Comparative benefits and harms of competing medications for adults with attention-deficit hyperactivity disorder: a systematic review and indirect comparison meta-analysis.
ABSTRACT Recommended medication prescribing hierarchies for adult attention-deficit hyperactivity disorder (ADHD) vary between different guideline committees. Few trials directly compare competing ADHD medications in adults and provide little insight for clinicians making treatment choices.
The objective of this study was to assess comparative benefits and harms of competing medications for adult ADHD using indirect comparison meta-analysis.
Eligible studies were English-language publications of randomized controlled trials comparing ADHD drugs to placebo. Data sources were electronic bibliographic databases, Drugs@FDA, manufacturer data, and reference lists. Two reviewers independently abstracted data on design, internal validity, population, and results. Benefits and harms were compared between drug types using indirect comparison meta-regression (ratio of relative risks).
Twenty-two placebo-controlled trials were included (n = 2,203). Relative benefit of clinical response for shorter-acting stimulants, primarily immediate release methylphenidate, was 3.26 times greater than for patients taking longer-acting stimulants (95% CI 2.03, 5.22) and 2.24 times greater than for patients taking longer-acting forms of bupropion (95% CI 1.23, 4.08). Immediate release methylphenidate is also the only drug shown to reduce ADHD symptoms in adults with substance abuse disorders. Neither non-stimulants nor longer-acting stimulants reduced adverse effects compared to shorter-acting stimulants. Key gaps in evidence were academic, occupational, social functioning, cardiovascular toxicity, and longer-term outcomes, influences of ADHD subtype and/or comorbidities, and misuse/diversion of the drugs.
Current best evidence supports using immediate release methylphenidate as first-line treatment for most adults with ADHD.
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ABSTRACT: Previously, in a 40-week, randomised, double-blind, placebo-controlled core study comprising three phases (9-week dose confirmation, 5-week open-label dose optimisation and 6-month maintenance of effect) in adults with attention-deficit/hyperactivity disorder (ADHD), methylphenidate modified-release long-acting formulation (MPH-LA) at 40-80 mg/day controlled ADHD symptoms as well as decreased functional impairment with a good tolerability profile (NCT01259492). Here, we report the long-term efficacy and safety from a 26-week, open-label extension phase of the same study (NCT01338818).CNS Drugs 09/2014; · 4.38 Impact Factor
Article: ADHD and pregnancy.[Show abstract] [Hide abstract]
ABSTRACT: Attention deficit hyperactivity disorder (ADHD) has been increasingly recognized and treated in children and adults in recent years. As a result, a growing number of women enter their reproductive years treated with medication for ADHD or are diagnosed and start medication during their reproductive years. A common question in perinatal psychiatry regards the risk-benefit profile of pharmacotherapy for ADHD, particularly with stimulants. At this time, there are no guidelines to inform the treatment of ADHD across pregnancy and the postpartum period. Concerns about in utero exposure to stimulants are based primarily on the impact these medications might have on fetal growth. While stimulants do not appear to be associated with major congenital malformations, more human data regarding potential behavioral teratogenicity are needed in order to understand both the short- and long-term risks. Severity of illness, presence of comorbid disorders, and degree of impairment have an impact on treatment decisions. Crucial considerations include driving safety and ability to function in occupational roles. While most women can successfully avoid the use of stimulant medication during pregnancy, there are cases in which the benefits of stimulant treatment outweigh known and putative risks of in utero medication exposure.American Journal of Psychiatry 07/2014; 171(7):723-8. · 13.56 Impact Factor
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ABSTRACT: The pharmacological treatment of individuals with attention deficit hyperactivity disorder (ADHD) and severe substance use disorder (SUD) is controversial, and few studies have examined the long-term psychosocial outcome of these treatments. Our aim was to investigate whether pharmacological treatment was associated with improved long-term psychosocial outcomes.Methods The present naturalistic study consisted of a long-term follow-up of 60 male patients with ADHD and comorbid severe SUD; all participants had received compulsory inpatient treatment due to severe substance abuse. The average interval between inpatient discharge and follow-up was 18.4 months. Thirty patients had received pharmacological treatment for ADHD, and 30 patients were pharmacologically untreated. The groups were compared with respect to mortality and psychosocial outcomes operationalized as substance abuse status, ongoing voluntary rehabilitation, current housing situation and employment status.ResultsThe groups were comparable with regard to the demographic and background characteristics. Overall, mortality was high; 8.3% of the participants had deceased at follow-up (one in the pharmacologically treated group and four in the untreated group; the between-group difference was not significant). The group that received pharmacological treatment for ADHD exhibited fewer substance abuse relapses, received more frequently voluntary treatments in accordance with a rehabilitation plan, required less frequent compulsory care, were more frequently accommodated in supportive housing or a rehabilitation center, and displayed a higher employment rate than the non-treated group.Conclusions The recommendations for the close clinical monitoring of high-risk populations and the prevention of misuse and drug diversion were fulfilled in the structured environment of compulsory care for the treated group. Pharmacological treatment of ADHD in individuals with severe SUD may decrease the risk of relapse and increase these patients’ ability to follow a non-pharmacological rehabilitation plan, thereby improving their long-term outcomes.Journal of Substance Abuse Treatment 11/2014; · 3.14 Impact Factor