Once a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) has been made, a decision has to be made about treatment. Most children do well with a combination approach of medication and behavioral therapy. The most likely medication to start with is a stimulant medication. And then the provider has to make a decision from many, many options. The question came up during a SmartCare PC2 call recently about how to make the decision of which medication to use and what to use as a next option if the first option does not work.
It is a somewhat complicated question and answer because there are multiple factors to look at: is this ADHD alone or co-morbid with something else; stimulant and non-stimulant choices; short-acting and long-acting formulations; dose and side effect considerations; an assortment of preparations available; and insurance considerations. If we start with the position of using a stimulant medication first, unless there is a reason not to (previously failed stimulant trial, significant co-morbid anxiety, substance abuse concerns, weight concerns), the first decision really is whether to start with a short-acting or long-acting formulation. Unless the child is very young, in most circumstances it would be appropriate to start with a long-acting formulation. If a child is unable to swallow a pill, there are long-acting versions that can still be used: Adderall XR capsules can be opened, Quillivant XR is a long-acting liquid methylphenidate preparation, and the Daytrana patch to name a few.
In terms of making the decision whether to start with a methylphenidate-based preparation or an amphetamine-based preparation, it mostly depends on provider preference. For children under the age of 6, it is slightly easier to get insurance approval for an amphetamine-based preparation because there is better research on the use of that class of stimulants in young children. If planning to prescribe a stimulant medication to a young child under the age of 6, it is best to start with an immediate release preparation, typically Ritalin or Adderall, and then to consider changing to a long-acting preparation over time if needed.
At this point there are so many preparations of long-acting stimulants, which can be confusing for providers. They are available in capsules, tablets, sprinkles, liquid, and patch forms. They mostly don’t vary much in terms of length of effect and side effect profile. Some vary in terms of how the active medication is released throughout the day. In general, if a patient does not do well on a long acting preparation from one class of stimulant, for example if s/he was started on Concerta, it probably does not make sense to try another long acting methylphenidate medication, but it makes more sense to try one from the amphetamine class instead.
Unfortunately many medication decisions are made based on what is covered by a patient’s health insurance. In the case of prescribing stimulant medications, this limitation can be seen as helpful to narrow down the choices available to the provider.
Given the seemingly never-ending list of stimulant options, providers might find it helpful to develop a list of stimulant medications they are comfortable prescribing, making sure to cover the basic insurances and the basic preparations and both short-acting and long-acting preparations. It might also be a good idea to develop a comfort level with some of the non-stimulant medication options, like Strattera, Tenex, and Clonidine. These have been discussed in previous e-Weekly newsletters and will be reviewed again soon in a future e-Weekly newsletter.