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Rheims S, Herbillon V, Gaillard S, Mercier C, Villeuve N, Villéga F, Cances C, Castelnau P, Napuri S, de Saint‐Martin A, Auvin S, Nguyen The Tich S, Berquin P, de Bellecize J, Milh M, Roy P, Arzimanoglou A, Bodennec J, Bezin L, Kassai B. Phosphatidylserine enriched with polyunsaturated n-3 fatty acid supplementation for attention-deficit hyperactivity disorder in children and adolescents with epilepsy: A randomized placebo-controlled trial. Epilepsia Open 2024; 9:582-591. [PMID: 38173190 PMCID: PMC10984292 DOI: 10.1002/epi4.12892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/24/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Attention-deficit hyperactivity disorder (ADHD) is a frequent comorbidity in children with epilepsy, which management mostly relies on the usual treatments of ADHD, especially methylphenidate. Supplementation with polyunsaturated n-3 Fatty Acid (PUFA) has been proposed as an alternative therapeutic approach in ADHD without epilepsy but has never been evaluated in epilepsy-associated ADHD. METHODS A multicenter double blind randomized placebo-controlled trial evaluating supplementation with PUFA, in eicosapentaenoic- and docosahexaenoic-acid form, conjugated to a phospholipid vector (PS-Omega3) in children aged >6 and <16-years old, and suffering from any type of epilepsy and ADHD (inattentive or combined type) according to DSM-V. After a 4-week baseline period, patients were allocated (1:1) either to placebo group or to PS-Omega 3 group and entered a 12 week-double-blind treatment period which was followed by a 12 week-open-label treatment period. The primary outcome was the reduction of the ADHD-rating scale IV attention-deficit subscore after 12 weeks of treatment. RESULTS The study was stopped early because of lack of eligible participants and the expected sample size was not reached. Seventy-four patients were randomized, 44 in PS-Omega3, and 30 in the placebo group. The reduction after 12 weeks of treatment in the inattention subscore of the ADHD-IV scale was -1.57 in the PS-Omega3 group, and -2.90 in the placebo group (p = 0.33, α = 5%). Results were similar after 24 weeks of treatment and for all other ADHD-related secondary outcomes, with no difference between placebo and PS-Omega3. CONCLUSION Our study remaining underpowered, no formal conclusion about the effect of Ps-Omega3 could be drawn. However, our data strongly suggested that the PS-Omega 3 formulation used in the current study did not improve ADHD symptoms in children with epilepsy. PLAIN LANGUAGE SUMMARY Supplementation with polyunsaturated n-3 Fatty Acid (PUFA) has been proposed in ADHD but has never been evaluated in patients with both epilepsy and ADHD. To address this issue, we conducted a multicenter double blind randomized placebo-controlled trial evaluating supplementation with PUFA in children with epilepsy and ADHD. The study was stopped early because of lack of eligible participants, hampering formal conclusion. However, the evolution of the ADHD symptoms at 12 and 24 weeks did not differ between placebo and PUFA supplementation, strongly suggesting that PUFA did not improve ADHD symptoms in children with epilepsy.
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Affiliation(s)
- Sylvain Rheims
- Department of Functional Neurology and EpileptologyHospices Civils de Lyon and Lyon 1 UniversityLyonFrance
- Lyon Neuroscience Research Center, INSERM U1028/CNRS UMR 5292Lyon 1 UniversityLyonFrance
- Epilepsy InstituteLyonFrance
| | - Vania Herbillon
- Lyon Neuroscience Research Center, INSERM U1028/CNRS UMR 5292Lyon 1 UniversityLyonFrance
- Epilepsy, Sleep and Paediatric Neurophysiology DepartmentHospices Civils de LyonLyonFrance
| | - Ségolène Gaillard
- Clinical Investigation Centre 1407, Hospices Civils de Lyon‐InsermHôpital Louis PradelBronFrance
| | | | | | | | | | | | | | | | - Stéphane Auvin
- Pediatric Neurology Department, AP‐HP, Robert‐Debré University HospitalCRMR Épilepsies Rares, EpiCARE MemberParisFrance
- INSERM NeuroDiderotUniversité Paris CitéParisFrance
- Institut Universitaire de France (IUF)ParisFrance
| | | | | | - Julitta de Bellecize
- Epilepsy, Sleep and Paediatric Neurophysiology DepartmentHospices Civils de LyonLyonFrance
| | - Mathieu Milh
- Department of Pediatric NeurologyAPHMMarseilleFrance
| | - Pascal Roy
- Department of BiostatisticsHospices Civils de LyonLyonFrance
| | - Alexis Arzimanoglou
- Lyon Neuroscience Research Center, INSERM U1028/CNRS UMR 5292Lyon 1 UniversityLyonFrance
- Epilepsy, Sleep and Paediatric Neurophysiology DepartmentHospices Civils de LyonLyonFrance
| | - Jacques Bodennec
- Lyon Neuroscience Research Center, INSERM U1028/CNRS UMR 5292Lyon 1 UniversityLyonFrance
- Epilepsy InstituteLyonFrance
| | - Laurent Bezin
- Lyon Neuroscience Research Center, INSERM U1028/CNRS UMR 5292Lyon 1 UniversityLyonFrance
- Epilepsy InstituteLyonFrance
| | - Behrouz Kassai
- Clinical Investigation Centre 1407, Hospices Civils de Lyon‐InsermHôpital Louis PradelBronFrance
- Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique‐Santé, CNRS, UMR 5558Lyon 1 UniversityVilleurbanneFrance
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Guo HL, Wu DD, Fu D, Li Y, Wang J, Zhang YY, Wang WJ, Huang J, Fang WR, Xu J, Hu YH, Liu QQ, Chen F. Individualized atomoxetine response and tolerability in children with ADHD receiving different dosage regimens: the need for CYP2D6 genotyping and therapeutic drug monitoring to dance together. Transl Psychiatry 2024; 14:151. [PMID: 38504095 PMCID: PMC10951231 DOI: 10.1038/s41398-024-02859-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/21/2024] Open
Abstract
Integrating CYP2D6 genotyping and therapeutic drug monitoring (TDM) is crucial for guiding individualized atomoxetine therapy in children with attention-deficit/hyperactivity disorder (ADHD). The aim of this retrospective study was (1) to investigate the link between the efficacy and tolerability of atomoxetine in children with ADHD and plasma atomoxetine concentrations based on their CYP2D6 genotypes; (2) to offer TDM reference range recommendations for atomoxetine based on the CYP2D6 genotypes of children receiving different dosage regimens. This retrospective study covered children and adolescents with ADHD between the ages of 6 and <18, who visited the psychological and behavioral clinic of Children's Hospital of Nanjing Medical University from June 1, 2021, to January 31, 2023. The demographic information and laboratory examination data, including CYP2D6 genotype tests and routine TDM of atomoxetine were obtained from the hospital information system. We used univariate analysis, Mann-Whitney U nonparametric test, Kruskal-Wallis test, and the receiver operating characteristic (ROC) curve to investigate outcomes of interest. 515 plasma atomoxetine concentrations of 385 children (325 boys and 60 girls) with ADHD between 6 and 16 years of age were included for statistical analysis in this study. Based on genotyping results, >60% of enrolled children belonged to the CYP2D6 extensive metabolizer (EM), while <40% fell into the intermediate metabolizer (IM). CYP2D6 IMs exhibited higher dose-corrected plasma atomoxetine concentrations by 1.4-2.2 folds than those CYP2D6 EMs. Moreover, CYP2D6 IMs exhibited a higher response rate compare to EMs (93.55% vs 85.71%, P = 0.0132), with higher peak plasma atomoxetine concentrations by 1.67 times than those of EMs. Further ROC analysis revealed that individuals under once daily in the morning (q.m.) dosing regimen exhibited a more effective response to atomoxetine when their levels were ≥ 268 ng/mL (AUC = 0.710, P < 0.001). In addition, CYP2D6 IMs receiving q.m. dosing of atomoxetine were more likely to experience adverse reactions in the central nervous system and gastrointestinal system when plasma atomoxetine concentrations reach 465 and 509 ng/mL, respectively. The findings in this study provided promising treatment strategy for Chinese children with ADHD based on their CYP2D6 genotypes and plasma atomoxetine concentration monitoring. A peak plasma atomoxetine concentration higher than 268 ng/mL might be requisite for q.m. dosing. Assuredly, to validate and reinforce these initial findings, it is necessary to collect further data in controlled studies with a larger sample size.
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Affiliation(s)
- Hong-Li Guo
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Dan-Dan Wu
- Department of Children Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Di Fu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Visiting graduate student from China Pharmaceutical University, Nanjing, China
| | - Yue Li
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Wang
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yuan-Yuan Zhang
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Jun Wang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Visiting graduate student from China Pharmaceutical University, Nanjing, China
| | - Jian Huang
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Rong Fang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jing Xu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ya-Hui Hu
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Qian-Qi Liu
- Department of Children Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Feng Chen
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China.
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Faraone SV, Newcorn JH, Wozniak J, Joshi G, Coffey B, Uchida M, Wilens T, Surman C, Spencer TJ. In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry. J Atten Disord 2024; 28:550-582. [PMID: 38334088 PMCID: PMC10947509 DOI: 10.1177/10870547231225818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry. METHOD Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD. RESULTS Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen. CONCLUSION The world is a better place because Joe Biederman was here.
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Affiliation(s)
| | | | - Janet Wozniak
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Gagan Joshi
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Mai Uchida
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Timothy Wilens
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Craig Surman
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Thomas J. Spencer
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
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Terao I, Kodama W, Tsuda H. The Dose-Response Relationship of Atomoxetine for the Treatment of Children With ADHD: A Systematic Review and Dose-Response Meta-Analysis of Double-Blind Randomized Placebo-Controlled Trials. J Atten Disord 2024; 28:431-438. [PMID: 38069471 DOI: 10.1177/10870547231214988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES The present study aimed to meta-analytically estimate the dose-response relationship of atomoxetine for treating children with ADHD. METHODS We systematically searched double-blind randomized placebo-controlled trials that evaluated the effectiveness of atomoxetine for treating ADHD in children. The search was carried out in PubMed, Cochrane Library, CINHAL, and ClinicalTrials.gov databases, covering articles from their inception until January 20, 2023. In addition, a dose-response meta-analysis was conducted. RESULTS In this dose-response meta-analysis, 12 double-blind randomized placebo-controlled trials involving 2,250 patients were included. The efficacy of atomoxetine increased up to a dosage of 1.4 mg/kg, after which it reached a plateau. CONCLUSIONS The first dose-response meta-analysis of atomoxetine dosing for children with ADHD conducted here enhances the robustness of the Food and Drug Administration and the European Medicines Agency dose recommendations.
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Seok JW, Soltis-Vaughan B, Lew BJ, Ahmad A, Blair RJR, Hwang S. Psychopharmacological treatment of disruptive behavior in youths: systematic review and network meta-analysis. Sci Rep 2023; 13:6921. [PMID: 37117632 PMCID: PMC10147946 DOI: 10.1038/s41598-023-33979-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/21/2023] [Indexed: 04/30/2023] Open
Abstract
To conduct a systematic review of the comparative efficacy of various psychotropic medications for the treatment of disruptive behavior (DBs) in youths. To this aim, we systematically reviewed randomized clinical trials (RCTs) of various psychotropic medications targeting symptoms of DBs and applied network meta-analysis to investigate their relative efficacy. Fifty-five RCTs meeting the inclusion criteria were selected. To predict and interpret relative treatment efficacy, we compared the efficacy of various psychotropic medications prescribed for DB symptoms based on their mechanism of action. Network meta-analysis revealed that for reducing DBs, second-generation antipsychotics, stimulants, and non-stimulant ADHD medications were more efficacious than placebo, and second-generation antipsychotics were the most efficacious. The dopaminergic modulation of top-down inhibitory process by these medications is discussed in this review. This study offers information on the relative efficacy of various psychotropic medications for the treatment of DB, and insight into a potential neurobiological underpinning for those symptoms. It also illustrates the potential utility of these neurobiological mechanisms as a target for future treatment studies.
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Affiliation(s)
- Ji-Woo Seok
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
- Digital Health Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Brigette Soltis-Vaughan
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Brandon J Lew
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Aatiya Ahmad
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - R J R Blair
- Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Soonjo Hwang
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA.
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Surushkina SY, Chutko LS. [Pharmacotherapy and psychotherapy of children with attention deficit hyperactivity disorder]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:21-25. [PMID: 36843455 DOI: 10.17116/jnevro202312302121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
The article presents a review of scientific publications devoted to the main psychotherapeutic approaches that have shown their effectiveness in correcting behavior in children with attention-deficit/hyperactive disorder (ADHD). The principles of psychotherapeutic methods are outlined to reduce the severity of the main symptoms of ADHD and improve the social adaptation of children with this disease. Approaches to the drug therapy of ADHD and the results of studies on the effectiveness of various drugs used to treat this pathology are considered.
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Affiliation(s)
- S Yu Surushkina
- N. Bekhtereva Institute of Human Brain Russian Academy of Sciences, St. Petersburg, Russia
| | - L S Chutko
- N. Bekhtereva Institute of Human Brain Russian Academy of Sciences, St. Petersburg, Russia
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Early Morning ADHD Symptoms and Functional Impairment: Impact on Patients and Caregivers, and Pharmacological Approaches to Management. CNS Drugs 2023; 37:31-44. [PMID: 36520318 DOI: 10.1007/s40263-022-00978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a common and impairing mental disorder. Individuals with ADHD typically experience symptoms from awakening throughout the entire day, contributing to impaired function at home, at school, and in the workplace. Treatment is available to address the symptoms of ADHD; however, the extent to which treatments afford improved function remains less clear. Impaired function in children and adolescents, particularly in the early morning where multiple tasks must be completed, from getting out of bed, and having breakfast to leaving for school on time, is common even among stimulant-treated children, and can increase stress upon caregivers and family members. Herein, we present a narrative review on early morning functioning impairment in children and adolescents with ADHD, its impact on caregivers, the rating scales available for clinicians to identify the degree of early morning functioning impairment, and the efficacy of currently available treatments in providing functional improvements to patients with ADHD during the early morning, identifying that only treatments that are available upon awakening have been shown to statistically separate from placebo for early morning functioning improvement.
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Topriceanu CC, Moon JC, Captur G, Perera B. The use of attention-deficit hyperactivity disorder medications in cardiac disease. Front Neurosci 2022; 16:1020961. [PMID: 36340760 PMCID: PMC9626759 DOI: 10.3389/fnins.2022.1020961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/03/2022] [Indexed: 09/02/2023] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with onset usually in childhood characterized by inattention, impulsivity, and hyperactivity causing a functional impairment. Untreated ADHD, or treatment delay is associated with adverse outcomes and poor quality of life. Although conservative management strategies such as behavioral and psychological interventions are important, pharmacological treatment has a strong evidence base with improved outcomes. ADHD medications are broadly divided into stimulant and non-stimulant medications. Stimulant medications are generally more effective than non-stimulants. Cardiovascular safety of ADHD medication has been a matter of debate for decades. Treatment guidelines advise the careful consideration of risks and benefits in people with cardiovascular diseases such as congenital heart disease or cardiomyopathy. Although stimulants can increase systemic blood pressure and heart rate, no significant associations were found between their use and serious cardiovascular events. Concerns regarding QT effects and attendant sudden cardiac death risks deter clinicians from initiating much-needed ADHD medications in patients with heart disease. This overly cautious approach is potentially depriving low-risk individuals from significant benefits associated with timely ADHD drug treatment. This review discusses the cardiovascular risks reportedly associated with ADHD medications, the evidence base for their safe usage in persons with established cardiovascular disease, and highlights future research directions.
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Affiliation(s)
- Constantin-Cristian Topriceanu
- Barnet, Enfield and Haringey Mental Health Trust, London, United Kingdom
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- Cardiac MRI Unit, Barts Heart Centre, London, United Kingdom
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom
| | - James C. Moon
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- Cardiac MRI Unit, Barts Heart Centre, London, United Kingdom
| | - Gabriella Captur
- UCL Institute of Cardiovascular Science, University College London, London, United Kingdom
- UCL MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
- Department of Cardiology, Centre for Inherited Heart Muscle Conditions, The Royal Free Hospital, London, United Kingdom
| | - Bhathika Perera
- Barnet, Enfield and Haringey Mental Health Trust, London, United Kingdom
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Ruppert K, Geffert C, Clement HW, Bachmann C, Haberhausen M, Schulz E, Fleischhaker C, Biscaldi-Schäfer M. Therapeutic drug monitoring of atomoxetine in children and adolescents with attention-deficit/ hyperactivity disorder: a naturalistic study. J Neural Transm (Vienna) 2022; 129:945-959. [PMID: 35391568 PMCID: PMC9217867 DOI: 10.1007/s00702-022-02483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/22/2022] [Indexed: 12/02/2022]
Abstract
The selective norepinephrine reuptake inhibitor atomoxetine is potentially among the first-line pharmacotherapy options for ADHD. Therapeutic drug monitoring (TDM) with the quantification and interpretation of atomoxetine serum concentrations is used to determine an individual dose followed by an optimal effectiveness and minimal side effects. The aim of this retrospective pharmacokinetic–pharmacodynamic analysis was to derive age-appropriate recommendations for the implementation of TDM to improve the efficacy and tolerability of atomoxetine in children and adolescents. Using the analytical method of high-performance liquid chromatography with UV detection, 94 serum concentrations of 74 patients between 6 and 21 years of age were determined. Therapeutic effectiveness and side effects were evaluated according to the categories “low”, “moderate”, and “significant”. As part of TDM, a time interval with maximum concentrations of 1–3 h after the administration of atomoxetine was determined for blood sampling. In this time interval, a significant correlation between the weight-normalized dose and the serum concentrations was found. The efficacy as well as the tolerability proved to be mainly moderate or significant. A preliminary therapeutic reference range was between 100 and 400 ng/ml. Naturalistic studies have limitations. Therefore, and due to a limited study population, the results have to be regarded as preliminary observations that must be confirmed in further studies. The preliminary therapeutic reference range for children and adolescents proved to be narrower than the reference range for adult patients. However, due to good efficacy and tolerability an exact reference range remained difficult to determine.
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Affiliation(s)
- Katrin Ruppert
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Hans-Willi Clement
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Bachmann
- Department of Child and Adolescent Psychiatry, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
| | - Michael Haberhausen
- Department of Child and Adolescent Psychiatry, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Eberhard Schulz
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Monica Biscaldi-Schäfer
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Wilens TE, Faraone SV, Hammerness PG, Pliszka SR, Uchida CL, DeSousa NJ, Sallee FR, Incledon B, Newcorn JH. Clinically Meaningful Improvements in Early Morning and Late Afternoon/Evening Functional Impairment in Children with ADHD Treated with Delayed-Release and Extended-Release Methylphenidate. J Atten Disord 2022; 26:696-705. [PMID: 34085581 PMCID: PMC8785267 DOI: 10.1177/10870547211020073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The Before School Functioning Questionnaire and Parent Rating of Evening and Morning Behavior-Revised assess early morning (BSFQ, PREMB-R AM subscale) and late afternoon/evening (PREMB-R PM subscale) functional impairment in children with ADHD. Clinically meaningful improvements were identified and applied to a trial of delayed-release and extended-release methylphenidate (DR/ER-MPH) in children with ADHD (NCT02520388) to determine if the statistically-determined improvements in functional impairment were also clinically meaningful. METHOD Clinically meaningful improvements in BSFQ/PREMB-R were established post hoc by receiver operating characteristics curves, using anchors of Clinical Global Impression-Improvement (CGI-I) = 1 and CGI-I ≤ 2. Percentages of participants achieving these thresholds were calculated. RESULTS Thresholds for CGI-I = 1/CGI-I ≤ 2, respectively, were 27/20 (BSFQ), 5/3 (PREMB-R AM), and 9/5 (PREMB-R PM)-point decreases. More children achieved clinically meaningful improvements with DR/ER-MPH versus placebo (all p < .05). CONCLUSION DR/ER-MPH increased proportions of children achieving clinically meaningful improvements in BSFQ and PREMB-R.
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Affiliation(s)
- Timothy E. Wilens
- Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Timothy E. Wilens, Massachusetts General Hospital, Yawkey 6900, 55 Fruit Street, Boston, MA 02114, USA.
| | | | - Paul G. Hammerness
- Harvard Medical School, Boston, MA, USA,Boston Children’s Hospital, MA, USA
| | - Steven R. Pliszka
- The University of Texas Health Science Center at San Antonio, TX, USA
| | | | - Norberto J. DeSousa
- Ironshore Pharmaceuticals & Development, Inc., Camana Bay, Grand Cayman, Cayman Islands
| | | | - Bev Incledon
- Ironshore Pharmaceuticals & Development, Inc., Camana Bay, Grand Cayman, Cayman Islands
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Castells X, Saez M, Barcheni M, Cunill R, Serrano D, López B, van Lissa CJ. Placebo Response and Its Predictors in Attention Deficit Hyperactivity Disorder: A Meta-Analysis and Comparison of Meta-Regression and MetaForest. Int J Neuropsychopharmacol 2021; 25:26-35. [PMID: 34355753 PMCID: PMC8756096 DOI: 10.1093/ijnp/pyab054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/13/2021] [Accepted: 08/05/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High placebo response in attention deficit hyperactivity disorder (ADHD) can reduce medication-placebo differences, jeopardizing the development of new medicines. This research aims to (1) determine placebo response in ADHD, (2) compare the accuracy of meta-regression and MetaForest in predicting placebo response, and (3) determine the covariates associated with placebo response. METHODS A systematic review with meta-analysis of randomized, placebo-controlled clinical trial investigating pharmacological interventions for ADHD was performed. Placebo response was defined as the change from baseline in ADHD symptom severity assessed according to the 18-item, clinician-rated, DSM-based rating scale. The effect of study design-, intervention-, and patient-related covariates in predicting placebo response was studied by means of meta-regression and MetaForest. RESULTS Ninety-four studies including 6614 patients randomized to placebo were analyzed. Overall, placebo response was -8.9 points, representing a 23.1% reduction in the severity of ADHD symptoms. Cross-validated accuracy metrics for meta-regression were R2 = 0.0012 and root mean squared error = 3.3219 for meta-regression and 0.0382 and 3.2599 for MetaForest. Placebo response among ADHD patients increased by 63% between 2001 and 2020 and was larger in the United States than in other regions of the world. CONCLUSIONS Strong placebo response was found in ADHD patients. Both meta-regression and MetaForest showed poor performance in predicting placebo response. ADHD symptom improvement with placebo has markedly increased over the last 2 decades and is greater in the United States than the rest of the world.
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Affiliation(s)
- Xavier Castells
- TransLab Research Group, Universitat de Girona, Girona, Spain,Department of Medical Sciences, Universitat de Girona, Girona, Spain,Economy Department; Research Group on Statistics, Econometrics and Health (GRECS), Universitat de Girona, Girona, Spain,Correspondence: Xavier Castells, MD, PhD, Department of Medical Sciences, Universitat de Girona, C/ Emili Grahit, 77, esc. B, 2n. Campus Centre. 17003 Girona, Spain ()
| | - Marc Saez
- Centre for Biomedical Research Network in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Maghie Barcheni
- Pharmacology, Toxicology and Therapeutics Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruth Cunill
- Parc Sanitari Sant Joan de Déu-Numància, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
| | - Domènec Serrano
- Department of Medical Sciences, Universitat de Girona, Girona, Spain,Economy Department; Research Group on Statistics, Econometrics and Health (GRECS), Universitat de Girona, Girona, Spain,Institut d’Assistència Sanitària, Girona, Spain
| | - Beatriz López
- Control and Intelligent Systems Engineering Research Group, Electrical; Electronic and Automatic Engineering Department, Universitat de Girona, Girona, Spain (Dr López)
| | - Caspar J van Lissa
- Department of Methodology and Statistics, Universiteit Utrecht, Utrecht, The Netherlands (Dr van Lissa)
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12
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Nasser A, Kosheleff AR, Hull JT, Liranso T, Qin P, Busse GD, Fava M, Maletic V, Rubin J, Lopez F. Evaluating the likelihood to be helped or harmed after treatment with viloxazine extended-release in children and adolescents with attention-deficit/hyperactivity disorder. Int J Clin Pract 2021; 75:e14330. [PMID: 33971070 PMCID: PMC8365735 DOI: 10.1111/ijcp.14330] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/16/2021] [Accepted: 05/03/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS When clinicians evaluate potential medications for their patients, they must weigh the probability of a treatment's benefits against the possible risks. To this end, the present analyses evaluate the novel nonstimulant viloxazine extended-release (viloxazine ER) using measures of effect size to describe the potential benefits of its treatment in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) as well as the risk of discontinuation because of intolerable adverse events. METHODS These post hoc analyses use pooled data from four pivotal Phase 3 trials in paediatric patients treated with viloxazine ER. The Likelihood to be Helped or Harmed (LHH) effect size measure was calculated to describe the probability of patients benefiting from treatment vs discontinuing. The Number Needed to Treat (NNT) was calculated from frequently used thresholds of response. The Number Needed to Harm (NNH) was calculated using discontinuations because of adverse events. RESULTS LHH values for viloxazine ER ranged from 5 to 13, suggesting that subjects were 5-13 times more likely to benefit from, rather than discontinue, viloxazine ER treatment. Specifically, NNT values for viloxazine ER treatment ranged from 6 to 7. NNH values for viloxazine ER treatment ranged from 31 to 74. By convention, single-digit NNTs (<10) suggest the intervention is potentially useful, while NNH values ≥10 for adverse events suggest it is potentially safe or tolerable. CONCLUSIONS These results indicate that patients with ADHD are likely to benefit from treatment with viloxazine ER, and are unlikely to discontinue, as viloxazine ER treatment was associated with favourable LHH, NNT, and NNH values. Clinicaltrials.gov: NCT03247530, NCT03247543, NCT03247517, NCT03247556.
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Affiliation(s)
- Azmi Nasser
- Supernus Pharmaceuticals, Inc.RockvilleMDUSA
| | | | | | | | - Peibing Qin
- Supernus Pharmaceuticals, Inc.RockvilleMDUSA
| | | | - Maurizio Fava
- Department of PsychiatryMassachusetts General HospitalBostonMAUSA
| | - Vladimir Maletic
- Department of Psychiatry/Behavioral ScienceUniversity of South Carolina School of MedicineGreenvilleSCUSA
| | | | - Frank Lopez
- Children’s Developmental CenterWinter ParkFLUSA
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13
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Loo SK, Salgari GC, Ellis A, Cowen J, Dillon A, McGough JJ. Trigeminal Nerve Stimulation for Attention-Deficit/Hyperactivity Disorder: Cognitive and Electroencephalographic Predictors of Treatment Response. J Am Acad Child Adolesc Psychiatry 2021; 60:856-864.e1. [PMID: 33068751 PMCID: PMC9714960 DOI: 10.1016/j.jaac.2020.09.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 09/12/2020] [Accepted: 10/08/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The current study applies a precision medicine approach to trigeminal nerve simulation (TNS), a Food and Drug Administration-approved neuromodulation treatment for attention-deficit/hyperactivity disorder (ADHD), by testing secondary outcomes of cognitive and electroencephalographic [EEG] predictors of treatment response among subjects from the original randomized controlled trial. METHOD Children aged 8 to 12 years with ADHD, were randomized to 4 weeks of active or sham TNS treatment, after which the sham group crossed over into 4 weeks of open-label treatment. TNS treatment responders (RESP) had an ADHD Rating Scale (ADHD-RS) Total score reduction of ≥25%, whereas nonresponders (NR) had <25% reduction posttreatment. Assessments included weekly behavioral ratings and pre-/posttreatment cognitive EEG measures. RESULTS The final sample was 25 RESP and 26 NR comprising 34 male and 17 female children, with a mean (SD) age of 10.3 (1.4) years. Baseline measures that significantly differentiated RESP from NR included: lower working memory, lower spelling and mathematics achievement, deficits on behavioral ratings of executive function (BRIEF), and lower resting state EEG power in the right frontal (F4) region (all p values <.05). Compared to NRs, responders showed significantly increased right frontal EEG power with TNS treatment, which was predictive of improved executive functions and ADHD symptomatology (β = 0.65, p < .001). When EEG findings and behavior were modeled together, the area under the curve (AUC) for BRIEF Working Memory scale was 0.83 (p = .003), indicating moderate prediction of treatment response. CONCLUSION Children with ADHD who have executive dysfunction are more likely to be TNS responders and show modulation of right frontal brain activity, improved/normalized executive functions, and ADHD symptom reduction. CLINICAL TRIAL REGISTRATION INFORMATION Developmental Pilot Study of External Trigeminal Nerve Stimulation for ADHD; http://clinicaltrials.gov; NCT02155608.
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14
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Nasser A, Hull JT, Liranso T, Busse GD, Melyan Z, Childress AC, A Lopez F, Rubin J. The Effect of Viloxazine Extended-Release Capsules on Functional Impairments Associated with Attention-Deficit/Hyperactivity Disorder (ADHD) in Children and Adolescents in Four Phase 3 Placebo-Controlled Trials. Neuropsychiatr Dis Treat 2021; 17:1751-1762. [PMID: 34113106 PMCID: PMC8184252 DOI: 10.2147/ndt.s312011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/13/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The ADHD Rating Scale (ADHD-RS) assesses 18 symptoms of inattention and hyperactivity/impulsivity and has been used in many clinical trials to evaluate the treatment effect of drugs on ADHD. The fifth edition of this scale (ADHD-RS-5) also assesses the impact of inattention and hyperactivity/impulsivity symptoms on six domains of functional impairment (FI): family relationships, peer relationships, completing/returning homework, academic performance at school, controlling behavior at school, and self-esteem. Here, we report the effect of viloxazine extended-release capsules (viloxazine ER), a novel nonstimulant treatment for ADHD in children and adolescents (ages 6-17 years), on FI from a post hoc analysis of four randomized, double-blind, placebo-controlled Phase 3 clinical trials (N=1354). PATIENTS AND METHODS ADHD-RS-5 investigator ratings of ADHD symptoms and FIs were conducted at baseline and weekly post-baseline for 6-8 weeks in the four trials. Change from baseline (CFB) in ADHD-RS-5 FI scores (Total score [sum of 12 FI items] and Inattention and Hyperactivity/Impulsivity subscale scores [sum of 6 corresponding FI items]) and the 30% and 50% Responder Rates (ADHD-RS-5 FI Total score) were compared between viloxazine ER and placebo. RESULTS The reduction (improvement) in ADHD-RS-5 FI scores (Total and subscale scores) and the percentage of responders (30% and 50%) at Week 6 were significantly greater in each viloxazine ER dose group vs placebo. In the 100-400 mg/day viloxazine ER groups, improvements were found as early as Week 1 (100-mg/day) or Week 2 (200-, 400-mg/day) of treatment. Analysis of individual items of ADHD-related FIs demonstrated that the effect of viloxazine ER was observed across all domains of impairment. CONCLUSION Significant improvements observed in ADHD-related FIs are consistent with the reduction in inattention and hyperactivity/impulsivity symptoms demonstrated in the viloxazine ER Phase 3 pediatric trials. Therefore, viloxazine ER provides clinically meaningful improvement of ADHD symptoms and functioning in children and adolescents with ADHD, starting as early as Week 1-2 of treatment.
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Affiliation(s)
- Azmi Nasser
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | - Joseph T Hull
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | - Tesfaye Liranso
- Department of Biostatistics, Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | - Gregory D Busse
- Department of Medical Affairs, Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | - Zare Melyan
- Department of Medical Affairs, Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | - Ann C Childress
- Center for Psychiatry and Behavioral Medicine, Inc., Las Vegas, NV, USA
| | - Frank A Lopez
- Children’s Developmental Center, Winter Park, FL, USA
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15
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Shaker NM, Osama Y, Barakat DH, Abdelgawad AA, Abdel Aziz K, Aly El-Gabry D. Atomoxetine in Attention-Deficit/Hyperactivity Disorder in Children With and Without Comorbid Mood Disorders. J Child Adolesc Psychopharmacol 2021; 31:332-341. [PMID: 34143680 DOI: 10.1089/cap.2020.0178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: Mood disorders are commonly associated with attention-deficit/hyperactivity disorder (ADHD), adding to the clinical complexity. Some symptoms associated with ADHD are often associated with an increase in emotional disorders and depression. Hence, the management of comorbid mood symptoms in the context of ADHD represents a particularly difficult clinical challenge. Few studies in literature, and probably none in the Arab world, have investigated the impact of individual common comorbid disorders on the efficacy of atomoxetine (a nonstimulant norepinephrine reuptake inhibitor) as a monotherapy for the treatment of these comorbid mood symptoms. Therefore, our aim was to investigate the effect of atomoxetine in a sample of drug-naive Egyptian children with ADHD, with and without comorbid mood disorders. Methods: A prospective, naturalistic, open-label study. Results: Atomoxetine is an effective treatment for the symptoms of ADHD in the presence of comorbid mood disorder, but with a slower rate of improvement than if applied in the absence of mood disorder; in addition, our study showed improvement regarding the depressive symptoms in the mood group after 1 month. Conclusions: The study highlighted that atomoxetine is an effective treatment for ADHD in the presence of comorbid mood disorder, and improves depressive symptoms in the mood group. It also predicts mild resistance to the effects of atomoxetine on ADHD with slower improvement than those with ADHD only.
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Affiliation(s)
- Nermin M Shaker
- Neuropsychiatry Department, Okasha Institute of Psychiatry, Ain Shams University, Cairo, Egypt
| | - Yara Osama
- Neuropsychiatry Department, Okasha Institute of Psychiatry, Ain Shams University, Cairo, Egypt.,Al Mashfa Psychiatric Hospital and Resort, Cairo, Egypt
| | - Doaa H Barakat
- Neuropsychiatry Department, Okasha Institute of Psychiatry, Ain Shams University, Cairo, Egypt
| | - Ahmed Adel Abdelgawad
- Neuropsychiatry Department, Okasha Institute of Psychiatry, Ain Shams University, Cairo, Egypt
| | - Karim Abdel Aziz
- Department of Psychiatry, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Dina Aly El-Gabry
- Neuropsychiatry Department, Okasha Institute of Psychiatry, Ain Shams University, Cairo, Egypt
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16
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Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions. CNS Spectr 2021; 26:202-221. [PMID: 32054558 DOI: 10.1017/s1092852919001822] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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.
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18
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Nasser A, Kosheleff AR, Hull JT, Liranso T, Qin P, Busse GD, O'Neal W, Fava M, Faraone SV, Rubin J. Translating Attention-Deficit/Hyperactivity Disorder Rating Scale-5 and Weiss Functional Impairment Rating Scale-Parent Effectiveness Scores into Clinical Global Impressions Clinical Significance Levels in Four Randomized Clinical Trials of SPN-812 (Viloxazine Extended-Release) in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. J Child Adolesc Psychopharmacol 2021; 31:214-226. [PMID: 33600233 PMCID: PMC8066343 DOI: 10.1089/cap.2020.0148] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objectives: Clinical trials in psychiatry frequently report results from lengthy, comprehensive assessments to characterize a subject emotionally, cognitively, and behaviorally before and after treatment. However, the potential treatment implications of these results and how they translate into clinical practice remain unclear. Conversely, the Clinical Global Impressions (CGI) scales are quick, intuitive assessments used to assess the functional impact of a treatment in clinically relevant terms. The objectives of the present analyses are to translate scores from comprehensive assessments of symptom severity and functional impairment into clinically meaningful CGI levels. Methods: These post-hoc analyses use data integrated from four pivotal Phase 3 trials in attention-deficit/hyperactivity disorder (ADHD) in children and adolescents treated with the novel nonstimulant SPN-812 (Viloxazine Extended-Release). In this study, we evaluated the ADHD Rating Scale-5 (ADHD-RS-5) and Weiss Functional Impairment Rating Scale-Parent (WFIRS-P), assessments of symptom severity and functional impairment, respectively, by linking these scales with the CGI scales at baseline and end of study. Results: For participants that improved, a one-level change on the CGI-Improvement (CGI-I) was associated with a 10-15-point change on the ADHD-RS-5, and a 0.2-0.5-point change on the WFIRS-P. On the CGI-I, ratings of much improved and very much improved were associated with a percent score decrease (i.e., improvement) of ∼55% and 80% on the ADHD-RS-5 and ∼40% and 70% on the WFIRS-P, respectively. Differences between children and adolescents were minor and are unlikely to be clinically meaningful. Conclusion: These post-hoc analyses provide clinically meaningful benchmarks for the interpretation of scores on the ADHD-RS-5 and WFIRS-P in terms of CGI evaluations in subjects with ADHD. These results may be useful for physicians seeking to understand a treatment's potential impact on their ADHD patients or for researchers looking to define their study results within a clinically relevant context. Data are from clinical trials NCT03247530, NCT03247543, NCT03247517, and NCT03247556.
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Affiliation(s)
- Azmi Nasser
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | | | - Joseph T. Hull
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | | | - Peibing Qin
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | | | - Welton O'Neal
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stephen V. Faraone
- Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Jonathan Rubin
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
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19
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Joshi G, Wilens T, Firmin ES, Hoskova B, Biederman J. Pharmacotherapy of attention deficit/hyperactivity disorder in individuals with autism spectrum disorder: A systematic review of the literature. J Psychopharmacol 2021; 35:203-210. [PMID: 33349107 DOI: 10.1177/0269881120972336] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the empirical evidence for the treatment of attention deficit/hyperactivity disorder (ADHD) in populations with autism spectrum disorder (ASD). METHODS A systemic PubMed, PsychINFO, Embase, and Medline database search of peer-reviewed literature was conducted. Included in the review were controlled trials published in English with sample sizes ⩾10 participants examining the safety and efficacy of anti-ADHD medication in ASD populations. Data was extracted on relevant variables of study design, demographics, associated psychopathology, medication dose, efficacy, and tolerability. RESULTS Nine controlled trials met the inclusion and exclusion criteria: five with methylphenidate, three with atomoxetine, and one with guanfacine. Sample sizes ranged from 10 to 128 with 430 children participating across all the trials. In all the trials, treatment response was significantly superior to placebo. However, almost all trials assessed only hyperactivity, and most included only participants with intellectual disability with high levels of irritability. None of the trials distinguished agitation from hyperactivity. The response on hyperactivity for methylphenidate and atomoxetine was less than that observed in the neurotypical population; however, the response for guanfacine surpassed results observed in neurotypical populations. Treatment-emergent mood lability (i.e. mood dysregulation and mood-related adverse events) was frequently associated with methylphenidate and guanfacine treatments. Worse treatment outcomes were associated with individuals with lower intellectual capability compared with those with higher IQs. CONCLUSIONS here is a scarcity of controlled trials examining ADHD treatments in ASD populations, particularly in intellectually capable individuals with ASD and in adults. Response to ADHD medications in ASD were adversely moderated by the presence of intellectual disability and mood lability.
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Affiliation(s)
- Gagan Joshi
- Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum Disorder, Massachusetts General Hospital, Boston, USA.,Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, Boston, USA.,Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Timothy Wilens
- Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum Disorder, Massachusetts General Hospital, Boston, USA.,Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, Boston, USA.,Department of Psychiatry, Harvard Medical School, Boston, USA
| | - Elizabeth S Firmin
- Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum Disorder, Massachusetts General Hospital, Boston, USA.,Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, Boston, USA
| | - Barbora Hoskova
- Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum Disorder, Massachusetts General Hospital, Boston, USA.,Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, Boston, USA
| | - Joseph Biederman
- Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum Disorder, Massachusetts General Hospital, Boston, USA.,Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, Boston, USA.,Department of Psychiatry, Harvard Medical School, Boston, USA
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Abstract
Once considered a condition of hyperactive boys, our knowledge and understanding of attention deficit hyperactivity disorder (ADHD) and has dramatically evolved.1 Landmark studies by Biederman, Kessler, Faraone, and others have changed and deepened our understanding of ADHD to include a condition which not only affects boys but quite often affects girls.1–5 The evolution of symptoms across the lifespan and the concomitant neurologic changes which underlie this symptomatic expression has similarly evolved.6 Studies by Dalsgaard and others have brought to light the significantly increased morbidity and mortality associated with preschoolers, children, and adults struggling with ADHD and associated conditions.7,8
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21
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Fu D, Wu DD, Guo HL, Hu YH, Xia Y, Ji X, Fang WR, Li YM, Xu J, Chen F, Liu QQ. The Mechanism, Clinical Efficacy, Safety, and Dosage Regimen of Atomoxetine for ADHD Therapy in Children: A Narrative Review. Front Psychiatry 2021; 12:780921. [PMID: 35222104 PMCID: PMC8863678 DOI: 10.3389/fpsyt.2021.780921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/28/2021] [Indexed: 12/12/2022] Open
Abstract
Atomoxetine, a selective norepinephrine (NE) reuptake inhibitor, was approved for attention deficit/hyperactivity disorder (ADHD) treatment in children, adolescents and adults. We searched the database PubMed/MEDLINE (2000 to October 1, 2021). Only publications in English were considered. Atomoxetine inhibits the presynaptic norepinephrine transporter (NET), preventing the reuptake of NE throughout the brain along with inhibiting the reuptake of dopamine in specific brain regions such as the prefrontal cortex (PFC). The novel mechanism of atomoxetine also includes several new brain imaging studies and animal model studies. It is mainly metabolized by the highly polymorphic drug metabolizing enzyme cytochrome P450 2D6 (CYP2D6). Atomoxetine is effective and generally well tolerated. ADHD is often accompanied by multiple comorbidities. A series of studies have been published suggesting that atomoxetine is effective in the treatment of ADHD symptoms for children with various types of comorbidity. In some cases, it is possible that atomoxetine may have a positive influence on the symptoms of comorbidities. Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses, and has a negligible risk of abuse or misuse. The latest guideline updated that clinical dose selection of atomoxetine was recommended based on both CYP2D6 genotype and the peak concentration. To have a more comprehensive understanding of atomoxetine, this review sets the focus on the mechanism, clinical efficacy and dosage regimen in detail, and also touches on those studies regarding adverse reactions of atomoxetine.
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Affiliation(s)
- Di Fu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China.,School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Dan-Dan Wu
- Department of Children Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Li Guo
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ya-Hui Hu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Xia
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xing Ji
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Rong Fang
- School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yun-Man Li
- School of Basic Medical Sciences and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jing Xu
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Department of Pharmacy, Pharmaceutical Sciences Research Center, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qian-Qi Liu
- Department of Children Health Care, Children's Hospital of Nanjing Medical University, Nanjing, China
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Childress AC, Beltran N, Supnet C, Weiss MD. Reviewing the role of emerging therapies in the ADHD armamentarium. Expert Opin Emerg Drugs 2020; 26:1-16. [PMID: 33143485 DOI: 10.1080/14728214.2020.1846718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder that can be treated with both pharmacologic and nonpharmacologic modalities. Effective drug treatments for ADHD have been available for more than six decades. However, initial treatments had limitations in duration of effect, need for multiple daily doses, requirement for patients to swallow intact tablets, adverse effects and risk for abuse and diversion. During the past 20 years, more than two dozen stimulant and nonstimulant drugs have been developed. Nonetheless, there remain unmet needs in the treatment of ADHD.Areas covered: New stimulant and nonstimulant formulations in development are reviewed with emphasis on drugs in phase II and III trials. Efficacy, mechanism of action and adverse effect data are described where available. Abuse liability studies are described for abuse-deterrent formulations in development.Expert opinion: The review found a robust pipeline of stimulants and nonstimulants. Medications in development are formulated to optimize onset and duration of effect, alter the time of administration, obviate the need to swallow whole capsules or tablets and to deter abuse. While each of these formulations may fill a unique niche, these incremental improvements based on new drug delivery technologies may lead to very significant clinical effects.
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Affiliation(s)
- Ann C Childress
- Center for Psychiatry and Behavioral Medicine, Inc., Las Vegas, NV, USA
| | - Nathalie Beltran
- Touro University Nevada, College of Osteopathic Medicine, Henderson, NV, USA
| | - Carl Supnet
- Touro University Nevada, College of Osteopathic Medicine, Henderson, NV, USA
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Drug Repurposing Approaches to Combating Viral Infections. J Clin Med 2020; 9:jcm9113777. [PMID: 33238464 PMCID: PMC7700377 DOI: 10.3390/jcm9113777] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 12/14/2022] Open
Abstract
Development of novel antiviral molecules from the beginning costs an average of $350 million to $2 billion per drug, and the journey from the laboratory to the clinic takes about 10–15 years. Utilization of drug repurposing approaches has generated substantial interest in order to overcome these drawbacks. A drastic reduction in the failure rate, which otherwise is ~92%, is achieved with the drug repurposing approach. The recent exploration of the drug repurposing approach to combat the COVID-19 pandemic has further validated the fact that it is more beneficial to reinvestigate the in-practice drugs for a new application instead of designing novel drugs. The first successful example of drug repurposing is zidovudine (AZT), which was developed as an anti-cancer agent in the 1960s and was later approved by the US FDA as an anti-HIV therapeutic drug in the late 1980s after fast track clinical trials. Since that time, the drug repurposing approach has been successfully utilized to develop effective therapeutic strategies against a plethora of diseases. Hence, an extensive application of the drug repurposing approach will not only help to fight the current pandemics more efficiently but also predict and prepare for newly emerging viral infections. In this review, we discuss in detail the drug repurposing approach and its advancements related to viral infections such as Human Immunodeficiency Virus (HIV) and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).
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Zaso MJ, Park A, Antshel KM. Treatments for Adolescents With Comorbid ADHD and Substance Use Disorder: A Systematic Review. J Atten Disord 2020; 24:1215-1226. [PMID: 25655767 PMCID: PMC4666815 DOI: 10.1177/1087054715569280] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Comorbid ADHD and substance use disorder (SUD) presents frequently in adolescence, a developmental period that may promote the emergence of substance misuse among individuals with ADHD. Comorbid ADHD and SUD in adolescence results in significant and unique treatment challenges, necessitating examination into effective interventions. Method: This systematic review examined existing research into the treatment of comorbid adolescent ADHD and SUD. Results: Findings from a small number of pharmacological intervention studies suggest potential efficacy of extended-release stimulant and nonstimulant medications. Efficacy of psychotherapeutic interventions has not been systematically examined. Conclusion: Current research on treatments for comorbid ADHD and SUD in adolescence is limited. Future placebo-controlled clinical trials using large samples are needed to examine the efficacy of psychotherapeutic interventions, the heightened risk of prescription stimulant misuse, and the long-term maintenance of treatment gains in this population. Clinical guidelines for the treatment of comorbid ADHD and SUD are discussed.
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Affiliation(s)
- Michelle J. Zaso
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Aesoon Park
- Department of Psychology, Syracuse University, Syracuse, NY, USA
| | - Kevin M. Antshel
- Department of Psychology, Syracuse University, Syracuse, NY, USA
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Adler LA, Solanto M, Escobar R, Lipsius S, Upadhyaya H. Executive Functioning Outcomes Over 6 Months of Atomoxetine for Adults With ADHD: Relationship to Maintenance of Response and Relapse Over the Subsequent 6 Months After Treatment. J Atten Disord 2020; 24:363-372. [PMID: 27521574 DOI: 10.1177/1087054716664411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objective: This study examines the relationship between maintenance of improved executive functioning (EF) in adults with ADHD with long-term symptom improvement with atomoxetine. Method: Data were collected from a yearlong, double-blind, placebo-controlled clinical study on adult patients with ADHD receiving atomoxetine (80-100 mg/day) for 24 weeks. Patients were then randomized to continue atomoxetine or placebo for 6 months. Executive functioning was rated with Behavior Rating Inventory of Executive Function-Adult Version: Self-Report™ (BRIEF-A: Self-Report™), and the T-scores were determined. Results: Postrandomization T-scores for atomoxetine patients were significantly better than those of placebo patients (3 and 6 months postrandomization). Patients with greater improvements in EF were more likely to show worsening of EF and to relapse after atomoxetine discontinuation. The maintenance of improved EF was significantly associated with improved ADHD symptoms (Conners' Adult ADHD Rating Scale-Investigator Rated: Screening Version [CAARS-Inv:SV] with adult prompts). Conclusion: Treatment with atomoxetine improved EF during the treatment phases. Improved EF was maintained up to 6 months after discontinuation of atomoxetine.
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Affiliation(s)
- Lenard A Adler
- New York University Langone Medical Center, New York City, NY, USA
| | - Mary Solanto
- New York University Langone Medical Center, New York City, NY, USA
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Bilac Ö, Percinel I, Kavurma C. Atomoxetine-related bruxism in a 7-year-old boy: A case report. Indian J Psychiatry 2020; 62:104-105. [PMID: 32001942 PMCID: PMC6964449 DOI: 10.4103/psychiatry.indianjpsychiatry_566_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/11/2019] [Accepted: 10/14/2019] [Indexed: 01/22/2023] Open
Affiliation(s)
- Öznur Bilac
- Department of Child and Adolescent Psychiatry, Manisa Mental Health Hospital, Manisa, Turkey. E-mail:
| | - Ipek Percinel
- Department of Child and Adolescent Psychiatry, Firat University, Elazig, Turkey
| | - Canem Kavurma
- Department of Child and Adolescent Psychiatry, Manisa Mental Health Hospital, Manisa, Turkey. E-mail:
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Redding ZV, Chawla P, Sabol KE. The use of reaction time distributions to study attention in male rats: the effects of atomoxetine and guanfacine. Psychopharmacology (Berl) 2019; 236:3579-3592. [PMID: 31321458 DOI: 10.1007/s00213-019-05329-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 07/08/2019] [Indexed: 02/07/2023]
Abstract
RATIONALE Norepinephrine (NE) is involved in the control of sustained attention. Studies of sustained attention in humans include measures of reaction time (RT) and RT variability (RTV). The present study tested the role of NE using components of the RT distribution in rats in a manner thought to be similar to human studies of RTV. OBJECTIVES This study tested the effects of increased synaptic NE (atomoxetine (ATX)) and α-2 receptor binding (guanfacine) on attentional lapses in rats. METHODS Male Sprague-Dawley rats (n = 20) were trained and tested in a two-choice RT task (2CRTT). Atomoxetine dose (saline, 0.1, 0.5, 1.0 mg/kg, i.p.), guanfacine dose (saline, 0.01, 0.1, 0.3 mg/kg, i.p.), and distractors were manipulated in three experiments. RT was divided into initiation time (IT) and movement time (MT). Analyses of distribution mode (peak) and deviation from the mode (skew) were then performed. RESULTS ATX and guanfacine had no effect on IT mode, reduced IT devmode, and increased MT mode. When distractors were introduced, ATX again improved devmode, but a lack of interaction between ATX and distractor indicated that ATX did not prevent distractor-induced impairments. CONCLUSIONS IT devmode is a measure of distribution skew thought to reflect lapses of attention. The effects of ATX on IT devmode suggest that increased synaptic NE reduces attentional lapses. These findings are consistent with human reports of reduced RTV after ATX administration. The same pattern of results with guanfacine suggests that the effects of increased NE are due in part to binding at α-2 noradrenergic receptors.
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Affiliation(s)
- Zach V Redding
- Department of Psychology, The University of Mississippi, PO Box 1848, University, MS, 38677, USA
| | - Pooja Chawla
- Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Karen E Sabol
- Department of Psychology, The University of Mississippi, PO Box 1848, University, MS, 38677, USA.
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Wolraich ML, Hagan JF, Allan C, Chan E, Davison D, Earls M, Evans SW, Flinn SK, Froehlich T, Frost J, Holbrook JR, Lehmann CU, Lessin HR, Okechukwu K, Pierce KL, Winner JD, Zurhellen W. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2019; 144:e20192528. [PMID: 31570648 PMCID: PMC7067282 DOI: 10.1542/peds.2019-2528] [Citation(s) in RCA: 532] [Impact Index Per Article: 106.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is 1 of the most common neurobehavioral disorders of childhood and can profoundly affect children's academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for evaluation and diagnosis of pediatric ADHD in 2000; recommendations for treatment followed in 2001. The guidelines were revised in 2011 and published with an accompanying process of care algorithm (PoCA) providing discrete and manageable steps by which clinicians could fulfill the clinical guideline's recommendations. Since the release of the 2011 guideline, the Diagnostic and Statistical Manual of Mental Disorders has been revised to the fifth edition, and new ADHD-related research has been published. These publications do not support dramatic changes to the previous recommendations. Therefore, only incremental updates have been made in this guideline revision, including the addition of a key action statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying process of care algorithm has also been updated to assist in implementing the guideline recommendations. Throughout the process of revising the guideline and algorithm, numerous systemic barriers were identified that restrict and/or hamper pediatric clinicians' ability to adopt their recommendations. Therefore, the subcommittee created a companion article (available in the Supplemental Information) on systemic barriers to the care of children and adolescents with ADHD, which identifies the major systemic-level barriers and presents recommendations to address those barriers; in this article, we support the recommendations of the clinical practice guideline and accompanying process of care algorithm.
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Affiliation(s)
- Mark L. Wolraich
- Section of Developmental and Behavioral Pediatrics, University of Oklahoma, Oklahoma City, Oklahoma
| | - Joseph F. Hagan
- Department of Pediatrics, The Robert Larner, MD, College of Medicine, The University of Vermont, Burlington, Vermont
- Hagan, Rinehart, and Connolly Pediatricians, PLLC, Burlington, Vermont
| | - Carla Allan
- Division of Developmental and Behavioral Health, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Eugenia Chan
- Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Dale Davison
- Children and Adults with Attention-Deficit/Hyperactivity Disorder, Lanham, Maryland
- Dale Davison, LLC, Skokie, Illinois
| | - Marian Earls
- Community Care of North Carolina, Raleigh, North Carolina
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Steven W. Evans
- Department of Psychology, Ohio University, Athens, Ohio
- Center for Intervention Research in Schools, Ohio University, Athens, Ohio
| | | | - Tanya Froehlich
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer Frost
- Swope Health Services, Kansas City, Kansas
- American Academy of Family Physicians, Leawood, Kansas
| | - Joseph R. Holbrook
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christoph Ulrich Lehmann
- Departments of Biomedical Informatics and Pediatrics, Vanderbilt University, Nashville, Tennessee
| | | | | | - Karen L. Pierce
- American Academy of Child and Adolescent Psychiatry, Washington, District of Columbia
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ayaydın H. Probable emergence of symptoms of trichotillomania by atomoxetine: a case report. PSYCHIAT CLIN PSYCH 2019. [DOI: 10.1080/24750573.2018.1439601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hamza Ayaydın
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Harran University, Urfa, Turkey
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Tanaka Y, Brod M, Lane JR, Upadhyaya H. What Is a Clinically Relevant Improvement in Quality of Life in Adults With ADHD? J Atten Disord 2019; 23:65-75. [PMID: 25876607 DOI: 10.1177/1087054715580395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To estimate a minimal clinically important difference (MCID) on the adult ADHD Quality of Life (AAQoL) scale. METHOD The MCID was determined from data from short-term ( N = 537) and long-term ( N = 440), placebo-controlled atomoxetine trials in adults with ADHD. For the anchor-based approach, change in clinician-rated Clinical Global Impressions-ADHD-Severity (CGI-ADHD-S) scores was used to derive MCID. For the distribution-based approach, baseline-to-endpoint mean ( SD) changes in AAQoL scores corresponding to 0.5 SD were computed. RESULTS The MCID was similar (approximately 8-point difference) between the short-term and the long-term treatment groups when either the anchor-based or distribution-based approach was used. CONCLUSION These results suggest that approximately 8 points in the change from baseline on the AAQoL is a MCID.
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Affiliation(s)
- Yoko Tanaka
- 1 Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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Pozzi M, Carnovale C, Peeters GGAM, Gentili M, Antoniazzi S, Radice S, Clementi E, Nobile M. Adverse drug events related to mood and emotion in paediatric patients treated for ADHD: A meta-analysis. J Affect Disord 2018; 238:161-178. [PMID: 29883938 DOI: 10.1016/j.jad.2018.05.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 04/09/2018] [Accepted: 05/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND ADHD is frequently comorbid with anxiety and mood disorders, which may increase the severity of inattention and hyperactivity symptoms. Emotional symptoms (anxiety, irritability, mood lability) also affect patients without comorbidity or emerge as adverse drug events. The influence of ADHD drugs on emotional symptoms demands investigation to improve therapies. METHODS Systematic review of trials reporting adverse events in patients pharmacologically treated for ADHD. Meta-analysis of the occurrence of irritability, anxiety, apathy, reduced talk, sadness, crying, emotional lability, biting nails, staring, perseveration, euphoria. Meta-regression analysis. RESULTS Forty-five trials were meta-analysed. The most frequently reported outcomes were irritability, anxiety, sadness, and apathy. Methylphenidates, especially immediate-release formulations, were most studied; amphetamines were half as studied and were predominantly mixed amphetamine salts. Reports on atomoxetine were scant. Meta-analysis showed that methylphenidates reduced the risk of irritability, anxiety, euphoria, whereas they worsened the risk of apathy and reduced talk; amphetamines worsened the risk of emotional lability. Factors influencing risks were study year and design, patients' sex and age, drug dose and release formulation. LIMITATIONS Possible discrepancy between adverse events as indicated in clinical trials and as summarised herein. Confounding due to the aggregation of drugs into groups; uninvestigated sources of bias; incomplete lists of adverse events; lack of observations on self-injury. CONCLUSIONS Methylphenidates appeared safer than amphetamines, although younger patients and females may incur higher risks, especially with high-dose, immediate-release methylphenidates. Only atomoxetine holds a black-box warning, but amphetamines and methylphenidates also did not show a safe profile regarding mood and emotional symptoms.
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Affiliation(s)
- Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Gabriëlla G A M Peeters
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Marta Gentili
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Stefania Antoniazzi
- IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy
| | - Emilio Clementi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy; Unit of Clinical Pharmacology, CNR Institute of Neuroscience, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, 20157 Milan, Italy.
| | - Maria Nobile
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
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Faraone SV, Childress A, Wigal SB, Kollins SH, McDonnell MA, DeSousa NJ, Sallee FR. Reliability and Validity of the Daily Parent Rating of Evening and Morning Behavior Scale, Revised. J Atten Disord 2018; 22:1066-1073. [PMID: 26700792 DOI: 10.1177/1087054715619009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Children with ADHD frequently manifest behavioral difficulties in the morning prior to school. We sought to assess the reliability and validity of the Daily Parent Rating of Evening and Morning Behavior Scale, Revised (DPREMB-R) morning score as a measure of morning behaviors impaired by ADHD. METHOD We used data from a clinical trial of HLD200 treatment in pediatric participants with ADHD to address our objectives. RESULTS The DPREMB-R morning score showed significant internal homogeneity, test-retest reliability ( r = .52-.45), and good concurrent validity ( r = .50-.71). CONCLUSION The DPREMB-R morning score could be a useful instrument for assessing treatment efficacy in the morning before school.
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Affiliation(s)
| | - Ann Childress
- 2 Center for Psychiatry and Behavioral Medicine, Inc., Las Vegas, NV, USA
| | | | | | | | - Norberto J DeSousa
- 6 Ironshore Pharmaceuticals & Development, Inc., Grand Cayman, Cayman Islands
| | - F Randy Sallee
- 6 Ironshore Pharmaceuticals & Development, Inc., Grand Cayman, Cayman Islands
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Abstract
For children and adolescents with uncomplicated psychiatric disorders, pediatricians are often the first prescriber of psychiatric medications. Mental health disorders commonly treated by pediatricians include attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety. There are several safe and effective first-line medications for these disorders. For ADHD, stimulants and nonstimulants can be used as first-line interventions. For anxiety and depression, selective serotonin reuptake inhibitors are well-established treatments and often well-tolerated. With appropriate support and training, pediatricians can increase access for children to necessary mental health treatments. [Pediatr Ann. 2018;47(8):e311-e316.].
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Vafaei A, Vafaei I, Noorazar G, Akbarzadeh R, Erfanparast L, Shirazi S. Comparison of the effect of pharmacotherapy and neuro-feedback therapy on oral health of children with attention deficit hyperactivity disorder. J Clin Exp Dent 2018; 10:e306-e311. [PMID: 29750089 PMCID: PMC5937964 DOI: 10.4317/jced.54586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 02/17/2018] [Indexed: 12/24/2022] Open
Abstract
Background Attention deficit hyperactivity disorder (ADHD) is a chronic and progressive mental disorder related to the childhood period. This study aims to compare the oral health of two groups of ADHD children: those under pharmacotherapy and those under neuro-feedback therapy. Material and Methods 72 ADHD children (aged 6-12) were divided into two 36 member groups: The pharmacotherapy group and the neuro-feedback therapy group. Unstimulated salivary flow (USF), DMFT, and plaque index were assessed in these children. Statistical analysis was carried out on the data with the independent t-test, which was performed using SPSS 16. The significance level of the study was p<0.05. Results In this study, the USF of ADHD children who used Ritalin was found to be significantly less than that of the neuro-feedback group (1.25 ± 1.21 vs. 1.91 ± 1.16 ml/min; p=0.002). Also, the plaque index (5.9 ± 3.1 vs. 3.94 ± 1.9; p=0.018) and DMFT scores (39% ± 9% vs. 31% ± 9%; p=0.018) were significantly higher for the pharmacotherapy group. Conclusions Neuro-feedback therapy is preferable to Ritalin treatment for ADHD children in terms of their oral health status. Key words:Attention deficit hyperactivity disorder, drug therapy, neurofeedback, oral health.
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Affiliation(s)
- Ali Vafaei
- Assistant Professor, Department of Pediatric Dentistry, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Iman Vafaei
- Postgraduate student, Department of Pediatrics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Gholamreza Noorazar
- Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rafegh Akbarzadeh
- Student, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Erfanparast
- Associate Professor, Department of Pediatric Dentistry, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sajjad Shirazi
- Lecturer and Researcher, Dental and Periodontal Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Molife C, Haynes VS, Nyhuis A, Faries DE, Gelwicks S, Kelsey DK, Alatorre CI. Healthcare utilization and costs of children with attention deficit/hyperactivity disorder initiating atomoxetine versus extended-release guanfacine. Curr Med Res Opin 2018; 34:619-632. [PMID: 29298540 DOI: 10.1080/03007995.2017.1421918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To compare 1-year direct healthcare costs and utilization among children and adolescents initiating non-stimulant medications atomoxetine (ATX) or extended-release guanfacine (GXR). METHODS In this retrospective, observational cohort study, children and adolescents aged 6-17 years with attention deficit/hyperactivity disorder (ADHD) who had ≥1 prescription claim for ATX or GXR between December 31, 2009 and January 1, 2011 were identified in the MarketScan Commercial or Multi-State Medicaid claims databases. The first claim was set as the index. Patients with no claims for other ADHD medications that overlapped with the days' supply for the index therapy during the post-period were classified as initiating monotherapy. All-cause and ADHD-related utilization and costs (2011 US$) and treatment patterns (adherence and persistence) were evaluated during the 12 months following index. Propensity score adjustment accounted for differences in patient characteristics, and bootstrapping was used for comparisons. RESULTS A total of 13,239 children and adolescents with ADHD met the study criteria (4,411 ATX initiators and 8,828 GXR initiators). There were 2,699 ATX monotherapy patients. In propensity-score-adjusted analyses, mean all-cause total costs were significantly less for monotherapy ATX initiators than for GXR initiators ($7,553 vs $10,639; difference = -$3,086, p < .0001), as were mean ADHD-related total costs ($3,213 vs $4,544; difference = -$1,330, p < .0001). Monotherapy ATX initiators had significantly fewer all-cause and ADHD-related total medical visits and ∼22 days shorter persistence to index therapy (p < .0001). Results were similar for secondary analyses comparing all ATX with all GXR initiators, regardless of monotherapy or combination regimen, and comparing only monotherapy initiators. CONCLUSIONS Children and adolescents with ADHD who initiated ATX monotherapy incurred lower all-cause and ADHD-related total healthcare costs than patients who initiated GXR. This was due in part to less healthcare resource utilization and slightly shorter persistence for ATX patients. These findings may aid decision-making and inform future studies, but must be tempered due to inherent observational research limitations.
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Affiliation(s)
- Cliff Molife
- a Eli Lilly and Company - Global Patient Outcomes and Real World Evidence , Lilly Corporate Center , Indianapolis , IN , USA
| | - Virginia S Haynes
- b Eli Lilly and Company - Health Outcomes , Lilly Corporate Center , Indianapolis , IN , USA
| | - Allen Nyhuis
- c Eli Lilly and Company , Lilly Corporate Center , Indianapolis , IN , USA
| | - Douglas E Faries
- b Eli Lilly and Company - Health Outcomes , Lilly Corporate Center , Indianapolis , IN , USA
| | - Steve Gelwicks
- b Eli Lilly and Company - Health Outcomes , Lilly Corporate Center , Indianapolis , IN , USA
| | | | - Carlos I Alatorre
- b Eli Lilly and Company - Health Outcomes , Lilly Corporate Center , Indianapolis , IN , USA
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Cornu C, Mercier C, Ginhoux T, Masson S, Mouchet J, Nony P, Kassai B, Laudy V, Berquin P, Franc N, Le Heuzey MF, Desombre H, Revol O. A double-blind placebo-controlled randomised trial of omega-3 supplementation in children with moderate ADHD symptoms. Eur Child Adolesc Psychiatry 2018; 27:377-384. [PMID: 28993963 DOI: 10.1007/s00787-017-1058-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Clinical trials and inconclusive meta-analyses have investigated the effects of omega-3 supplements in children with Attention-Deficit Hyperactivity Disorder (ADHD). We performed a randomised placebo-controlled trial to evaluate the efficacy of omega-3 fatty acids. METHODS Children aged 6-15 years with established diagnosis of ADHD were randomised 1:1 to receive either supplements containing docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) or a placebo for 3 months. Psychotropic or omega-3-containing treatments were not authorised during the study. The primary outcome was the change in the Attention-Deficit Hyperactivity Disorder Rating Scale version 4 (ADHD-RS-IV). Other outcomes included safety, lexical level (Alouette test), attention (Test of Attentional Performance for Children-KiTAP), anxiety (48-item Conners Parent Rating Scale-Revised-CPRS-R), and depression (Children's Depression Inventory-CDI). RESULTS Between 2009 and 2011, 162 children were included in five French child psychiatry centres. The mean age was 9.90 (SD 2.62) years and 78.4% were boys. The inclusion ADHD-RS-IV at was 37.31 (SD 8.40). The total ADHD-RS-IV score reduction was greater in the placebo group than in the DHA-EPA group: -19 (-26, -12) % and -9.7 (-16.6, -2.9) %, respectively, p = 0.039. The other components of the Conners score had a similar variation but the differences between groups were not significant. Two patients in the DHA-EPA group and none in the placebo group experienced a severe adverse event (hospitalisation for worsening ADHD symptoms). CONCLUSION This study did not show any beneficial effect of omega-3 supplement in children with mild ADHD symptoms.
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Affiliation(s)
- Catherine Cornu
- INSERM, CIC1407, 69500, Bron, France. .,Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Equipe EME, 69100, Lyon, France. .,Service de Pharmacologie Clinique, Hospices Civils de Lyon, 69500, Bron, France. .,Centre d'Investigation Clinique - Hôpital Louis Pradel, 28, Avenue du Doyen Lépine, 69500, Bron, France.
| | - Catherine Mercier
- Université Claude Bernard Lyon 1, 69100, Lyon, France.,Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, 69003, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, CNRS, UMR 5558, 69100, Villeurbanne, France
| | | | | | - Julie Mouchet
- Université Claude Bernard Lyon 1, 69100, Lyon, France
| | - Patrice Nony
- Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Equipe EME, 69100, Lyon, France.,Service de Pharmacologie Clinique, Hospices Civils de Lyon, 69500, Bron, France
| | - Behrouz Kassai
- INSERM, CIC1407, 69500, Bron, France.,Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Equipe EME, 69100, Lyon, France.,Service de Pharmacologie Clinique, Hospices Civils de Lyon, 69500, Bron, France
| | | | - Patrick Berquin
- Service de Neurologie Pédiatrique, Hôpital Nord, 80054, Amiens, France
| | - Nathalie Franc
- Service de Médecine Psychologique Enfants et Adolescents, Hôpital Saint-Eloi, 34295, Montpellier, France
| | - Marie-France Le Heuzey
- Service de psychiatrie de l'enfant et de l'adolescent, Hôpital Robert Debré, 75935, Paris, France
| | - Hugues Desombre
- Unité de Psychologie Médicale et de Liaison, Hôpital femme-Mère-Enfant, 69500, Bron, France
| | - Olivier Revol
- Service de Psychopathologie de l'enfant et de l'adolescent, Hôpital Pierre Wertheimer, 69500, Bron, France
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Abosi O, Lopes S, Schmitz S, Fiedorowicz JG. Cardiometabolic effects of psychotropic medications. Horm Mol Biol Clin Investig 2018; 36:hmbci-2017-0065. [PMID: 29320364 DOI: 10.1515/hmbci-2017-0065] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/18/2017] [Indexed: 12/27/2022]
Abstract
Background Many psychiatric disorders including schizophrenia, bipolar disorder and major depression convey an excess burden of cardiovascular morbidity and mortality. The medications used to treat these conditions may further adversely affect cardiovascular risk and exacerbate health disparities for vulnerable populations. There is a clinical need to appreciate the cardiometabolic adverse effects of psychotropic medications. Methods This paper reviews the most relevant cardiometabolic effects of psychotropic medications, organized around the components of metabolic syndrome. When known, the molecular and physiological mechanisms underlying any adverse cardiometabolic effects are detailed. Results Many commonly used psychotropic medications, particularly antipsychotics, mood stabilizers and some antidepressants, have been independently associated with cardiometabolic risk factors such as insulin resistance, obesity and dyslipidemia. Stimulants, antidepressants that inhibit reuptake of norepinephrine, some antipsychotics and valproic acid derivatives may also increase blood pressure. Conclusion Understanding, assessing and subsequently managing cardiometabolic complications of psychotropic medications are important to mitigate the excess cardiovascular morbidity and mortality in the clinical populations prescribed psychotropic medications. There is considerable variability in risk between medications and individuals. Timely management of iatrogenic cardiometabolic effects is critical.
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Affiliation(s)
- Oluchi Abosi
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA
| | - Sneha Lopes
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA
| | - Samantha Schmitz
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA.,Department of Epidemiology College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Jess G Fiedorowicz
- Department of Epidemiology College of Public Health, The University of Iowa, Iowa City, IA, USA.,Department of Psychiatry, The University of Iowa, 200 Hawkins Drive, W278 GH, Iowa City, IA 52242, USA, Phone: +319-384-9267.,Department of Internal Medicine, The University of Iowa, Iowa City, IA, USA.,François M. Abboud Cardiovascular Research Center, The University of Iowa, Iowa City, IA, USA.,Iowa Neuroscience Institute, The University of Iowa, Iowa City, IA, USA.,Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA, USA
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Abstract
SummaryPsychiatry uses some of the most controversial treatments in medicine. This may be partly because several are administered under coercion and opposed to the patient's expressed will, under the protection of the relevant mental health legislation. Electroconvulsive therapy (ECT) is perhaps the archetypal controversial treatment; although it is considered to be effective, the research supporting it is much less impressive than one would expect. The prescription of stimulant drugs for childhood attention-deficit hyperactivity disorder (ADHD) and substitution therapy (such as methadone maintenance) in addictions treatment remain topical and appear to be subject to political interference. ‘Treatment’ for homosexuality and psychosurgery were common in the past but are now rare. These issues are discussed to give insight into how once common controversial treatments can decline and become obsolete. However, seclusion and covert medication remain in practice and are highly scrutinised.Learning Objectives• Recognise that many controversial treatments, such as psychosurgery, have been superseded by psychotropic drugs used since the 1950s• Be aware of the limitations of evidence supporting controversial treatments, such as stimulants for childhood ADHD and ECT for depression in adults• Be aware that controversial treatments are highly emotive and may be viewed negatively by the public or politicians, despite evidence for their safety and effectiveness
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Causal Role of Noradrenaline in the Timing of Internally Generated Saccades in Monkeys. Neuroscience 2017; 366:15-22. [DOI: 10.1016/j.neuroscience.2017.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 09/27/2017] [Accepted: 10/02/2017] [Indexed: 01/31/2023]
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Shafrin J, Shrestha A, Chandra A, Erder MH, Sikirica V. Evaluating Matching-Adjusted Indirect Comparisons in Practice: A Case Study of Patients with Attention-Deficit/Hyperactivity Disorder. HEALTH ECONOMICS 2017; 26:1459-1466. [PMID: 27620206 DOI: 10.1002/hec.3408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 06/10/2016] [Accepted: 08/11/2016] [Indexed: 06/06/2023]
Abstract
Differences in patient characteristics across trials may bias efficacy estimates from indirect treatment comparisons. To address this issue, matching-adjusted indirect comparison (MAIC) measures treatment efficacy after weighting individual patient data to match patient characteristics across trials. To date, however, there is no consensus on how best to implement MAIC. To address this issue, we applied MAIC to measure how two attention-deficit/hyperactivity disorder (ADHD) treatments (guanfacine extended release and atomoxetine hydrochloride) affect patients' ADHD symptoms, as measured by the ADHD Rating Scale IV score. We tested MAIC sensitivity to: matched patient characteristics, matched statistical moments, weighting matrix, and placebo-arm matching (i.e., matching on outcomes in the placebo arm). After applying MAIC, guanfacine and atomoxetine had similar reductions in ADHD symptoms (Δ: 0.4, p < 0.737). The results were similar for three of four sensitivity analyses. When we applied MAIC with placebo-arm matching, however, guanfacine reduced symptoms more than atomoxetine (Δ: -3.9, p < 0.004). We discuss the implication of this finding and advise MAIC practitioners to carefully consider the use of placebo-arm matching, depending on the presence of residual confounding across trials. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | | | - Amitabh Chandra
- John F. Kennedy School of Government, Harvard University, Cambridge, MA, USA
| | - M Haim Erder
- Global Health Economics and Outcomes Research and Epidemiology, Shire, Wayne, PA, USA
| | - Vanja Sikirica
- Global Health Economics and Outcomes Research and Epidemiology, Shire, Wayne, PA, USA
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Faraone SV, Schachar RJ, Barkley RA, Nullmeier R, Sallee FR. Early Morning Functional Impairments in Stimulant-Treated Children with Attention-Deficit/Hyperactivity Disorder Versus Controls: Impact on the Family. J Child Adolesc Psychopharmacol 2017; 27:715-722. [PMID: 28394175 PMCID: PMC5651955 DOI: 10.1089/cap.2016.0164] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Children with attention-deficit/hyperactivity disorder (ADHD) frequently manifest early morning functional (EMF) impairments before school. We conducted a quantitative research survey to assess the impact of these EMF impairments on the family unit (caregiver, spouse/partner, and siblings). STUDY DESIGN We developed an online survey questionnaire to collect data from 300 primary caregivers of children with ADHD and 50 primary caregivers of children who did not have ADHD. RESULTS Although the ADHD children we surveyed were currently treated with stable doses of stimulants as their primary ADHD medication for at least 3 months, their parents reported high levels of EMF impairments in the child, which had a substantial negative effect on the emotional well-being of parents, on parents' functioning during the early morning routine, and on the level of conflict with siblings. The impact of EMF impairments on family functioning was mediated by the severity of the index child's impairments. CONCLUSIONS EMF impairments exert a pervasive and significantly negative emotional and functional burden on not only the primary caregiver but also on the spouse/partner and siblings. This work suggests that adequate ADHD symptom control during the early morning period may be an unmet need for school-age children with ADHD being treated with stimulants. More work is needed to confirm this finding and determine the degree to which symptom control at other times of day is also an unmet need.
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Affiliation(s)
- Stephen V. Faraone
- Departments of Psychiatry and Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, New York
| | - Russell J. Schachar
- Department of Psychiatry and Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Russell A. Barkley
- Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina
| | - Rick Nullmeier
- Ironshore Pharmaceuticals & Development, Inc., Camana Bay, Grand Cayman, Cayman Islands
| | - F. Randy Sallee
- Ironshore Pharmaceuticals & Development, Inc., Camana Bay, Grand Cayman, Cayman Islands
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42
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Abstract
INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) is a complex neurobehavioral disorder affecting millions of patients worldwide. Effective treatments have been available for more than 60 years in the form of immediate-release (IR) stimulants However, stimulants have a high risk for abuse and are associated with adverse effects Including elevated blood pressure and heart rate, insomnia and decreased appetite. IR formulations also require multiple daily dosing. The search for improved safety, tolerability and convenience has led to the development of multiple extended-release (ER) stimulant and non-stimulant formulations. Areas covered: Adverse effects of (ER) products including amphetamine, methylphenidate, clonidine and guanfacine will be reviewed and their significance discussed. Expert opinion: Limitations of currently marketed medications have led to the search for drugs with efficacy comparable to ER stimulants and a more favorable adverse event profile. Several are in development, but their potential utility is not yet known. Current research is also focused on finding specific genetic defects in patients with ADHD. Exciting progress has been made with the identification of mGluR receptor defects in some patients. However because of the heterogeneity of the disorder, effective targeted treatments for the majority of patients with ADHD does not appear likely in the near future.
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Affiliation(s)
- Ann Childress
- a Center for Psychiatry and Behavioral Medicine, Inc ., 7351 Prairie Falcon Road, Las Vegas , Nevada , United States
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Kim HW, Kim E, Kim JH, Park J, Bahn GH, Lee YJ, Jhung K, Shin D. The Revised Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder (III) - Pharmacological Treatment -. Soa Chongsonyon Chongsin Uihak 2017. [DOI: 10.5765/jkacap.2017.28.2.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Hyo-Won Kim
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Eunjoo Kim
- Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Ji-Hoon Kim
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Korea
| | - Jangho Park
- Department of Psychiatry, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Geon Ho Bahn
- Department of Psychiatry, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yeon Jung Lee
- Department of Psychiatry, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Kyungun Jhung
- Department of Psychiatry, International St. Mary’s Hospital, Catholic Kwandong University, Incheon, Korea
| | - Dongwon Shin
- Department of Psychiatry, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
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Gayleard JL, Mychailyszyn MP. Atomoxetine treatment for children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): a comprehensive meta-analysis of outcomes on parent-rated core symptomatology. ACTA ACUST UNITED AC 2017; 9:149-160. [PMID: 28110366 DOI: 10.1007/s12402-017-0216-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 08/08/2015] [Indexed: 11/24/2022]
Abstract
Attention-Deficit/Hyperactivity Disorder (ADHD) impacts a significant number of children and adolescents and often leads to deleterious functional impairment. Psychostimulant medication has historically been the first line of pharmacological intervention, though recent years have seen greater attention paid to non-stimulant alternatives. The objective of the present study was to conduct the most comprehensive meta-analysis to date evaluating the efficacy of atomoxetine in reducing core symptomatology of ADHD according to parent report. Selection criteria were applied, and studies were located by searching electronic databases, review of reference sections, and contact with expert researchers; article searching began on 10/01/2013, and the final search was conducted on 09/01/2014. A total of 42 studies met inclusion criteria-33 with control groups and 9 without-for a total sample of 8398 individuals. For those receiving atomoxetine, the summary pre-post (e.g., standardized mean gain) effect size estimate was 1.37 (95% CI [1.24, 1.51], p < .001); atomoxetine was found to statistically significantly outperform control conditions overall (Z = 4.07, p < .001), though results differed by the type of control group; for instance, when comparing atomoxetine to alternative medications as controls, significant differences were no longer present. The non-stimulant atomoxetine led to significant improvement in core ADHD symptomatology and should be considered as a viable pharmacological treatment option for ADHD.
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Affiliation(s)
- Jessica L Gayleard
- Department of Psychology, Towson University, 8000 York Road, Towson, MD, 21252, USA
| | - Matthew P Mychailyszyn
- Department of Psychology, Towson University, 8000 York Road, Towson, MD, 21252, USA. .,Division of Psychology and Neuropsychology, Mt. Washington Pediatric Hospital, Baltimore, MD, USA.
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45
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Sieluk J, Palasik B, dosReis S, Doshi P. ADHD medications and cardiovascular adverse events in children and adolescents: cross-national comparison of risk communication in drug labeling. Pharmacoepidemiol Drug Saf 2017; 26:274-284. [PMID: 28083936 DOI: 10.1002/pds.4164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/02/2016] [Accepted: 12/13/2016] [Indexed: 11/06/2022]
Abstract
PURPOSE Regulators approve written medical information for healthcare professionals and consumers, but the consistency of these sources has not been studied. We investigated the consistency of information regarding four cardiovascular risks of attention-deficit/hyperactivity disorder (ADHD) medications approved in four countries. METHODS Professional and consumer product labeling for five ADHD medications approved in Australia, Canada, the UK, and the USA were obtained in March/April 2016. Language describing the relationship between medication and elevated blood pressure and/or heart rate, myocardial infarction, stroke, and sudden death was extracted verbatim and classified into one of four categories based on the described relationship between medication and adverse event: "confirmed," "unconfirmed," "mixed," and "not mentioned." We judged the consistency of messages delivered to healthcare professionals and consumers as either "consistent" or "inconsistent." RESULTS We obtained 20 healthcare professional labels and 20 corresponding consumer labels for the five ADHD medications registered in all four countries. Not all professional and consumer labeling contained language regarding all four adverse events. Of the 80 theoretically evaluable drug-risk pairs, 38 (48%) were not evaluable because of absence of mention of the adverse event in the consumer label. For the remaining 42, the potential causal relationship was expressed consistently in professional and consumer labeling in 25 (60%) cases. The cardiovascular risk profile was not described consistently across all four countries for any of the five drugs. CONCLUSIONS Product labeling provides healthcare professionals and consumers with inconsistent messages regarding the potential causal relationship between stimulant use and specific cardiovascular risks in children and adolescents. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jan Sieluk
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Brittany Palasik
- University of Utah Hospitals and Clinics, Salt Lake City, UT, USA
| | - Susan dosReis
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Peter Doshi
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Comparative efficacy and safety of attention-deficit/hyperactivity disorder pharmacotherapies, including guanfacine extended release: a mixed treatment comparison. Eur Child Adolesc Psychiatry 2017; 26:875-897. [PMID: 28258319 PMCID: PMC5532417 DOI: 10.1007/s00787-017-0962-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 02/13/2017] [Indexed: 10/29/2022]
Abstract
This study compared the clinical efficacy and safety of attention-deficit/hyperactivity disorder (ADHD) pharmacotherapy in children and adolescents 6-17 years of age. A systematic literature review was conducted to identify randomized controlled trials (RCTs) of pharmacologic monotherapies among children and adolescents with ADHD. A Bayesian network meta-analysis was conducted to compare change in symptoms using the ADHD Rating Scale Version IV (ADHD-RS-IV), Clinical Global Impression-Improvement (CGI-I) response, all-cause discontinuation, and adverse event-related discontinuation. Thirty-six RCTs were included in the analysis. The mean (95% credible interval [CrI]) ADHD-RS-IV total score change from baseline (active minus placebo) was -14.98 (-17.14, -12.80) for lisdexamfetamine dimesylate (LDX), -9.33 (-11.63, -7.04) for methylphenidate (MPH) extended release, -8.68 (-10.63, -6.72) for guanfacine extended release (GXR), and -6.88 (-8.22, -5.49) for atomoxetine (ATX); data were unavailable for MPH immediate release. The relative risk (95% CrI) for CGI-I response (active versus placebo) was 2.56 (2.21, 2.91) for LDX, 2.13 (1.70, 2.54) for MPH extended release, 1.94 (1.59, 2.29) for GXR, 1.77 (1.31, 2.26) for ATX, and 1.62 (1.05, 2.17) for MPH immediate release. Among non-stimulant pharmacotherapies, GXR was more effective than ATX when comparing ADHD-RS-IV total score change (with a posterior probability of 93.91%) and CGI-I response (posterior probability 76.13%). This study found that LDX had greater efficacy than GXR, ATX, and MPH in the treatment of children and adolescents with ADHD. GXR had a high posterior probability of being more efficacious than ATX, although their CrIs overlapped.
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Benn A, Robinson ESJ. Differential roles for cortical versus sub-cortical noradrenaline and modulation of impulsivity in the rat. Psychopharmacology (Berl) 2017; 234:255-266. [PMID: 27744551 PMCID: PMC5203835 DOI: 10.1007/s00213-016-4458-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 10/03/2016] [Indexed: 12/31/2022]
Abstract
RATIONALE Atomoxetine is a noradrenaline re-uptake inhibitor licensed for the treatment of adult and childhood attention deficit hyperactivity disorder. Although atomoxetine has established efficacy, the mechanisms which mediate its effects are not well understood. OBJECTIVES In this study, we investigated the role of cortical versus sub-cortical noradrenaline by using focal dopamine beta hydroxylase-saporin-induced lesions, to the prefrontal cortex (n = 16) or nucleus accumbens shell (n = 18). METHODS Healthy animals were tested by using the forced-choice serial reaction time task to assess the impact of the lesion on baseline performance and the response to atomoxetine and the psychostimulant amphetamine. RESULTS We observed attenuation in the efficacy of atomoxetine in animals with lesions to the nucleus accumbens shell, but not the prefrontal cortex. Amphetamine-induced increases in premature responses were potentiated in animals with lesions to the prefrontal cortex, but not the nucleus accumbens shell. CONCLUSIONS These data suggest that noradrenaline in the nucleus accumbens shell plays an important role in the effects of atomoxetine. Under these conditions, prefrontal cortex noradrenaline did not appear to contribute to atomoxetine's effects suggesting a lack of cortical-mediated "top-down" modulation. Noradrenaline in the prefrontal cortex appears to contribute to the modulation of impulsive responding in amphetamine-treated animals, with a loss of noradrenaline associated with potentiation of its effects. These data demonstrate a potential dissociation between cortical and sub-cortical noradrenergic mechanisms and impulse control in terms of the actions of atomoxetine and amphetamine.
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Affiliation(s)
- Abigail Benn
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Biomedical Sciences Building, University Walk, Bristol, BS8 1TD, UK
| | - Emma S J Robinson
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Biomedical Sciences Building, University Walk, Bristol, BS8 1TD, UK.
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48
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Luan R, Mu Z, Yue F, He S. Efficacy and Tolerability of Different Interventions in Children and Adolescents with Attention Deficit Hyperactivity Disorder. Front Psychiatry 2017; 8:229. [PMID: 29180967 PMCID: PMC5694170 DOI: 10.3389/fpsyt.2017.00229] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 10/25/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Our study is an analysis of multiple publications involving assessing the comparable efficacy and tolerability of six interventions, which are lisdexamfetamine dimesylate (LDX), atomoxetine (ATX), methylphenidate (MPH), clonidine hydrochloride (CLON), guanfacine extended release (GXR), and bupropion, for young patients (6-18 years old) suffering from attention deficit hyperactivity disorder (ADHD). METHODS A conventional meta-analysis (MA) was performed to give direct comparisons and a network meta-analysis (NMA) was used to show the combination of direct and indirect evidence. Ranking preference for all the interventions under a certain outcome was given by the surface of cumulative ranking curve area (SUCRA). RESULTS Overall, 15,025 participants from 73 studies were involved in our analysis. In the pairwise MA, LDX was associated with less withdrawal than ATX for lack of efficacy. MPH showed less effectiveness than LDX according to ADHD Rating Scale score. Based on the analysis of our NMA, significant results of efficacy that LDX is a competitive drug were observed when evaluating LDX in comparison with other drugs except for CLON. ATX and GXR presented higher rates of abdominal pain morbidity versus inactive treatment. CONCLUSION The stimulants LDX and MPH are still highly recommended because they are highly effective and are tolerated well by patients. Among the non-stimulants, CLON can be taken into consideration for its appreciable effectiveness and tolerability. ATX and GXR can be seen as moderate choices.
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Affiliation(s)
- Ruiling Luan
- Department of Pharmacy, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Zhiling Mu
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Fang Yue
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shaoying He
- Department of Pediatrics, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
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Lee S, Choi JW, Kim KM, Kim JW, Kim S, Kang T, Kim JI, Lee YS, Kim B, Han DH, Cheong JH, Lee SI, Hyun GJ, Kim BN. The Guideline of Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder: Developed by ADHD Translational Research Center. Soa Chongsonyon Chongsin Uihak 2016. [DOI: 10.5765/jkacap.2016.27.4.236] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sumin Lee
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Won Choi
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung-Min Kim
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Sooyeon Kim
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | | | - Johanna Inhyang Kim
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Young Sik Lee
- Department of Psychiatry, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Bongseog Kim
- Department of Psychiatry, Sanggye Paik Hospital, School of Medicine, Inje University, Seoul, Korea
| | - Doug Hyun Han
- Department of Psychiatry, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Jae Hoon Cheong
- Uimyung Research Institute for Neuroscience, Sahmyook University, Seoul, Korea
| | - Soyoung Irene Lee
- Department of Psychiatry, Soonchunhyang University College of Medicine, Bucheon Hospital, Bucheon, Korea
| | - Gi Jung Hyun
- Department of Psychiatry, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Bung-Nyun Kim
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
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50
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Mohammadpour N, Jazayeri S, Tehrani-Doost M, Djalali M, Hosseini M, Effatpanah M, Davari-Ashtiani R, Karami E. Effect of vitamin D supplementation as adjunctive therapy to methylphenidate on ADHD symptoms: A randomized, double blind, placebo-controlled trial. Nutr Neurosci 2016; 21:202-209. [PMID: 27924679 DOI: 10.1080/1028415x.2016.1262097] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Previous studies have shown that serum levels of vitamin D were lower in attention deficit hyperactivity disorder (ADHD) children compared to healthy controls. The aim of the study was to determine the effect of vitamin D supplementation as adjunctive therapy to methylphenidate on symptoms of children with ADHD. METHODS Sixty-two children aged 5-12 years with a diagnosis of ADHD based on DSM-IV criteria were randomly assigned into two groups to receive either 2000IU vitamin D or placebo in addition to methylphenidate for 8 weeks. Symptoms severity was assessed by Conner's Parent Rating Scale-Revised[S] (CPRS), ADHD rating scale-IV (ADHD-RS), and Weekly Parent Ratings of Evening and Morning Behavior (WPREMB) at weeks 0, 4, and 8. Serum levels of 25(OH)D were measured at baseline and after 8 weeks. Anthropometric variables, dietary intake, physical activity, sun exposure, and side effects were assessed. RESULTS Fifty-four participants completed the trial. After 8 weeks of supplementation, serum levels of 25(OH)D significantly increased in the vitamin D group. ADHD symptoms decreased significantly in both groups (P < 0.05). Evening symptoms and total score of WPREMB scale were significantly different at weeks 4 and 8 between the two groups (P = 0.013, 0.016, respectively), but no differences were found in symptoms by CPRS and ADHD-RS scales. DISCUSSION Vitamin D supplementation as adjunctive therapy to methylphenidate improved ADHD evening symptoms. Future research is needed to clarify vitamin D effects as monotherapy in ADHD and its mechanism. The trial was registered in www.irct.ir is (IRCT201404222394N10).
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Affiliation(s)
- Nakisa Mohammadpour
- a Department of Clinical Nutrition , School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences , Tehran , Iran
| | - Shima Jazayeri
- b Pediatric Growth and Development Research Center , Institute of Endocrinology and Metabolism, Iran University of Medical Sciences , Tehran , Iran.,c Department of Nutrition , School of Public Health, Iran University of Medical Sciences , Tehran , Iran
| | - Mehdi Tehrani-Doost
- d Department of Psychiatry, Roozbeh Hospital , Tehran University of Medical Sciences , Iran
| | - Mahmoud Djalali
- e Department of Cellular and Molecular Nutrition , School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences , Tehran , Iran
| | - Mostafa Hosseini
- f Department of Epidemiology and Biostatistics , School of Public Health, Tehran University of Medical Sciences , Tehran , Iran
| | - Mohammad Effatpanah
- g Ziaean Hospital, School of Medicine, International Campus , Tehran University of Medical Sciences , Tehran , Iran
| | - Rozita Davari-Ashtiani
- h Behavioral Sciences Research Center, Imam Hossein Hospital , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Elham Karami
- a Department of Clinical Nutrition , School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences , Tehran , Iran
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