COMMENTARY

Recognizing and Managing Stimulant Complications

Adelaide S. Robb, MD

Disclosures

November 14, 2006

In This Article

Introduction

Attention-deficit/hyperactivity disorder (ADHD) affects 8% to 10% of school-aged children and 4% to 6% of adolescents; 4% of adults continue to be symptomatic.[1,2] Stimulants are the treatment of choice, with reported levels of response as high as 70%, according to practice parameters and treatment guidelines.[3] Studies have also shown that the duration of treatment and compliance improves long-term outcomes, leading to enhanced school performance; higher IQ and achievement testing scores; fewer driving difficulties; and lower rates of drug, alcohol, and tobacco use.[4,5,6,7,8,9,10,11,12,13] Studies have shown that remaining on treatment improves short- and long-term outcomes, and benefits continue without the development of tolerance.[3,14,15,16]

The success of treatment depends on adherence and compliance and issues that may affect adherence and compliance. Noncompliance rates for stimulants range between 20% and 65%.[17] Several factors improve compliance in patients receiving stimulant treatment, including the use of longer-acting stimulant preparations.[16,18] Several studies of compliance showed that long-acting preparations enjoyed better compliance, fewer switches, and more persistence on treatment compared with short-acting preparations.[19,20] Factors associated with poorer compliance rates include adolescent age, rebound, lack of knowledge about ADHD and its treatment, and side effects.[21,22] Long-acting stimulants and nonstimulant medications have improved compliance rates because of once-daily dosing and lower rates of rebound. As primary care and specialty physicians learn more about ADHD and its persistence, they can teach patients and their parents, thus improving the understanding of ADHD and its treatment across the patient life span.

The remaining issue that affects adherence to stimulants is treatment-emergent side effects. By recognizing and managing side effects, clinicians can improve treatment adherence in their patients with ADHD. This column discusses common and rare side effects of stimulant treatment and how to manage or minimize these symptoms in patients with ADHD. The side effects will be categorized according to duration (short- and long-term) and described by organ systems involved.

For patients receiving stimulant medications, using a side-effect rating scale, such as the Pittsburgh Side-Effect Rating Scale, and obtaining baseline height, weight, and vital signs allow the physician to monitor growth and differentiate treatment-emergent side effects from those present at baseline. One crossover study of methylphenidate (MPH) and dextroamphetamine in Australia showed that many "side effects" were present at baseline and improved with treatment.[23] In the same study, only 1.6% of those taking either stimulant discontinued treatment because of side effects. Patients may stop using medications because of treatment-emergent side effects even more often in clinical practice than in a clinical trial.

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