Prevalence of Comorbidity and Pattern Drug Use among Children with Attention-deficit hyperactivity disorder: A Single Center in Thailand

Transcription

1 The 25th Federation Of Asian Pharmaceutical Association (FAPA) Congress 2014 Kota Kinabalu, Sabah, Malaysia 9th - 12th October, 2014 Prevalence of Comorbidity and Pattern Drug Use among Children with Attention-deficit hyperactivity disorder: A Single Center in Thailand Juthathip Suphanklang Pharm.D 2 nd year pharmacy resident The College of pharmacotherapy of Thailand Faculty of pharmacy, Silpakorn University

2 Introduction Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disorder in childhood characterized by three clusters of symptoms: Inattention Hyperactivity Impulsivity

3 Diagnostic Criterias for ADHD A. Either 1 or 2 1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities b) Often has difficulty sustaining attention in tasks or play activities c) Often does not seem to listen when spoken to directly d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) e) Often has difficulty organizing tasks and activities f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or home-work) g) Often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) h) Is often easily distracted by extraneous stimuli i) Is often forgetful in daily activities The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV). Copyright American Psychiatric Association

4 Diagnostic Criteria for ADHD A. Either 1 or 2 2) Six (or more) of the following symptoms of hyperactivity-impulsivity impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity y a) Often fidgets with hands or feet or squirms in seat b) Often leaves seat in classroom or in other situations in which remaining seated is expected c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) d) Often has difficulty playing or engaging in leisure activities quietly e) Is often on the go or often acts as if driven by a motor f) Often talks excessively The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV). Copyright American Psychiatric Association

5 Diagnostic Criteria for ADHD A. Either 1 or 2 Impulsivity g) Often blurts out answers before questions have been completed h) Often has difficulty awaiting turn i) Often interrupts or intrudes on others (eg, butts into conversations or games) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age. C. Some impairment from the symptoms is present in 2 or more settings (eg, at school [or work] or at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, or personality disorder). The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV). Copyright American Psychiatric Association

6 Area of brain implicated in ADHD Clinical Psychology Review 2006;26:

7 Predominant ADHD Inadequate respond MPH/DMPH DEX/MXA Inadequate respond Atomoxetine or Guanfacine ER or Bupropion Atomoxetine or Guanfacine ER or Bupropion Pharmacotherapy: A Pathophysiologic Approach. 8 th ed p

8 Coexisting conditions Comorbidity Percentage Oppositional defiant disorder 40 Anxiety disorders Learning disorders Mood disorders Conduct disorder Substance use disorders d Tic disorders 5 10 Child Adolesc Psychiatr Clin N Am 2000;9:

9 Predominant comorbidity Tourette s disorder Bipolar and/or severe aggression Anxiety/depression Dopamine antaginist or α2 agonist Atypical antipsychotic, y lithium or anticonvulsant Antidepressant Pharmacotherapy: A Pathophysiologic Approach. 8th ed p

10 Review Treatment of ADHD and rationale drug used First line regimen : Methylphenidate efficacy factor from U/D, Age, mother history Comorbidity of patients effect on treatment regimen of ADHD

11 Pharmacologic therapy 1. Stimulant Drugs Used in the treatment of ADHD Ritalin Concerta Pharmacotherapy: A Pathophysiologic Approach. 8 th ed p

12 Pharmacologic therapy 2. Second generation (Atypical) Antipsychotics for ADHD Pharmacotherapy: A Pathophysiologic Approach. 8 th ed p

13 Pharmacologic therapy 3. Antidepressant for ADHD Bupropion Nortriptyline Imipramine Atomoxetine Pharmacotherapy: A Pathophysiologic Approach. 8 th ed p

14 Objective 1). The objective of this study is to describe the pattern drug use of ADHD in Thai children. 2). To describe the prevalence of comorbidity

15 METHODS

16 Methods: A retrospective study was conducted among children (6-12 years old) with ADHD from children and adolescent psychiatric outpatient unit at Hau Hin hospital, Prajuabkirikhan province, Thailand. The data was collected during January 2013-March 2014.

17 Methods: Inclusion criteria 1. Patients were visited on first time at children and aldolescent psychiatric outpatient unit 2. Patients were diagnosed with ADHD including other comorbidity Exclusion criteria 1. Patients were not diagnosed with ADHD 2. Patients were below 6 years old and more than 12 years old.

18 RESULTS

19 Demographic Data Gender -Male -Female Patient characteristics Patient numbers (N=87) (%) 70(80.5) 17 (19.5) Birth weight Low Birth Weight Infant (<2,500 g) 10(13.3) 3) Comorbidity - Oppositional defiant disorder - learning disorder - anxiety disorder - borderline intellectual problem - No comorbidity -Others 28 (32.2) 21 (24.1) 8 (9.2) 5 (5.8) 12 (13.8) 13 (15.0) Underlying disease - Accidental injury 19 (54.3) - Epilepsy 9 (25.7) - Asthma and allergy 7 (20.0) 0) N=75 N= 35

20 Percentage of comorbid disease Percentage of comorbidity Oppositional defiant disorder Learning disorder Anxiety disorder Borderline intellectual problem No comorbidity Others Others 15 No comorbidity 13.8 Borderline intellectual problem 5.8 Anxiety disorder 9.2 Learning disorder 24.1 Oppositional defiant disorder 32.2

21 The first three rank of underlying diseases Percent of underlying disease Accidental injury Epilepsy Asthma and allergy Asthma and allergy 20 Epilepsy 25.7 Accidental injury 54.3

22 Pattern of medication use Percentage of pattern drug use Methyphenidate monotherapy Atypical antiphychotics Combined regimen No treatment Missing Missing 1.2 No treatment 8.1 Mean dosage of methylphenidate = 14.9 mg/day Mean dosage of risperidone = 0.55 mg/day Combined regimen 34.5 Atypical antiphychotics 2.3 Methyphenidate monotherapy 54.0

23 The combined regimen was used in patient with ODD and LD Comparative of regimen ODD Learning disorder 3.60% No treatment 9.5% No statistical significance Combined regimen 33.3% 53.60% 3.58% atypical antiphychotic 4.8% 39.30% 30% methyphenidate 52.4%

24 Discussion In 62% stimulants were instituted either at the beginning of treatment or as an "add-on" after behavioral management proved to be insufficient. Among cases that received stimulants, 28% needed the combination of other psychotropic medications, mostly antidepressant and anxiolytic drugs. J Med Assoc Thai 2008 Dec;91(12):

25 Discussion PLoS ONE 2013; 8(1): e54152.

26 Conclusion The most comorbidity of ADHD was ODD and LD. It seems to use the combined regimen in ODD patient. However it had to be studied the benefit of such regimen in the future.

27 Thanks for yr attention n