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printer friendlyADHD Medicines: Adderall, Concerta, Dexedrine, Focalin, Metadate, Ritalin, Strattera and More
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Human beings are rarely created in perfect form, so the great majority of us arrive in this world with unique differences. Some differences are blessings; others are handicaps. Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world. I consider poor vision a condition of "human-ness." People can also have other conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.--all well recognized differences that can impair the pursuit of a normal life if not dealt with in some manner.
ADHD is characterized by a prolonged history of inattention, impulsiveness, and variable amounts of hyperactivity. It is important to emphasize that all of these symptoms are normal human characteristics. All of us are forgetful and inattentive at times. We all at times become nervous and fidgety, and we certainly are impulsive to some degree. It's part of our "human-ness." ADHD, then, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but from the DEGREE to which we manifest these symptoms. ADHD people have an overabundance of these normal human characteristics.
WHO SHOULD TAKE MEDICATION, AND WHY?
Returning to the vision
analogy, there are a number of options open to an individual who has bad
eyesight. One option is to attempt to correct the problem. This could involve
wearing glasses to correct the visual deficiency. Perhaps glasses can totally
correct the problem, or perhaps they can only partially help. After the glasses
are in place, we are in a position to assess
what further problems
are interfering with success. Then we can address these issues as well.
ADHD is a medical condition. Dr. Alan Zametkin has clearly demonstrated that there is something uniquely different about the metabolism of the brain affected by ADHD. If a person meets the criteria for a diagnosis of ADHD and is not succeeding academically or socially up to expectations, medication should be a PRIMARY OPTION of therapeutic intervention. The opportunity to eliminate the symptoms- toms of a medical condition partially or completely should be available to all. Many children benefit enormously from the use of medication. Many families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan. As many as 80% of individuals will show a positive response to one of the medical treatments.
Since it is impossible
to determine who will respond favorably to medication, I always offer a trial
of medication to each diagnosed patient. If medication will help alleviate
the symptoms and does not elicit any unfavorable effects, then
the patient may choose
to utilize medication as one part of therapy for ADHD.
WHAT IMPROVEMENT SHOULD BE SEEN?
In the early 1930's,
Dr. Charles Bradley noted some dramatic effects of stimulant medications
on patients with behavior and learning disorders. He
found that the use of
stimulants "normalized" many of the systems that we use for successful living. People on medication
IMPROVED their attention span, concentration, memory, motor
coordination, mood, and on-task behavior. At the same time they DECREASED
daydreaming, hyper- activity, anger, immature behavior, defiance, oppositional
behavior.It was evident that medical treatment allowed intellectual capabilities
that were already present to function more appropriately.
When medication is used appropriately, patients notice a significant improve- ment in control. Objective observers should notice better control of focus, concentration, attending skills, and task completion. Many children are able to cope with stress more appropriately, with fewer temper outbursts, less anger, and better compliance. They relate and interact better with siblings and friends. Less restlessness, motor activity and impulsiveness are noted.
It is very important
to remember what medicine does and does not do. Using medication
is like putting on glasses.
It enables the system to function more appropriately. Glasses
do not make you behave,
write a term paper, or even get up in the morning. They allow your eyes to
function more normally IF YOU CHOOSE to open them. YOU are still in charge
of your vision. Whether you open your eyes or not, and what you choose to
lookat, are controlled by you. Medication allows your nervous system to send
its chemical messages more efficiently, and thus allows your skills and knowledge
to function more normally. Medication does not provide skills or motivation
to perform. ADHD individuals often complain of forgotten appointments,
incomplete homework, miscopied assignments, frequent arguments with siblings
and parents, excessive activity, and impulsive behaviors. With medication,
many of these problems dramatically improve. Patients successfully treated
with medication typically can go to bed
at night and find that
most of the day went the way they had planned.
WHO SHOULD PRESCRIBE MEDICATIONS?
Medications can be prescribed by a licensed physician, physician's assistant or nurse practitioner only. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training, and social skill assistance. Parents and adults should look for a physician, physician assistant or nurse practitioner who has a special interest and knowledge in dealing with ADHD individuals.
MEDICAL TRIALS
It is necessary to establish a team for an appropriate evaluation of the medication trial.I gather information from sources who spend time with my patients. This might include parents, teachers, spouses, friends, co-workers, grandparents, tutors, piano teachers, coaches, etc. As gradually increasing dosages are administered, input is gathered from these observers. Various rating scales are available to assist in gathering factual data. However, the true assessment is whether the ADHD patient's quality of success in life has improved. For this information, I find no scale takes the place of conversations with observers.
When evaluating patients during a trial of medication, I will treat them throughout the day, seven days a week. Treating them only at school or only at work is totally inadequate. I need all involved observers, assisting in the evaluation process. Furthermore, I want to know if treatment has an effect on non- academic issues. After the trial of medication, if positive results are evident, then the family and/orthe patient can make informed decisions as to when the medication is helpful. Many patients find the medication is helpful throughout all waking hours. Others may need it only during certain times of the day.
WHAT IS THE CORRECT MEDICATION?
At the present stage of medical knowledge, there is not a method of predicting which medication will be most helpful for any individual. At best, physicians can make educated decisions based on information about success rates with individual medications. In general, a large percentage of patients will respond favorably to Ritalin or Dexedrine, and one of these is usually my first choice. If one stimulant does not work effectively, the others should be tried, for experience has proven that individuals may respond quite differently to each one. Many patients respond remarkably well to imipramine or desipramine, and some physicians feel this group of medications is under used. Each family and physician must be willing to try different medications in order to determine the best and most effective therapy. This is the only way to find the appropriate treatment modality.
In some patients who have multiple diagnoses such as ADHD and depression, or ADHD and oppositional-defiant disorder, or ADHD and Tourette Syndrome, combinations of drugs are being successfully utilized for treatment.
WHAT IS THE CORRECT DOSE?
If medications work, there is a best dose for each individual. Unfortunately, medical knowledge is not at a point where it can predict what the correct dose will be. This isnot an unusual circumstance in medicine, however. For a person with diabetes, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is needed to determine the best treatment. For ADHD medi- cations, there is no magic formula. The dose cannot be detemined by age, body weight, or severity of symptoms.
In fact, it appears
that the correct dose is extremely individual and is not really predictable.
Again, similar to people who need glasses, the kind of prescription and the
thickness of the lenses is not dependent on any measurable parameter other
than what you say enables you to see well. The dose of medication is determined
solely by what ADHD patients need to improve their symptoms.
You must be willing to
experiment with carefully observed dosage changes to determine your child's
correct dosage. Once the correct dosage is determined,
it does not seem to change
significantly with age or growth. Medication continues to work effectively
through the teenage years and into adulthood if needed.
SUMMARY
Individuals with ADHD will present with a variety of well-defined symptoms and behaviors. Medication may be extremely helpful in alleviating some of these symptoms and will make the other forms of accompanying therapies much more meaningful and effective. Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.
MEDICATIONS: OVERVIEW
ADDERALL (four amphetamine salts)
Form: Long-acting
tablets: 10 mg and 20 mg
Dosage: Very individual,
usually between 5 mg and 20 mg, once or twice a day
Duration of Action:
Usually last 6-12 hours. May be given once or twice a day, dependingon
length of therapeutic effect. Duration of effect varies from person
to person.
Effects:
Same as Ritalin
Possible Side Effects:
Less affect on sleep, appetite, growth and rebound. No roller coaster
effect.
Pros: Only
needs to be given once or twice a day, often fewer side effects. Very
nice medication when effective.
Cons: Does
not work well for everybody. Relatively new on the market and not much
clinical experience at this time.
**See article at our web site
on ADDerall
CONCERTA (methylphenidate)
Form: 10 hour long acting tablet--unique delivery
system that delivers a constant therapeutic level of methlyphenidate for
ten full hours. Concerta 18 mg, 36 mg. and 54 mg.
Dosage: Dosage will vasy as with all methylphenidate
products. Conderta 18 mg is approxiamtely equivalent to Ritalin
5 mg three times a day. Concerta 36 mg approximately equals Ritalin
10 mg three times a day. Concerta 54 mg equalts Ritalin 15 mg
three times a day.
Duration
of Action: 10 hours of consistent therapy with no highs or lows
throughout the day.
Effects: Same as Ritalin
Pros:Unique delivery system avoids multiple dosing
thought the day. No dosage at school. No rebounding with missed
doses. Less anxiety and worry.
Cons: None know at this time.
**Learn more at their
web site www.alza.com
RITALIN TABLETS (methylphenidate)
Form: Short acting
tablets administered by mouth. Ritalin 5 mg, 10 mg, 20 mg
Dosage: Very individual.
Average 5 mg - 20 mg every 4 hours. I prescribe 5 mg to start and raise by
5 mg every 4-5 days with close observation until correct dose is achieved.
Duration of Action:
Rapid acting Ritalin starts to work in 15-20 minutes, which is extremely helpful
for the child who has trouble starting his day, Some children will
need medication 20 minutes BEFORE time to get up. It will last about
3'/24 hours, and so the effective dosage will need to be repeated every
31/2-4 hours to maintain positive effects during the waking hours. By virtue
of its short action, Ritalin is discontinued every night and must be
restarted each morning.
Effects: Ritalin
is one of the best and most dependable medications for treatment of ADHD symptoms.
It specifically improves concentration, memory, and control of frustration
and anger.
Possible Side Effects:
Moderate appetite suppression, mild sleep disturbances, transient
weight loss, irritability, motor ties may occur if dose is too high
(will disappear on lower dose). (Patients with Tourette Syndrome --
if Ritalin makes ties worse, discontinue. In some Tourette patients, ties
decrease on stimulants.) Overdose effects with stimulants: depression, lethargy,
"loss of spark." If this occurs, lower the dose.
Pros: Excellent
safety record. Very easy to use and evaluate. Very specific control of medication
timing. Most dramatic improvement for many individuals. May be used
with most other commonly used medications.
Cons: Must be administered
frequently during the day. Inconvenient to use at school. May experience
moderate rebound reaction -- anger, frustration, temper when medication wears
off. Possible roller coaster effect during the day as medication level
fluctuates.
RITALIN SR 20 (methylphenidate sustained release)
Form: Long acting
tablets administered by mouth. Ritalin SR 20.
Dosage: Very individual.
Two to three tablets may be needed. I use it primarily in conjunction with
regular Ritalin to smooth out peaks and valleys and prevent rebound.I
give 1/2-1 tablet of Ritalin SR 20 with each dose of regular Ritalin.
Duration of Action:
Long acting, about 6-8 hours. BE AWARE -- although called SR20it actually
appears to release only 5-7 mg of medication (not 20 mg) over 6-8 hours.
Effects: Same as
Ritalin tablets.
Possible Side Effects:
Same as Ritalin.
Pros: Excellent
safety record. May be most effective when used in conjunction with regular
Ritalin. Tends to smooth out the peaks and valleys of regular tablets.
Given with regular Ritalin 15-20 minutes before the child gets out
of bed in the morning, it will prolong the positive effect of regular Ritalin
to five hours (the lunch hour).
Cons: Does not
always work in a predictable fashion, and sometimes not at all.
DEXEDRINE SPANSULES (dextroamphetamine)
Form: Long acting,
administered by mouth, Dexedrine Spansules 5, 10, 15 mg.
Dosage: Very individual:
Average is 5-20 mg.
Duration of Action:
Very individual. May take 1-2 hours to be effective. Usually lasts6-8
hours. In some it may be effective all day. In others it may only last four
hours.
Effects: Same as
Ritalin.
Possible Side Effects:
Same as Ritalin.
Pros: Excellent
safety record. May be the best drug for some individuals: longer acting,
smoother course of action. May avoid lunch time dose at school.
Cons: Slow onset
of action. Remember, it takes 1-2 hours to work and may require a short-acting
dose at first in the AM to start the day.
DEXEDRINE TABLETS (dextroamphetamine)
Form: Short-acting
tablets administered by mouth. Dexedrine tablets 5 mg.
Dosage: Very individual:
Average 1-3 tablets each dose.
Duration of Action:
Rapid onset of action 20-30 minutes. Lasts 4 hours.
Effects: Same as
Ritalin.
Possible Side Effects:
Same as Ritalin
Pros: Excellent
safety record. Rapid acting. Some patients who do well on Dexedrine prefer
the tablets over the Spansules. The more rapid rate of onset is apparently
more effective for these individuals.
Cons: Same as Ritalin.
CYLERT(pemoline)
Form: Long-acting
tablets administered by mouth. Cylert 37.5, 75 mg.
Dosage: Very individual.
Duration of Action:
Slow onset of action, thought to be a medication that will last allday, but
in most cases lasts 6-8 hours.
Effects: Same as
Ritalin
Possible Side Effects:
Same as Ritalin. However, has been known to cause mild liver damage.
Pros: Long acting,
may eliminate lunch dose.
Cons: Not as safe
as the other stimulants. Would only use if other stimulants are not effective.
Should NEVER be first drug of choice. Has caused hepatitis and
death. Must do
liver function blood test every six months.
TOFRANIL and NORPRAMINE (imipramine and desipramine)
Form: Tablets
administered by mouth. 10, 25, 50, and 100 mg tablets.
Dosage: Very individual.
I start with a low dose 10-25 mg, and raise slowly as needed.
Duration of Action:
Variable. Often has a 24-hour effect, and therefore can be administered at
night. Some patients prefer to split the dose and take every 12 hours.
Effects: Often
relatively low doses can improve ADHD symptoms within a few days, but may
take 1-3 weeks for full effect. Higher doses may improve depression
symptoms and mood swings, which are often seen in ADHD individuals.
Possible Side Effects:
Nervousness, sleep problems, tiredness, and upset stomach, dizziness,
dry mouth, unusually fast heart rate. May affect conduction time of
the heart, leading to irregular heart rate. May affect blood count
(rare).
Pros: Often works
when stimulant medications are not helpful, and may be the drug of choice
for many individuals. Prolonged duration eliminates school dose. Smoother
course of action. Often helps with mood swings and depression. May
be used in conjunction with stimulant medications.
Cons: Can affect
the heart conduction rate, therefore requires an EKG prior to the medication
trial and after treatment level has been established. Can affect the
blood count, therefore
requires a complete blood count with all illnesses. Need to be careful
when taking other medications. Consult doctor for list of medications
to avoid. Medication needs to be increased and decreased gradually.
Should not start and stop abruptly.
CLONIDINE (catapres)
Form: Patches applied
to back of shoulder. Catapres TTS-1, TTS-2, TTS-3 (expensive). Tablets
administered by mouth. Catapres tablets--1 mg., 2 mg., 3 mg. (low price)
Duration of Action:
Patches will last 5-6 days. Tablets are short acting, last 4-6 hours.
Effects: Often
will improve ADHD symptoms, although not always as dramatically as Ritalin.
Decreases facial and vocal ties in Tourette Syndrome. Often has a dramatic
positive effect on oppositional defiant behavior and anger management.
Possible Side Effects:
Major side effect is tiredness, particularly if raised too quickly.Will normally
disappear with time. Some patients may notice dizziness, dry mouth.Some will
notice increased activity, irritability, conduct disorder and should
discontinuethe medication.
Pros: Excellent
delivery system if patch is used. No pills required. Frequent positive effect
on oppositional defiant behavior, and obsessive compulsive behavior.
Does not effect sleep or appetite. Positive effect on tic behavior.
Cons: Does not
usually work as well as Ritalin for ADHD symptoms. Patch causes
skin irritation in many
and cannot be tolerated.
WELLBUTRIN (bupropion hcl)
Form: 75
mg (yellow-gold) 100 mg (red)
Dosage: 75-300
mg daily (average) in three divided doses
Duration of Action:
Long acting medication (half-life of 24 hours)
Effects: A few
studies suggest improvement in ADHD. In general, not as good as stimulants.Very
helpful in conjunction with stimulants for depression.
Possible Side Effects:
Can cause seizures (1/4000) if dose STARTED too rapidly. Raise dose
slowly. Cannot use if seizure disorder is present. May cause dry
mouth, anorexia, rash, sweating, tremors, tinnitus
Pros: Very
good medication to use for treatment of depression
Cons: Very
little evidence that it is helpful for ADHD. Studies are still in progress.
WELLBUTRIN SR (bupropion hcl long-acting)
Form: 100 mg (blue)
150 mg (purple)
Dosage: 100-150
mg twice a day
Duration of Action:
Effective for over 24 hours
Effects, Possible Side
Effect, Pros, Cons: Same as Wellbutrin
Dr. Mandelkorn trained in pediatrics and adolescent medicine and was a mental health fellow under Dr. Michael Rothenberg. An adult with ADHD who has a son with ADHD, Dr. Mandelkorn specializes in the diagnosis and treatment of ADHD in children and adolescents. He maintains a private practice in Mercer Island, Washington. His ADHD clinic presently follows over 600 children with ADHD. Dr.Mandelkorn lectures nationwide about management
