Future of Adult ADHD


Experts in psychiatry discuss the future of ADHD management as well as challenges when approaching treatment of adult ADHD.

Stephen Faraone, PhD: Let's move on and talk about what the unmet needs are given the current drugs that we have for treating adult ADHD that are approved by the FDA. What's the future for adult ADHD? What are the challenges for treating ADHD that might be solved by developments in the pharmaceutical industry? Andrew, I'll start with you this is this is one for everybody.

Andrew Cutler, MD: I will be happy to start. OK. Steve, there are several unmet needs, even though we do have many options particularly in the stimulant world. Obviously, we need more non stimulant options, as I mentioned before there's only 2 non-stimulants currently approved for adults. I don't know about you guys, but I have a lot of about you guys, but I have a lot of patients who are on a stimulant and let's say an SSRI, because I'm trying to manage both the ADHD and the depression or the anxiety. And at least with the newest of the non-stimulants extended release viloxazine that drug that has demonstrated efficacy for depression and anxiety as well as ADHD, and perhaps I can use one medicine instead of 2. We also need medicines with better safety profiles, I'm always concerned about as people get older I'm very concerned about cardiovascular issues, and other medical conditions, drug, drug interactions because they're on multiple medications. And the 2 approved non stimulants, the norepinephrine reuptake inhibitors have warnings about blood pressure and heart rate as do stimulants. That's certainly a concern of mine. We always worry about abuse, misuse, and diversion of our medications. That's another area that we need to be thinking about as we're managing these patients and then not every patient is the same, not every patient has the same limitations, the same functional impairments, the same quality of life issues. Just having more options to be able to tailor to people's cluster of symptoms, and you had mentioned for instance, Steve earlier about executive function, this is something that I'm, I believe is a big part of ADHD especially in adults. And medications that work for that, because the rating scales that we use, at least the ADHD RS, is not specifically geared towards looking at executive function very well. I know you would agree.

Stephen Faraone, PhD: That's right, it's not, and when studies have used the appropriate rating scales, like the brief, what we find is that the current medications, they help produce executive dysfunction somewhat, but not enough. The effect is much larger for the symptoms of ADHD than it is for executive functions, or emotional dysregulation as well.

Andrew Cutler, MD: You know, well said, I completely agree with you about emotional dysregulation that is something that is underappreciated as well.

Stephen Faraone, PhD: The challenge for misuse, abuse and diversion is that is a big one? There have been efforts to try to develop manipulation and resistant forms of stimulants, I hope they'll become successful, but there's it’s a difficult path, regulatory path to follow. But we may be seeing that in the next few years.

Theresa Cerulli, MD: I could add my wish list, what I would like to see is a non-stimulant or at least non controlled is probably better word, non-controlled medication for ADHD available 24/7. It's not going to be there from the time you wake up in the morning until the time you put your head on the pillow in the evening, that has the effect size. In other words, robustness of response, not just improved symptomatology, but the robustness of a stimulant, so a non-controlled substance with the 24/7 availability, and the effect size of a stimulant, that's what I would like to see.

Stephen Faraone, PhD: That's the holy grail for ADHD treatment

Theresa Cerulli, MD: Not asking too much am I?

Andrew Cutler, MD: Well not only that, one that works consistently. My sense is that stimulants work reliably for the vast majority of patients, and studies suggest it's up to 80%, but non stimulants are more like they're more 40 to 60% maybe patients, something that's more consistent in more patients too.

Stephen Faraone, PhD: I'm going to add another one more unmet need before we move on to our case presentation, and that is the ability to do precision medicine, to be able to predict who responds to what medication. Currently, we can do it very well, I've got some data recently published showing that we can predict well who would respond to extended release viloxazine after 2 weeks of treatment. But that's still not good enough, we need to be able to have something which tells the clinician, there's a good chance that this person is going to do well on this non-stimulant, or this is formulation. We're not there yet, but I do expect we're going to get there in 5 or 10 years.

Craig Chepke, MD, FAPA: I'll throw in one thing really quick, why not a long-acting injectable non-stimulant. Obviously, we can't do it with stimulants, but with non-stimulants it is a potential option. If Theresa can make her wish list, I can go for that one.

Stephen Faraone, PhD: That's a good one, yes, I'd like that, it's a very creative one, thank you.

Transcripts edited for clarity

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