Unfortunately, it was not possible for our experts to answer all questions posed during the hour-long seminar. Professor Jeffrey newcorn has taken the time to respond to your questions on "Psychopharmacology of ADHD". Find the responses here.
1 | What is the best add on drug, in MPH works well, but maximum dosage is reached (or causes weight loss in high dosage) and the patient has only partial remission?
Probably the most common add-on is adding short acting stimulant to augment the duration of effect of long acting stimulant. Beyond that, the alpha-2 agonists work very well together with stimulants and are very good for behavioral control. Plus they have a very long duration of effect. Also, in selected cases, atomoxetine or viloxazine and even buprprion could be considered as add-on medications.
2 | I would be keen to hear expert thoughts on combination stimulant treatment (Ritalin and Dexamphetamine) in adult patients and the dosing in those combinations.
Bottom line is that there is not an absolute contraindication, and there might be rare circumstances where one might consider it, but its best to use the same medication and not mix. The only circumstance that I would consider mixing is for someone on a long-acting amphetamine formulation who needs short acting later, you could consider MPH over AMP because of its shorter half-lef (in someone who is sensitive to sleep problems with stimulants).
3 | MPH seems to be safe in Patients with epilepsy. Do you know it thats the case for other ADHD drugs?
The atomoxetine have not been systematically evaluated in patients with patients with epilepsy. During the clinical trials, only 0.1%(1/748) adults with ADHD repoted epilepsy. See Wernicke et al., Dev Med Child Neurol 2007 Jul;49(7):498-502.
4 | Many of my patients with ADHD who have unstructured lives (usually living alone, unemployed and not in education) struggle to appraise if medication works for them. Can you recommend alternative approaches in helping such people manage their subjective difficulties, or should we be reducing medication use in such patients?
Organizational skill training is very helpful for children and adults with ADHD regardless of whether they are on medication, and would be very helpful in the circumstance you mentioned here. As far as deciding whether medication works, its most important to identify target symptoms - the two or three behaviors that the patient wants to make better. Target behaviors usually lie at the interface of symptoms and functional status.
5 | Do you have any thoughts on predictors of response to methylphenidate vs amphetamine molecules, as a seoncdary follow up, any new data on which might be better in treating emotional dysregulation symptoms of ADHD?
If you look at the International Consensus statement on ADHD published by the World Federation under Steve Faraone's leadership, you will see that both stimulants and atomoxetine have positive data in relation to treatment of emotion regulation. Effect sizes are better for stimulants on average. One problem, though, is that stimulants have a relatively short duration of action and problems with emotion regulation often occur at any time of day. In this regard, alpha-2 agonists could be helpful. But there is limited study of their effects on irritability or other symptoms outside the core symptoms of ADHD.
6 |Long Covid and post Covid symptoms like "brain fog" suggests that Covid may affect brain function in a similar way to ADHD. So, I assume that this effect in those with ADHD will be compounded and so are those with ADHD at double jeopardy and more vulnerable to Covid sequelae than the general population?
There is not sufficient evidences showed that ADHD is a risk factor for Covid sequelae. But amount of publications showed patients with ADHD is more vulnerable for Covid and Other mental disorder during pandemic. Furthermore, attention deficit is one of the most common symptoms of long-term effects of Covid.
7 | I see spleep disorders with LDX (Vyvanse / Elvanse), and loss of appetite with younger Patients. What can you suggest?
For insomnia - giving the drug earlier, shifting to a shorter acting formulation, adding on an effective ADHD medication that supports sleep. For appetite, give after breakfast, alter when one eats, allow liberal snacking. If all else fails, cyproheptadine - an antihistamine drug often used for weight gain - can be given and usually leads to increased appetite and supports weight gain.
8 | Who decide and what are the criteria weather ADHD person should or should not take medications?
I would advise to consider impairment in function, difficulty with peer interactions and self-esteem (in childen), job and relationship failure in older people, and availability or ability to participate in psychosocial treatment as considerations in whether to use medication.
9 | What do you think of studies by Fran Levin and one from Denmark showing high doses of stimulants reduce but substance abuse and ADHD?
The studies of Fran Levin and colleagues that essentially use amphetamine in higher dose as a replacemtn therapy are well designed and should be given seriuos consideration.
10 | Does anyone have experience using solriamfetol off label for ADHD?
A case report (Naguy A, et al. CNS Spectr. 2021) showed the effect of solriamfetol for a 15-year-old male diagnosed with ADHD. The boy accepted methylphenidate and atomoxetine administration but showed poor outcomes. After 4 weeks titration with maximum solriamfetol dose of 150 mg qd, parents’ observations in tandem with school reports were very reassuring.
11 | I am honoured and thrilled to listen all the speakers. I am from North Macedonia, I am child and adolescent psychiatrist. It is good for you since you have many medication options. We have a big problem, as we do not have any psychostimulant medication and we must give other unappropriate drugs for the condition. We even do not have guanfacine or clonidine. And my prescriptions are not valid in EU. Thus, the parents could not buy it in other countries. Would you like to give any suggestions or contact from some pharmaceutical company that will be interested for this market at the Balkans? Or idea for other solution?
No specific recommendations here about who to contact about getting medications for compassionate use. But consider bupropion as an alternative to stimulants that may be more widely available.
12 | Is extended release viloxazine any better than other non-stimulants?
Viloxazine is a norepinephrine reuptake inhibitor that has post-snaptic effects at a variety of serotonin receptors. The serotonergic effects are of uncertain meaning - they may contribute to response but this has not been demonstrated. Viloxazine has a longer half-life than atomoxetine does in extensive CYP2D6 metabolizers (93-95% of the population). There are no comparator studies of the two drugs.
a. If one starts taking stimulants as a grown up, could that have a long-term positive effect on the brain? (I've read it's possible with kids if medication is started in very young age).
b. Does the patient HAVE to take breaks in medicating, in order to avoid getting used to them?
c. Is there a known connection of ADHD and fibromyalgia?
There are no studies that, to my mind, conclusively show that treatment with stimulants or any other medication has positive long-term effects on the brain after the treatment is discontinued. This would be a very difficult and costly experiment to do. Separating out positive effects from medication vs development would be very difficult. For the issue of breaks in treatment and potential tolerance, the short answer is that this can be helpful for selected peoplle but isn't needed for the large majority of people. Again, this is an area where considering individual needs and tailoring treatment to that is essential.
14 | MTF or LDX in first-line treatment ?