg/dl) in Iran. Treatment outcomes were assessed using the Conners' Rating Scale and Clinical Global Impression (CGI) Scale at baseline and 3 and 6 weeks after starting the drugs administration. Side effects were rated by a checklist and body weight was measured at each visit. There were no significant differences between the two protocols in Parent Conners' Rating Scale scores (P > 0.05) and CGI scores (P > 0.05). Both groups showed a significant improvement in ADHD symptoms over the 6 weeks of treatment for Parent Conners' Rating Scale (P < 0.001). The combination group used significantly lower doses of methylphenidate compared to the other group (P = 0.002). The most common adverse effects were anorexia (21.7%) and daytime drowsiness (17.4%) in combination treatment group and insomnia (33.3%) and anorexia (25%) in methylphenidate group. Risperidone and methylphenidate may be effective and well tolerated in preschool children with ADHD, and adding risperidone to methylphenidate may decrease the occurrence of some side effects of methylphenidate such as insomnia and anorexia and lower the dose of methylphenidate may be needed to control symptoms.