Adult ADHD Treatment: Access to Different Drug Formulations


Experts in treatment of attention-deficit/hyperactivity disorder discuss the benefits of different drug formulations and the potential for abuse of immediate-release medications.

Theresa Cerulli, MD: I worry that the immediate-release medications are certainly the ones we know tend to be abused, diverted. There’s more risk there. They have a street value higher than the extended-release preparations. Not to say that all of them can’t be abused, people find a way to get creative, certainly. But the ones we worry about most are the immediate-release ones. So, I tend to start with long-acting formulations, whether it’s methylphenidate or amphetamine products. I very much ask the same questions you do with regard to any history. One question I ask, having learned secrets of my patients over the years, they often have tried something. They’ve taken their kids’, their brother’s medication, tried it for a couple of days. They’re not going to come out necessarily and tell you. So, if you open the door to say, “have you by any chance ever experienced taking somebody else’s medication?” And give that wink and nod….

Anthony Rostain, MD, MA: I love that question. I think that’s a great question.

Theresa Cerulli, MD: I open the door because they’re not going to come out and say it, I’ve learned over the years.

Anthony Rostain, MD, MA: No.

Theresa Cerulli, MD: Usually, I’ll get, “I did. I didn’t want to say anything. It actually really helped.” I say, “Good, what was it? Let’s start there.” Then the other thing on the formulations, we talk about prodrugs. We haven’t had many options in the ADHD [attention-deficit/hyperactivity disorder] field with prodrugs. There’s been lisdexamfetamine for years, a prodrug amphetamine. And it wasn’t until very recently that we’ve had a methylphenidate prodrug, so we can talk more about that. But the prodrugs, with something that’s a continuous release, it’s that sustained PK [pharmacokinetic] curve that feels a little different. Even if you’re talking about the same active ingredient in a prodrug, if it’s a smoother release and absorption of the active ingredient, it can feel quite different and sometimes more tolerable to an individual and lasts longer.

Anthony Rostain, MD, MA: Yes. In children, sometimes I consider, some of the liquid preparations are continuous release. It takes a bit of time to proceed down the digestive effect. And then in the early days when Concerta was released and using the osmotic pump, you could say that wasn’t a prodrug, but there really was a profile that looked different than the 2 peaks you see with the biphasic release. But you’re right, I think we’re moving into a new period now where we’re going to see more prodrugs. I think it’s very exciting because that also reduces the abuse potential.

Theresa Cerulli, MD: Yes, absolutely.

Transcript edited for clarity

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