It’s been a big ADHD news week. Figures that it would be the same week that I am ranting about med approval for Adderall XR, which already carries the black box FDA warning the advisory panel recommended yesterday for Adderall, Concerta and Ritalin.
For the record, I do not think these medications should be taken lightly. Part of the reason for the warning is the concern on the part of the advisory panel that stimulant medications are being overprescribed. If requiring a medication guide and warning causes prescribers to consider all possibilities before prescribing instead of just reacting in a knee-jerk fashion, it’s a good thing, not a bad thing.
On the other hand, Medgadget reports:
The Canadian Journal of Clinical Pharmacology found that long-acting, once-daily CONCERTA is significantly more effective than usual care with immediate release methylphenidate (IR-MPH) in achieving symptom remission in children with attention deficit hyperactivity disorder (ADHD). The study also demonstrated that the CONCERTA group experienced a significant reduction, compared to immediate release methylphenidate, in the severity of the symptoms of ADHD. At study endpoint, 44 percent of patients taking CONCERTA achieved remission compared to 16 percent of patients on IR-MPH.
We now have a study done by an independent group showing that a long-acting medication is more effective than a short-acting medication, and concerns about the health issues surrounding the very same medication by the FDA advisory panel.
Here’s how I sort it all out: Stimulant medications should not be prescribed lightly. They should be prescribed after a complete evaluation by a qualified professional. That evaluation should include a complete physical. After prescribing, there should be adequate followup including blood pressure and heart rate measurements monthly and preferably at different points in the day to measure when the medication is at full strength.
That doesn’t happen often enough, usually because these evaluations are made on the fly without seeking the input from teachers and other caregivers and where kids really might have other issues that are unrelated to ADHD. Once that diagnosis is complete, then the practitioner should have the absolute right to prescribe the best medication for that child without regard to whether it is listed on a formulary or not. If a black box warning and heightened awareness mean more care in diagnosis and prescription, it’s good for everyone.
On the other hand, I always get nervous when I see negative press like this because it brings out everyone who is looking for a reason to rule out medication without giving it reasonable consideration. It’s important to keep in mind that the FDA concerns stem from a very, very small percentage of deaths where, by the way, there were more factors than the medications in play (abuse, comorbid conditions, known heart murmurs, etc). It lends fodder to the group that believes that stimulants in any form for children are evil ways for parents to avoid parenting.
The middle ground is safest: Learn all that you can, get the very best medical advice and evaluations available, consider medications to be a single prong in a multi-prong approach to ADHD, and then go forward. It’s as wrong to assume that medications aren’t part of the solution as it is to assume they are the only solution.
Update: Dr. Sogn writes:
As with many other medications, parents must weigh the significant risk of long-term impairment from untreated ADHD with the rare, unexpected, but potentially serious adverse events associated with stimulants. The evidence from over sixty years of clinical experience and hundreds of studies currently finds that these medications are safe for the majority of children and adolescents who take them.
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