Which medications in the drug class Stimulants are used in the treatment of Pediatric Attention Deficit Hyperactivity Disorder (ADHD)?

Updated: Nov 20, 2018
  • Author: Maggie A Wilkes, MD; Chief Editor: Caroly Pataki, MD  more...
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Answer

Stimulants

Psychostimulants stimulate the areas of decreased activation to a higher state of arousal. The spectrums of therapeutic efficacy and adverse effects of all the FDA-scheduled category II psychostimulants for ADHD (ADD) are similar. For any individual, therapeutic efficacy may vary greatly among drugs, preparations, or formulations (generic vs brand name).

The most common adverse effects include anorexia, sleep disturbances, mild anxiety, and rebound (eg, post-therapeutic agitation, anger, lethargy). Most individuals who take psychostimulants for ADHD (ADD) develop tolerance for the adverse effects within a few weeks. Although adverse-effect profiles, akin to therapeutic profiles, are similar for all psychostimulants, patients have their own positive and negative responses, which vary among the drugs.

Individuals with certain current or latent coexistent psychiatric disorders (eg, psychosis, bipolar disorder, some disorders of anxiety or depression) are particularly vulnerable to the adverse effects of stimulants if they do not receive concurrent medication, psychological counseling, or both for the coexistent condition.

The following contains FDA-approved dosing information and FDA-stated contraindications. Of note, many experts question the FDA's maximums for most stimulant medications (see the Table above for ranges). Experts also question several comorbidities thought to be contraindications because evidence suggests that tics may be as likely to improve with stimulants as worsen with them. Furthermore, blood pressure improves in some individuals with hypertension receiving stimulants, whereas others simply need a slight increase in their dose of antihypertensive. Finally, although the FDA lists glaucoma as a contraindication, the specific concern is only narrow-angle glaucoma.

Dextroamphetamine (Dexedrine, Dexedrine Spansules, Dextrostat)

Increases amount of circulating dopamine and norepinephrine in cerebral cortex by blocking reuptake of norepinephrine or dopamine from synapse. Short-acting brands fairly similar in cost; generic is 50-60% less expensive. Dexedrine available as 5-mg scored tab. Dextrostat available as 5-mg or 10-mg scored tab. Dexedrine Spansules (CR) available as 5-mg, 10-mg, or 15-mg Spansules

Methylphenidate (Aptensio XR, Concerta, Cotempla XR-ODT, Jornay PM)

Stimulates cerebral cortex and subcortical structures. Generic and branded-generic (Methylin and Metadate regular or ER) formulations 50-60% less expensive than Ritalin. LA preparations more expensive than short-acting preparations. Concerta (LA) tends to be more expensive than other preparations; 1 cap of Concerta, similar to other stimulants, costs the same whatever dose.

Although clinical difference between generic drug and branded-generics or Ritalin has not been verified, many patients have enough variability among preparations that they are willing to pay the price difference. Many experts observed enough variability that they do not prescribe plain generic products unless patient (or insurance) insists. FDA allows for 20% variability in certain parameters between generics and brands and determines equivalence solely by pharmacokinetics and not data from clinical studies.

Dextroamphetamine and amphetamine mixture (Adderall, Mydayis)

Produce CNS and respiratory stimulation. CNS effect may occur in cerebral cortex and reticular activating system. May have direct effect on alpha-receptor and beta-receptor sites in peripheral system and release stores of norepinephrine in adrenergic nerve terminals. Mixture contains various salts of amphetamine and dextroamphetamine. Adderall is available as 5-mg, 7.5-mg, 10-mg, 12.5-mg, 15-mg, 20-mg, or 30-mg scored IR tabs and 10-mg, 20-mg, and 30-mg XR caps. Mydayis is also available as 12.5 mg, 25 mg, 37.5 mg, 50 mg extended release caps.

Dexmethylphenidate (Focalin, Focalin XR)

Contains pharmacologically active d-enantiomer of racemic methylphenidate. Blocks norepinephrine and dopamine reuptake into presynaptic neuron and increases release of these monamines into extraneuronal space.

Methylphenidate transdermal patch (Daytrana)

CNS stimulant. Therapeutic action for ADHD (ADD) not known but thought to block norepinephrine and dopamine reuptake into presynaptic neuron and to increase release of these monoamines into extraneuronal space. Racemic mixture composed of the d-enantiomer and l-enantiomer. The d-enantiomer is more pharmacologically active than the l-enantiomer. Transdermal administration exhibits minimal first-pass effect compared with PO administration; consequently, lower dose of transdermal methylphenidate (on mg/kg basis) compared with PO dose of methylphenidate may still produce higher d-methylphenidate level.

Available in 4 dosage strengths. Different-sized patches contain different amounts of methylphenidate and deliver different amounts over 9-h dose period. Respective patch sizes, methylphenidate content per patch, and dose delivered over 9 h are 12.5, 18.75, 25, and 37.5 cm2; 27.5, 41.3, 55, and 82.5 mg; and 10, 15, 20, and 30 mg. Onset of desired effect occurs approximately 2 h after application and persists 3-4 h after removal.

Lisdexamfetamine (Vyvanse)

Inactive prodrug of dextroamphetamine. Elicits CNS stimulant activity. Blocks norepinephrine and dopamine reuptake in presynaptic neurons and increases release of these monoamines in extraneuronal space. It is indicated for initial and maintenance treatment of ADHD in children aged 6-17 years and adults.

Amphetamine (Dyanavel XR, Evekeo)

Noncatecholamine, sympathomimetic amine that elicits CNS stimulant activity. The precise mechanism by which amphetamines produce mental and behavioral effects are unclear. Available as short-acting tablets (Evekeo) that need 2-3 doses/day in children aged 3 y or older. It is also available as a long-acting, once daily oral suspension (Dyanavel XR) or extended release oral disintegrating tablets (Adzenys XR-ODT) for patients aged 6 y or older.


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