Treatment Landscape for the Management of ADHD - Episode 9
Transcript: Theresa Cerulli, MD: How about the stimulants? You’ve shared, Andy, the information on the nonstimulants. Ann, would you like to begin talking about the short- and intermediate-acting stimulant medications we have?
Ann C. Childress, MD: Sure, Theresa. We have methylphenidates and we have amphetamines. They’re old staples. They’ve been on the market for a long time. Amphetamines were first looked at with Benzedrine in the 1930s. And in the methylphenidate class, Ritalin. Immediate-release methylphenidate was first approved by the FDA in 1955.
The methylphenidates come in several different formulations. There is a liquid formulation, there are chewable tablets, and there are tablets that you swallow. They start working pretty quickly. Their onset of effect is between 30 and 45 minutes. Their duration isn’t too long. It’s between 3 and 4 hours, so folks often need to take the medication 2 or 3 times a day. Methylphenidate is approved up to 60 mg by the FDA. That’s really important because when people are getting treated, I often will see somebody who comes in on 5 mg twice a day, or 10 mg twice a day. Those are fine as starting doses, but that’s not enough to get extended efficacy.
As far as other methylphenidates, there’s Focalin. That’s actually a dexmethylphenidate, and it really is intermediate. It’s duration of effect is 4 to 6 hours, and it is approved only up to 20 mg. Normally, folks start with a 2.5-mg dose twice a day and then go up from there.
If you look at the amphetamines, there’s dextroamphetamine. This drug lasts about 3 to 5 hours. It’s approved up to 40 mg for ADHD [attention deficit hyperactivity disorder] and up to 60 mg for narcolepsy. If you look at the package insert, 1 of the things it says is you shouldn’t need more than 40 mg to treat ADHD. It doesn’t necessarily say you can’t go above that.
Dextroamphetamine comes in a number of different tablet sizes—from 2.5-mg tablets all the way up to 30-mg tablets. The generic dextroamphetamine, which isn’t too expensive, is available as 5- and 10-mg doses. Then there is a branded formulation that has a number of different tablet strengths. This option is called Zenzedi. Adderall is more of an intermediate-acting drug. It lasts for about 4 to 6 hours. It is available as 5-mg tablets up to 30-mg tablets. It’s onset of effect really isn’t as quick as with Dexedrine [dextroamphetamine] and immediate-release methylphenidate. It’s probably about an hour, or an hour and a half. Its duration is about 5 to 7 hours. If you look at 1 of the newer ones that is branded, Evekeo [amphetamine sulfate], that is 50/50, regarding d- [dextroamphetamine] and l-amphetamine [levoamphetamine]. Adderall is 3 to 1, in regard to d- [dextroamphetamine] and l-amphetamine [levoamphetamine]. Evekeo has an onset somewhere between 30 and 45 minutes. In a classroom trial that I was the lead investigator on, we were able to squeeze about 10 hours out of it. That is when everybody is dose optimized and, in the best of all situations, compared with placebo. But if you look at things in general, it’s probably more like 5 or 6 hours that folks are going to get out of it. You can dose it once or twice a day. And you can start at 5 mg and go all the way up to 40 mg. You can increase all these medications on a weekly basis. You don’t have to start low and go slow. You can start low and ramp things up pretty quickly. It’s really important to do that to get the best therapeutic effect.
Andrew J. Cutler, MD: You know, Ann, I’m surprised by how commonly the immediate-release preparations are still used today. I know not just for augmentation, sometimes we’ll use them to extend the duration. But there are a lot of people who are just managed on immediate-release preparations.
Ann C. Childress, MD: That’s true. I’m sure Tim wants to bang his head on the wall when he hears that, looking at substance abuse.
Theresa Cerulli, MD: We will absolutely cover that topic.
Transcript Edited for Clarity