Q&A: ADHD expert offers clinical guidance on prescribing stimulants
ADHD is marked by a pattern of inattention and/or hyperactivity-impulsivity that affects daily functioning. According to data from the National Comorbidity Survey Replication, the overall prevalence of adult ADHD in the U.S. is 4.4%, and the estimated lifetime prevalence among those aged 18 to 44 years is 8.1%.
Diagnosing, and subsequently treating, adult ADHD requires a multifaceted approach that includes a thorough evaluation, consideration of cooccurring conditions, patient education and weighing of risks and benefits of treatment with stimulants on a case-by-case basis.
Healio Psychiatry spoke with Anthony L. Rostain, MD, professor of psychiatry at the Hospital of the University of Pennsylvania and the Children's Hospital of Philadelphia, for clinical guidance on the who, what, when and how of prescribing stimulants. – by Stacey L. Adams
What does the patient profile of adult ADHD look like?
In addition to meeting the criteria for ADHD, symptoms of the disorder have to have been present since childhood to some extent; it does not have to have been diagnosed in childhood, but ADHD is not something a patient will have developed in the last year. Plus, there needs to have been impairment as result of the difficulty, especially in adulthood. In other words, it must be causing a problem with achieving some occupational, familial or self-care obligations or expectations.
The patient can be male or female, college aged or even someone in their later years. We see ADHD in elderly patients, but in that population, you need to be sure it’s not a sign of the onset of dementia.
For women in menopause, many of complain of attentional difficulties; they could very well benefit from a stimulant medication. There is a category called ADHD unspecified, which applies to someone who does not have lifelong ADHD but, because a variety of circumstances, they are having most of the symptoms without the historical background. For example, a postmenopausal executive complains she can’t keep track of things anymore, she’s really disorganized and can’t focus. She might be diagnosed as ADHD unspecified type because she didn’t have it earlier — she may have had minimal difficulties, but the onset of menopause has really triggered a difficulty with functioning.
What things should a psychiatrist consider before starting a patient on stimulants ?
Before you start a patient on a stimulant, you must have a correct diagnosis of ADHD. This means you have completed a thorough evaluation and are certain that ADHD is the true diagnosis in order to reduce the potential for misuse or abuse of stimulants by people who are claiming they have ADHD but may not. Moreover, it needs to be clear that no other co-occurring conditions are interfering with the patient’s functioning, such as depression, anxiety, substance use or learning disabilities. There are certain people who are not suitable for stimulants, such as those with a history of stimulant abuse or misuse and/or substance use, or patients who may have bipolar disorder or another serious psychiatric illness that is not currently being adequately treated because there is a risk of using stimulants in these individuals.
You should not start a patient on a stimulant without providing ample psychoeducation about ADHD and looking at all the different reasons someone may or may not benefit from medication. You should also consider nonmedication approaches so that you are not just giving a prescription the first time you suspect ADHD. If you are convinced that the patient has ADHD and you’ve decided you’re going to start treating them pharmacologically, then they are a candidate for stimulant medication.
Another important component of the work up is to take a very careful medical history, which includes making sure the person doesn’t have any cardiac issues or family history of early death from heart disease or sudden death. You also want to make sure they’re sleeping and eating properly. Medical history should also include history of seizures, head trauma or concussions, and any other chronic illness that might be affecting the patient’s general health, such as autoimmune disorders and asthma.
You must find out what other medications they’re taking to avoid combining stimulants with another medication that could be stimulating or have cardiotoxicity. If they’re on a tricyclic antidepressant or Wellbutrin (bupropion hydrochloride, GlaxoSmithKline), you might want to be careful at that point.
Last but not least, a collateral informant should be interviewed using standardized scales and/or a conversation over the phone to validate the difficulties the patient is having. It should be someone who knows the patient in the here and now and could answer a set of questions relating to their symptoms and functional impact. Ideally, it would be someone who knew the patient as a child.
What are the treatment options?
For those reticent about taking a stimulant medication, or those who have had bad effects before, or for whom you are concerned about misuse, there are several non-stimulant options.
With respect to stimulants, the treatment options are methylphenidate long-acting compounds or amphetamine-based long-acting compounds.
There are two methylphenidate compounds FDA-approved for adult ADHD: One is a long-acting OROS compound (Concerta, Janssen) and the other is extended-release dexmethylphenidate (Focalin, Novartis). Concerta lasts somewhere around 9 to 12 hours and Focalin lasts anywhere from 7 to 8 hours. Because a patient’s metabolism determines how long the medication will last, I recommend using the patient’s body weight to determine whether to start at the lower or medium end of the dosing range approved by the FDA.
With respect to extended-release amphetamines, three are FDA-approved for adults: mixed amphetamine salts extended-release (Adderall, Shire), lisdexamfetamine dimesylate (Vyvanse, Shire) and mixed salts of a single-entity amphetamine product (Mydayis, Shire). Adderall XR lasts 7 to 8 hours, Vyvanse lasts 10 to 12 hours, and Mydayis lasts up to 16 hours.
I often suggest trying one product from each class of medication to see which one is better for the patient. Evidence shows that almost half of patients respond equally well to either one, but about one-fourth of patients respond better to one than the other. Given those uncertainties, it’s always good to start with one class and switch to the other if needed. It’s very important for people to know there are two different classes of medications available as one might be preferable to the other. Unfortunately, there’s no way to know which one works best ahead of time.
What are the risks associated with stimulant use?
Cardiac problems can be exacerbated by these medications, including chest pain, syncope, arrythmias – any of these problems need to be ruled out. Even if they are ruled out, the patient can still develop cardiac difficulties, so pulse rate, blood pressure and cardiovascular status must always be monitored carefully. You should also always be aware that stimulants can induce manic symptoms, so watch for mania and/or psychosis. Also, make sure you monitor for appetite and/or appetite suppression. These are not meant to be weight loss agents (even though some people may like that aspect) so watch for excessive weight loss. It’s helpful to instruct patients about how to eat without being hungry so a patient doesn’t become hypoglycemic throughout the day. Peripheral vascular problems like Reynaud’s syndrome develop in some people, so you have to watch for it. And for people with a history of seizures, stimulants can alter the seizure threshold.
Last but not least, it’s important to monitor interactions if the patient is on any other medications. If you’re already on an activating agent, you might have trouble falling asleep if you take a long-acting stimulant.
How should the clinician determine whether to continue a patient on stimulants?
The number one question is: Is it helping the patient/are they benefitting? Number two: Are they tolerating it? And number three: Is there any evidence that they are developing resistance or tolerance? If this is occurring, you need to ask yourself how much higher you can raise the dose before getting into a potentially toxic range. Some patients require greater than what the PDR lists, in which case I would consult with someone who’s experienced if there are questions. There’s often pushback from insurance, but between 10% to 15% of patients need higher than standard doses to maintain clinical response.
It is good medical practice to utilize a standardized way of measuring treatment effect. The starting dose might not be the right dose, so there should always be a stepwise increment in dosing in the initial 1 or 2 months until you find the optimized response on a standardized scale. Whatever ADHD scale you’re using should be filled out at each visit, so you can quantify the percent improvement in ADHD symptoms. In addition, there should be assessment of patient functional status. Whatever global functioning rating you’re giving that person, you want to see evidence that the functioning is improving. It might not improve right away, but hopefully over time, they’ll describe they’re doing better at work, getting along better with their family, or feeling more organized and able to take care of their daily needs than they were before. Fewer problems, more success, so to speak.
If medication should be discontinued, what's the best way?
It is fine to quickly discontinue a stimulant medication, since it is cleared from the brain and body by the end of the day. Thus, the patient can just stop at any given time. If they’ve been on it for a long time, the patient may feel a bit of withdrawal — similar to if you stop drinking coffee; they may be sleepier than usual, experience lethargy, feel less focused — but after 3 or 4 days that passes and they’re back to their baseline. If you’re concerned about whether they’re on the right dose, and/or you want to go down slowly, that’s fine too, but there’s no need to take weeks and weeks to discontinue, like with SSRIs.
What about misuse/abuse potential?
This is a serious concern. Cognitive enhancement occurs all the time – which I would call misuse rather than abuse. However, it is important to distinguish the two: Misuse is when you are taking a medication you were not prescribed but are taking it for generally reasons that are therapeutically indicated. For example, taking a stimulant even though the person does not have ADHD because it helps one to focus. Or, if someone has a prescription for a stimulant but is using it to stay up late at night.
Abuse occurs when a person is using the stimulant for purposes of reaching a state of euphoria, when it’s administered intranasally and/or if the patient is using mega doses. This is extremely concerning because when it is introduced nasally or via IV injection, you’re creating potential for physical problems like stroke and high blood pressure, and for psychosis and paranoia. Abuse is a real health emergency and requires intensive medical treatment.
Misuse is generally a different kettle of fish. Obviously, it is wrong, and we do not want to foster diversion or enable inappropriate distribution of stimulants. But if people are following the general guidelines they don’t need medical treatment, they just need to be given an ultimatum such as, “You’re breaking the law by doing this, and I’m not going to prescribe for you anymore.” You don’t need to worry about detoxing them.
In any case, prior to starting a stimulant you have to get an agreement from the patient that they are to use the medication as prescribed and are not to share it with anyone. If they do, it’s time to say, “I can’t keep prescribing for you; let’s deal with bigger issue here.”
Some red flags that might indicate a person isn’t using medication as prescribed include asking for early refills, wanting short-acting not long-acting formulations or going to multiple places or different doctors and getting more than one prescription at a time. We now have state surveillance systems in place, so I’m able to look on our Pennsylvania drug prescribing website to see how well patients have been following directions and whether they’re doctor shopping or filling excessive amounts of prescriptions.
Any other tips for clinicians?
Keep talking to the patient about how they’re using the medication and whether there are barriers to adherence. Are people forgetting? Are they feeling embarrassed? Are they worried about stigma? Are they afraid of becoming dependent? Always talk to patients about their own feelings about taking a medication. Most patients don’t want to be taking a medication or to be dependent on a medication, so reassuring them that at any point they decide they want to stop, it can be done. I can’t emphasize enough the shared decision making or collaborative problem-solving approach helps to ensure a good treatment alliance — that’s probably the best predictor of successful care in any field of medicine. Try to help patients set realistic goals of what they’re expecting of the medication because we’ve seen a lot of magical thinking that needs to be corrected. People come in and say, “This is going to help me straighten out my life,” and it doesn’t come that easily. You still have to work at improving yourself. The adage I always quote is “pills don’t teach skills” — pills help you learn, but you still have to work at making positive changes in coping with life.
National Institute of Mental Health. Attention-Deficit/Hyperactivity Disorder (ADHD). https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd.shtml. Last updated November 2017. Accessed July 11, 2018.
Disclosure: Rostain reports receiving scientific advisory board honoraria from Arbor, Ironshore and Shire.