DRUGS FOR ADHD: ADOLESCENTS TO ADULTS

Transcription

1 DRUGS FOR ADHD: ADOLESCENTS TO ADULTS

2 DISCLOSURE Natasha Rodney-Cail, Pharmacist, Drug Evaluation Unit Has no conflicts of interest Dr. James Chandler, MD, FRCPC Has no conflicts of interest

3 STEVEN Age 18 Diagnosed with ADHD, combined type, at 8 years of age Taking Biphentin 50 mg OD, last 6 years Just started university and would like to stop his ADHD medication

4 SARAH 25 years old ADHD, combined type, diagnosed at age 16 Finished university, started work 2 years ago ADHD has not been re-evaluated as an adult Currently taking Foquest 70 mg OD

5 Ontario Drug Policy Research Network Treatments for Attention Deficit Hyperactivity Disorder in Adults Final Pharmacoepidemiology Report. Accessed September 14,

6 3 CORE SYMPTOMS Hyperactivity Inattention Impulsivity

7 Predominantly Inattentive Combined Inattention with hyperactivity Inattention without hyperactivity Predominantly Hyperactive-Impulsive Hyperactivity without inattention ADHD

8 Inattention remains Adults with ADHD are rarely hyperactive Hyperactivity may become restlessness

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10 DSM-5 Criteria Before the age of 12

11 ADHD IN ADULTS Prevalence Magnitude

12 CLINICAL QUESTIONS When is the best time to reassess the transition from adolescents to adults? Do all adult patients with ADHD require medication? When diagnosed as children and progress into adulthood When diagnosed as adults Adult onset? How often should medication therapy be reassessed? Things to consider when evaluating medication therapy

13 DRUGS USED TO TREAT ADHD 1 st line Long acting stimulants 2 nd line Short or intermediate acting stimulants and non-stimulant

14 WHAT TO CONSIDER..

15 HEALTH CANADA APPROVED FORMULATIONS Class/Drug Formulation Typical Dose Long Acting Stimulants Methylphenidate Mixed amphetamine salts Lisdexamphetamine Intermediate Acting Stimulants Methylphendiate Dextroamphetamine Short Acting Stimulants Methylphenidate Dextroamphetamine Non-Stimulants Atomoxetine Guanfacine MPH-OROS MPH-ER MPH-CR MAS-XR LIS-DEX MPH-SR DEX-SR MPH-IR DEX-IR ATX GUAN-ER mg/day mg/day mg/day mg/day 20-70mg/day mg/day mg/day mg/day mg/day mg/day 1-7 mg/day

16 STEPPED APPROACH TO PRESCRIBING

17 OUTCOMES IN CLINICAL TRIALS Symptoms Quality of life Executive function Functional outcomes

18 EVIDENCE IN ADOLESCENTS? Stimulants (methylphenidate, mixed amphetamine salts XR, lisdexamphetamine) Studied in a small number of short-term trials ( 4 weeks) Generally superior to placebo in improving core ADHD symptoms, but associated with reports of appetite and sleep disturbances. QOL not different among groups Non-stimulant (atomoxetine) Pooled with children Improvement on ADHD rating scale maintained to 24 months in open label extension.

19 RESPONSE RATE FOR IMPROVEMENT OF SYMPTOMS For HC approved stimulants and non-stimulants for adults Number needed to treat = 2 to 6 DERP 2011

20 What is the evidence for ADHD drug treatments in Adults?

21 MPH OROS ATX Placebo MPH IR DEX- IR PATIENT REPORTED CLINICAL RESPONSE, N=4,575 = significant compared to placebo = not significant compared to placebo

22 MAS-XR MPH OROS Placebo ATX MPH-IR DEX-IR OBSERVER REPORTED CLINICAL RESPONSE, N=3,548 = significant compared to placebo = not significant compared to placebo

23 MAS-XR MPH OROS Placebo ATX LIS-DEX QUALITY OF LIFE, N=3,394 = significant compared to placebo = not significant compared to placebo

24 MAS-XR MPH OROS Placebo ATX LIS-DEX EXECUTIVE FUNCTION, N=2,140 = not significant compared to placebo

25 FUNCTIONAL IMPROVEMENTS Trial data lacking for functional improvements Social Academic Occupational productivity DERP and ODPRN.

26 DIFFERENCES BETWEEN THERAPIES No differences for: Patient reported clinical response QOL Executive function High dose mixed amphetamine salts better than other therapies at improving observer reported clinical response

27 LONG TERM EFFICACY IN ADULTS RCTs (maximum duration ~ 6 months) Long acting methyphenidate or atomoxetine (5 trials) Improvement in symptom scales > with active treatment vs. placebo Open label extension trials Sustained symptomatic improvement Long acting methylphenidate up to 2 years Mixed amphetamine salts and lisdexamphetamine up to 1 year Atomoxetine up to 4 years

28 Is there evidence for ADHD medications during the transition from adolescents to adults?...

29 QUALITY OF THE EVIDENCE Cochrane Review: Immediate release methylphenidate for ADHD in adults Cochrane Review: Amphetamines for ADHD in adults Improved severity of symptoms, as assessed by clinicians or patients, in the short term, did not improve retention to treatment. Associated with higher attrition due to AE. The short duration of studies and restrictive inclusion criteria limits the external validity of these findings. None of the included studies had an overall low risk of bias. Overall, the evidence generated by this review is of low or very low quality.

30 SAFETY

31 EVIDENCE FOR ADVERSE EFFECTS IN ADULTS Evidence (up to 6 months) Treatments are not associated with increased odds of serious AE HC approved medications associated with higher odds of withdrawal due to AE Odds of being a responder is similar to odds of withdrawal due to AE Evidence (up to 4 years) Long term stimulant treatment associated with increases in BP and HR There is little data on the long term safety of stimulants in adults 50 years of age No differences between treatments for odds of withdrawal due to AE.

32 EVIDENCE ON THE RISK OF ABUSE, MISUSE OR DIVERSION Evidence suggests that misuse/abuse and diversion occurs; it is most prevalent in college age students It is estimated that the number of potentially inappropriate prescriptions in Canada is low

33 PROSPECTIVE COURSE OF ADHD ADOLESCENTS TO ADULTS A significant number of people choose to stop medication for a variety of reasons. Side effects Desire for independence A lack of continuity of healthcare Social stigma Remission Lack of continued effect? When should patients be evaluate/re-evaluated for continued medication?

34 STEVEN Age 19 Diagnosed with ADHD, combined type, at 8 years of age Taking Biphentin 50 mg OD, last 6 years Just started university and would like to stop his ADHD medication

35 SARAH 25 years old ADHD, combined type, diagnosed at age 16 years Finished university and started work 2 years ago ADHD has not been re-evaluated as an adult Currently taking Foquest 70 mg OD for past year