Around the Practice: Management of Adult with Attention Deficit/Hyperactivity Disorder (ADHD) - Episode 19

Case 3: Factors Driving Treatment Selection in Adult ADHD

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ADHD experts discuss factors that drive treatment selection when selecting therapy for an adult with ADHD.

Stephen Faraone, PhD: Craig, let’s talk about some other factors that might drive treatment selection. There are things like mechanism of action. There’s obviously efficacy, safety data, long-term use data, comorbidities. Can you give us a bird’s-eye view of how you put that all together when you think about what medication you’re going to choose for a patient?

Craig Chepke, MD, FAPA: This is a continuation of the discussion we’ve been having all day. Is that it’s very individualized. But it comes down to a couple common threads. First, are we looking at stimulants versus non-stimulants, when talking about pharmacological techniques? A number of guidelines, including the Canadian ADHD guidelines, recommend not just the stimulants as first-line treatment, but long-acting stimulants. I want to reiterate again that we should be favoring the long-acting stimulants. And then when you look at which family of stimulants. That varies, as well. Both are efficacious. One can work well for one, and not for another. But in general, there was a meta-analysis that was done, and a systematic review a couple of years ago, showing that the best risk/benefit ratio for adolescence, in their opinion, was methylphenidate. And for adults, best risk/benefit was for amphetamines. That’s still not a hard and fast rule, though. Many clinicians will, even in adults, start with a methylphenidate if they’ve been untreated before. Often, I will do that. It depends on the individual patient. Figuring out what is going to fit their needs. Theresa brought up earlier, and Andy echoed it, the shared decision making. Very crucial. Because no matter what we think, if the patient doesn’t have a say in it, A, they’re not going to adhere to it. And B, it’s probably not going to be as good of a fit as we think it is. Because we can only assess so much. Taking that guideline information, and that knowledge that we have from our education, our experience. And then coupling that, and partnering with the patient, of their lived experience, that they’re the expert on. And concluding together on how to impact the person’s life in the best way. Trying to marry the individual experience with the guidelines, and everything in between, on a continual basis.

Stephen Faraone, PhD: And Andy, do you have an evidence-based hierarchy in your choice of medications for adults with ADHD?

Andrew J. Cutler, MD: It would be nice if we had some type, as you mentioned, some type of biomarker or precision medicine guidance. I always joke. Our friends in other fields of medicine, such as oncology, they can do a test and tell you the best chemotherapy. And if we had something like that, we’d be like real doctors, is what I always joke. But how I think about it is this. And let me also back up and say, unfortunately, in America- Craig referenced the CANMAT [Canadian Network for Mood and Anxiety Treatments] guidelines. In America, we don’t yet have adult ADHD treatment guidelines. I know you, Steve, are working on those and we need them.

Stephen Faraone, PhD: The American Professional Society for ADHD and Related Disorders is initiating, this month, a program to develop guidelines for treating- diagnosing and treating ADHD in adults. We’re hoping it’ll be ready by early next year.

Andrew J. Cutler, MD: And I know you’ve published some quality indicators that are extremely helpful, to help guide us. As Craig said, we would agree. Just as with kids, stimulants have the best effect size, the best efficacy data, and are usually considered first-line, I would say. Unless there’s a situation where a patient is not appropriate for a stimulant, or refuses a stimulant, for whatever reason. Substance abuse, cardiovascular safety issues, whatnot. Certainly, we must remember, if somebody has a bipolar disorder, we need to manage that. Then you could be adequately mood stabilized. We’ll treat them with an atypical antipsychotic first. Then you can consider treating the ADHD. Between the amphetamine, I completely agree with Craig 100% while it is true that amphetamines probably do, in general, work a little better for adults, I’ve done the clinical trials with the newer extended-release methylphenidates in adults. And it had some do very well. I’m not averse to using those in adults. I have sort of the feel for who’s better for an amphetamine, who’s better for an methylphenidate. It’s not necessarily scientific, just from years of seeing patients. And then I tailor the formulation and the duration into this. I want to revisit this case for a second. Because I think we assumed here that I’m not clear on. She said that she can’t turn it off. She’s taking this mixed amphetamine salt extended release, and at the end of the workday, she can’t shut it off, and has some trouble with insomnia. Most people would look at that and think, “Oh, the medicine’s lasting too long and causing the insomnia.” But I think those of us experienced ADHD providers have said, “No. Wait a minute. It's possible it wore off too soon. The ADHD came roaring back, and that’s why she can’t shut off.” And I think that’s more likely, considering that mixed amphetamine salt XR is one of the ones Craig referred to earlier. That, while we call it extended-release, it’s not as extended release or as not long-acting as some of the others. And very often, I hear that, too, where there’s insomnia. But as we talked about it, it could be from the ADHD. It’s just they can’t unwind- mind off. Do I switch now to an even longer-acting formulation? Do I augment with a booster? Which is not ideal, because now I’m prescribing immediate release. What are the various comorbidities that I’m trying to address? These are all some of the ways that I think through what my treatment plan is going to be.

Transcript edited for clarity