Children and adolescents with bipolar disorder (BD) have a high incidence of comorbid attention-deficit/hyperactivity disorder (ADHD). In this paper, we report a consecutive case series on 7 patients with pediatric BD and ADHD who were treated with atomoxetine-and all but one were also treated in conjunction with mood stabilizers. All patients were outpatients at the Stanford Pediatric Bipolar Disorders Clinic. Information on patients was collected in a retrospective chart review. All but 1 patient demonstrated significant improvement in symptoms of ADHD. No patients had episodes of hypomania or mania during the treatment period. Adverse effects of atomoxetine treatment included sedation, nausea, and decreased appetite. These cases suggest that atomoxetine may be a safe and effective treatment for ADHD in conjunction with mood stabilizers in children with BD.
"In contrast, medications typically used to treat ADHD have been used with this population with better success, at least in controlling the ADHD symptoms in PBD children and adolescents. Hah and Chang  reported on 7 patients with both ADHD and PBD who were treated with atomoxetine in conjunction with mood stabilizers. They found that 6 of the 7 improved in symptoms of ADHD and none of the patients had a manic or hypomanic episode during the treatment period which ranged from 1.5 months to 18 months. "
[Show abstract][Hide abstract] ABSTRACT: Eleven previous reports have shown potential benefit of a 36-ingredient micronutrient formula (known as EMPowerplus) for the treatment of psychiatric symptoms. The current study asked whether children (7-18 years) with pediatric bipolar disorder (PBD) benefited from this same micronutrient formula; the impact of Attention-Deficit/Hyperactivity Disorder (ADHD) on their response was also evaluated.
Data were available from an existing database for 120 children whose parents reported a diagnosis of PBD; 79% were taking psychiatric medications that are used to treat mood disorders; 24% were also reported as ADHD. Using Last Observation Carried Forward (LOCF), data were analyzed from 3 to 6 months of micronutrient use.
At LOCF, mean symptom severity of bipolar symptoms was 46% lower than baseline (effect size (ES) = 0.78) (p < 0.001). In terms of responder status, 46% experienced >50% improvement at LOCF, with 38% still taking psychiatric medication (52% drop from baseline) but at much lower levels (74% reduction in number of medications being used from baseline). The results were similar for those with both ADHD and PBD: a 43% decline in PBD symptoms (ES = 0.72) and 40% in ADHD symptoms (ES = 0.62). An alternative sample of children with just ADHD symptoms (n = 41) showed a 47% reduction in symptoms from baseline to LOCF (ES = 1.04). The duration of reductions in symptom severity suggests that benefits were not attributable to placebo/expectancy effects. Similar findings were found for younger and older children and for both sexes.
The data are limited by the open label nature of the study, the lack of a control group, and the inherent self-selection bias. While these data cannot establish efficacy, the results are consistent with a growing body of research suggesting that micronutrients appear to have therapeutic benefit for children with PBD with or without ADHD in the absence of significant side effects and may allow for a reduction in psychiatric medications while improving symptoms. The consistent reporting of positive changes across multiple sites and countries are substantial enough to warrant a call for randomized clinical trials using micronutrients.
"There are limited data to guide the clinician in the management of bipolar disorder (BD) and ADHD. Hah and Chang54 reported a consecutive case series on 7 patients with pediatric BD and ADHD who were treated with atomoxetine. The majority (6) of patients were treated concurrently with mood stabilizers. "
[Show abstract][Hide abstract] ABSTRACT: This review examines and summarizes the pharmacodynamic and pharmacokinetic properties, short- and longer-term efficacy, the moderating effect of comorbid disorders, as well as short- and long-term safety and tolerability of atomoxetine for the treatment of pediatric attention-deficit/hyperactivity disorder (ADHD).
A systematic literature search was performed to review the extant literature on articles pertaining to the pharmacological treatment with atomoxetine in pediatric and/or adolescent ADHD.
There is an extensive literature on atomoxetine; over 4000 children have participated in clinical trials of atomoxetine, demonstrating its short- and longer-term efficacy. In addition, studies have examined the moderating effect of comorbid disorders on atomoxetine response, as well as atomoxetine's therapeutic potential for other psychiatric conditions. Short- and longer-term safety and tolerability continue to be reported.
Atomoxetine is indicated for both acute and maintenance/extended treatment of pediatric ADHD. Clinicians and families must be familiar with atomoxetine's evidence base, including its profile of clinical response and its possible effectiveness in the presence of comorbidity.
[Show abstract][Hide abstract] ABSTRACT: Attention deficit hyperactivity disorder (ADHD) is a common chronic condition with childhood onset that can continue into adulthood. Medication is a fundamental element in the management of this disorder. Atomoxetine is the newest nonstimulant medication approved by the United States Food and Drug Administration (FDA) for the treatment of ADHD. It is the only nonstimulant medication approved by the FDA for treatment of adult ADHD. Atomoxetine is a norepinephrine reuptake inhibitor that selectively inhibits the presynaptic norepinephrine transporter. A growing body of literature supports the use of atomoxetine both in children and adults with ADHD. This paper summarizes information from the literature about atomoxetine, including pharmacokinetics, pharmacodynamics, clinical trials, dosing, and side-effects.
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