Presented by the National Resource Center on ADHD

Transcription

1 Presented by the National Resource Center on ADHD

2 Timothy E. Wilens, M.D. Massachusetts General Hospital Harvard Medical School

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4 Timothy E. Wilens, M.D. Massachusetts General Hospital Harvard Medical School Disclaimer: The information provided here is supported by Cooperative Agreement Number CDC-RFA-DD from the Centers for Disease Control and Prevention (CDC). The Ask the Expert webinars contents are solely the responsibility of the invited guest Expert and do not necessarily represent the official views of CDC. Neither CHADD, the National Resource Center on ADHD, nor the CDC endorses, supports, represents or guarantees the accuracy of any material or content presented in the Ask the Expert webinars, nor endorses any opinions expressed in any material or content of the webinars. CHADD and the National Resource Center on ADHD offer webinars for educational purposes only; the information presented should not be regarded as medical advice or treatment information.

5 To Ask A Question:

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7 Send us your feedback about today s webinar! An will arrive shortly with a link to take the survey. Thank you for helping us plan future webinars that meet the interests of the ADHD community!

8 Timothy E. Wilens, M.D. Massachusetts General Hospital Harvard Medical School

9 Dr. Wilens has served as a consultant, speaker, or has received grant support from the following (past 3 years) NIH (NIDA) Pharmaceuticals: Euthymics, Shire, Theravance, Tris National Football League (ERM Associates) and Minor/Major League Baseball Dr. Wilens authored Straight Talk About Psychiatric Medications for Kids (Guilford Press 2008 most recent ed.); and co-edited MGH Comprehensive Clinical Psychiatry (Mosby-Elselvier 2014/2015 release) and ADHD Across the Lifespan (Cambridge Press, 2014/2015 release) Some of the products discussed are not FDA approved for ADHD or other psychopathology; others may not be FDA approved in the manner discussed (e.g. dosing, combination therapy)

10 ADHD is the most commonly diagnosed neurobehavioral disorder of childhood Increase in prevalence & treatment over past decade Continues into adulthood in about ½ of cases Untreated ADHD related to academic/occupational difficulties and sequalae Treatment of ADHD should include consideration of educational evaluation and accommodation, psychosocial treatments for the individual and family Medication (pharmacotherapy) is also considered among first line treatments (ADHD Practice Parameters. JAACAP 1997;36:89S 2007: Greenhill L et al., JAACAP 2002 Wilens & Spencer, Postgraduate Medicine, 2011; Visser et al. JAACAP 2013)

11 Dopamine Norepinephrine OH OH CH 2 CH 2 NH 2 OH CH CH 2 NH 2 OH OH Bupropion Amphetamine CH 2 CH NH 2 CH 3 Methylphenidate O COCH 3 NH

12 Thickness (mm) Prospective study utilizing two MRI scans in 43 youths (age 9-20 years) with ADHD. Mean baseline and endpoint raw cortical thickness (±SEM) in the left middle/inferior frontal gyrus 4.8 On psychostimulants (n = 19) Typically developing cohort* Off psychostimulants (n = 24) Time 1 (mean age, 12.5 years) Time 2 (mean age, 16.4 years) For most participants, cognitive data was not collected at both timepoints. Increased cortical thinning in the group that stopped taking stimulants was not associated with any difference in clinical outcome. Effects of treatment with nonstimulants cannot be excluded, although prevalence of nonstimulant use was low *Derived from 620 scans of 294 typically developing youths Shaw et al. Am J Psychiatry. 2009;166:58-63.

13 ADHD Stimulant Dosing (Dosing may exceed FDA approved limits*) Medication Starting Dose Usual Dosing (hours they last) Methylphenidate Ritalin 5 mg QD/BID 3x s/day (4 hr) Focalin 2.5 mg Twice daily (5-6hr?) Concerta 18 mg QD Daily (12h) MetadateCD 10 mg QD Daily (8-10h) Ritalin LA 10 mg QD Daily (10-12hr) Focalin (XR) 5 mg QD Daily (10-12 hr) MTS patch 10 mg Daily (8-16 hr) Amphetamine Dexedrine 2.5 to 5 mg QD 2-3 x /day (4hr) Dex Spansule 5 mg Twice daily (6 hr) Vyvanse mg Daily (12-14 hr) (Wilens, Spencer, Biederman, Ann Review Medicine 53:2002; Wilens CNS Drug 2008; Wilens and Spencer, PostGraduate Medicine 2011)

14 % of Subjects Reporting anorexia insomnia headache abdominal pain Placebo Add XR 10 Add XR 20 Add XR 30 nervousness emotional lability

15 Cardiovascular problems Growth suppression Development of tics Substance abuse

16 Atomoxetine = Strattera* Alpha Agonists (extended-release [XR] guanfacine = Intuniv; clonidine = Kapvay) Combination stimulant + alpha agonists XR* Antidepressants Bupropion = Wellbutrin Tricyclics Modafinil = Provigil Research Natural agents (fish oils, metadoxine) Combined (e.g. atomoxetine + stimulants) Research * Denotes FDA-approved (Wilens and Spencer, Postgraduate Med, 2011)

17 When treating disorders along with ADHD, consider treating the most severe disorder first Anxiety ADHD Antisocial Substance Abuse Mood

18 Untreated ADHD is problematic Medications effective in treating ADHD Many stimulant preparations and nonstimulants Largely predictable side effects Safe longer term effects, but ongoing studies Data on combination with other medications emerging Stay tuned for new research in this area

19 To Ask A Question:

20 Timothy E. Wilens, M.D. Massachusetts General Hospital Harvard Medical School

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22 The information provided in this episode of Ask the Expert is supported by Cooperative Agreement Number 5U38DD from the Centers for Disease Control and Prevention (CDC). The Ask the Expert webinars contents are solely the responsibility of the invited guest Expert and do not necessarily represent the official views of CDC. Neither CHADD and the National Resource Center on ADHD, nor the CDC endorses, supports, represents or guarantees the accuracy of any material or content presented in the Ask the Expert webinars, nor endorses any opinions expressed in any material or content of the webinars. CHADD and the National Resource Center on ADHD offer webinars for educational purposes only; the information presented should not be regarded as medical advice or treatment information.