ADHD Pharmacological Approach: Stimulants



Frank Lopez, MD: As we know, ADHD [attention deficit/hyperactivity disorder] is associated with a lack of appropriate use of dopamine. But it’s not just dopamine. It’s norepinephrine and it’s also serotonin. Until now you know we have really had a limited armamentarium in terms of medications. As we know, we have the stimulants and we have nonstimulants. But typically they’re addressing primarily the dopamine and norepinephrine, enhancing them either presynaptically or postsynaptically or inhibiting them.

Theresa Cerulli, MD: That’s the ADHD story, right?

Frank Lopez, MD: That’s right.

Theresa Cerulli, MD: We’ve thought about this as a condition that’s involved with dopamine and norepinephrine. I know you’re setting the stage for our discussion around some novel approaches, but traditionally this is what we’ve had. With the stimulants, Frank, I know there are concerns. The FDA-approved options right now are some stimulants and nonstimulants such as atomoxetine, guanfacine extended release, and clonidine extended release. The stimulants, do you want to comment on those? What do we have for stimulant options right now?

Frank Lopez, MD: For our stimulant options, we have 5 that are short-acting—these are amphetamines at this point—and 8 long-acting. In the methylphenidate family, we have four short-acting and 12 long-acting. Essentially, we have the same molecule; we just have different delivery systems. This is interesting because we’ll come across many patients for whom we try 1 delivery system and it’s a complete and utter failure. But if you allow yourself, and the parent allows you to try the same molecule but in a different delivery style, it could mean a world of difference. But then you go to the nonstimulants, which are the ones you were mentioning, and again we only have 3 that are approved and all 3 are essentially long-acting. You have the atomoxetine, and then you have the guanfacine extended release and the clonidine extended release.

But there are other molecules in the pipeline. What I like to tell people is if they want more information on the newer molecules, go to I have parents who will actually ask for that. I’ll say you can go ahead and go there, but be careful when you go to the internet. You might get more confused. There may be information there that is not quite right. And then the next visit they go, “Oh, by the way, doctor, I read”—and when they say that, all of a sudden my coronaries go, “Let’s get ready. Here it comes.” So it’s really quite interesting.

Theresa Cerulli, MD: Right. One of the things they often read about is the risk of substance abuse, the potential with stimulant medications. When you’re bracing yourself, I’m assuming that’s 1 of the things you expect to hear from parents, understandably so. Stimulants carry the black box warning, yet we use them frequently to treat ADHD.

Frank Lopez, MD: Correct. You have to spend some time explaining that to them, and once you do and you put it in terms that they can work with, they accept the risk. The risk is low. It’s not a high-risk situation, especially if you’ve taken the time and looked thoroughly at the child. Some clinicians will—and I’m included in those—actually do some labs and even an ECG [electrocardiogram] prior to starting medication. I realize that these medications are safe and effective. However, we have an old saying, that books don’t feel pain and books don’t bleed. If the family is concerned or afraid of using a stimulant, even a nonstimulant, why not support them and say, “Look, we can tell you. We have evidence; it’s evidence based. This is safe and effective, but you have concerns. Would you like to proceed and get some basic labs?” Many times they will say, “No, it’s not necessary,” but other times we have parents who are really nervous, and we do that to bring that level of parental anxiety down. There are lots of data to support the safety of these medications across the board. Again, newer molecules, newer delivery systems, provide more variability in our armamentarium to treat the patient.

Theresa Cerulli, MD: In follow-up, not just diagnostically and initially screening with regard to safety, I do check blood pressure and heart rate in my patients. We get weights, we check heights—some of the things that we need to measure for safe use of the medications we’re prescribing for our patients.

Frank Lopez, MD: Without any doubt. That brings up another question, and this is a question I hope we’ll address a little later. In the era of COVID-19 [coronavirus disease 2019], how are we getting all our anthropometric measurements? Because you need to know. At what point do you have to bring that patient in?

Theresa Cerulli, MD: We are absolutely going to cover that and need to cover that because it’s so important for clinicians to hear. I’m going to shelve that discussion just for a minute. As we’re talking about some of the treatment options, I already heard you say—and I fully agree—that it’s important to combine both pharmacological and nonpharmacological interventions for the best treatment outcomes for our patients. Both are important. I often will say to families, when you’re working with medication, you’re treating the underlying neurobiology. You’re working from the inside out. And when you’re talking about the supportive measures—the nonpharmacological measures such as exercise, coaching, parent training, CBT [cognitive behavioral therapy]—you’re working from the outside in. Those combined approaches—not just in my practice but in my own family, as I’ve shared—are really essential for helping with functioning. ADHD is not just affecting the individual; it’s the whole family system. It’s because of the challenges with not just attention and impulse control but with, as I said, organization. So where one’s phone is, getting to one’s hockey game on time, making it on the bus in the morning, having the homework that you did last night actually getting to the teacher to be turned in. All those things, it becomes a family system’s issue and how the family is functioning. If 1 person is slightly attention deficit and the other is attention surplus, people might need to be the supportive team.

Frank Lopez, MD: You have an external brain.

Theresa Cerulli, MD: Right, and that structure is so needed.

Transcript Edited for Clarity

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