Stimulant medication to treat attention-deficit/hyperactivity disorder
ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders with a prevalence of 3-4%. Methylphenidate has been used for treatment for over 50 years and is the most common drug treatment for the disorder. I want to add some points:
Despite the widespread use of stimulant medication, no comprehensive systematic review has been done of both benefits and harms. A Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials [1] showed that within the short follow-up periods (typical of the included trials), there is some evidence that methylphenidate is associated with increased risk of adverse events (sleep problems and decreased appetite), no evidence that it increases the risk of serious adverse events. But trials of long follow-up periods are missing. Another Cochrane systematic review evaluated the effects of methylphenidate in adults with ADHD (2). The effect sizes across the different assessments of symptoms were similar to the analyses of the first publication (standardised mean difference 0.60). The authors noted here again, that data on adverse events were limited by the short duration of the included trials.
Atomoxetine is a norepinephrine reuptake inhibitor which is approved for the treatment of attention deficit hyperactivity disorder. Atomoxetine also acts as an NMDA receptor antagonist: glutamatergic dysfunction may be central in etiology and pathophysiology of this disorder. Efficacy may be less than treatments with stimulants, but the important advantage is that atomoxetine does not have abuse liability. Unlike stimulants, atomoxetine can be abruptly stopped without significant discontinuation effects, it`s relatively non-toxic in overdose.
1) Storebø OJ et al. Methylphenidate for attention-deficit/hyperactivity disorder in children and adolescents: Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials BMJ 2015;351:h5203 2015; 351 doi: https://doi.org/10.1136/bmj.h5203 BMJ
2) Epstein T et al. Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2014 Sep 18;(9):CD005041. doi: 10.1002/14651858.CD005041.pub2.3)
Competing interests:
No competing interests
18 July 2017
Detlef Degner
senior consultant, Psychiatry
Department of Psychiatry, Medical School of Georg-August University, Goettingen
Rapid Response:
Stimulant medication to treat attention-deficit/hyperactivity disorder
ADHD is one of the most commonly diagnosed and treated childhood psychiatric disorders with a prevalence of 3-4%. Methylphenidate has been used for treatment for over 50 years and is the most common drug treatment for the disorder. I want to add some points:
Despite the widespread use of stimulant medication, no comprehensive systematic review has been done of both benefits and harms. A Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials [1] showed that within the short follow-up periods (typical of the included trials), there is some evidence that methylphenidate is associated with increased risk of adverse events (sleep problems and decreased appetite), no evidence that it increases the risk of serious adverse events. But trials of long follow-up periods are missing. Another Cochrane systematic review evaluated the effects of methylphenidate in adults with ADHD (2). The effect sizes across the different assessments of symptoms were similar to the analyses of the first publication (standardised mean difference 0.60). The authors noted here again, that data on adverse events were limited by the short duration of the included trials.
Atomoxetine is a norepinephrine reuptake inhibitor which is approved for the treatment of attention deficit hyperactivity disorder. Atomoxetine also acts as an NMDA receptor antagonist: glutamatergic dysfunction may be central in etiology and pathophysiology of this disorder. Efficacy may be less than treatments with stimulants, but the important advantage is that atomoxetine does not have abuse liability. Unlike stimulants, atomoxetine can be abruptly stopped without significant discontinuation effects, it`s relatively non-toxic in overdose.
1) Storebø OJ et al. Methylphenidate for attention-deficit/hyperactivity disorder in children and adolescents: Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials BMJ 2015;351:h5203 2015; 351 doi: https://doi.org/10.1136/bmj.h5203 BMJ
2) Epstein T et al. Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2014 Sep 18;(9):CD005041. doi: 10.1002/14651858.CD005041.pub2.3)
Competing interests: No competing interests