What is the pharmacological treatment of various subtypes of ADHD?
Written by:The psychotropic drugs are the mainstay of treatment of ADHD, an alteration that affects about 5% of children and adolescents and symptoms persist at a high rate in adult life.
The psychopharmacological treatment of ADHD began in 1937 when Bradley observed that an amphetamine derivative, Benzedrine, improved hyperactivity in a group of children with behavioral disorders.
Since then, the investigation of psychostimulants has continued to advance, it is currently the psychopharmacological group of choice in the treatment of ADHD.
Psychostimulants
Psychostimulants are psicofarmacos that improve care, reduce hyperactivity and impulse control increase. The most used is methylphenidate, The pharmacokinetics of psychostimulants depends on the form of presentation.
The fast-acting methylphenidate absorbed in thirty minutes, which may already be showing clinical effects, the maximum concentration is reached within two hours and has a therapeutic effect of 3-4 hours in some cases five hours ( in children or adolescents poor metabolizers ).
The long-acting methylphenidate allows a single dose taken in the morning plasma concentrations remain stable, having a duration according therapeutic and patient presentation. There are three types of presentation, methylphenidate extended release of osmotic technology ( gold ) and methylphenidate extended release ( 50/50 and 30/70 ). Methylphenidate of osmotic presentation has a stable and long life, up to 12 hours and the other 6/7 and 8/9 hours respectively.
The methylphenidate is an effective and safe psychostimulant. There are now hundreds of studies double blind placebo controlled and effective 70-80 % of children and adolescents with ADHD. Note that in children under six, clinical response can be erratic, with lower efficacy and major side effects.
To start a treatment is essential to have practiced a precise medical diagnosis, based not only on indirect assessments of opinion questionnaires for parents and teachers.
as Initiate treatment should carry out appropriate monitoring, controlling weight, height, blood pressure and heart rate. No analytical sanguinea is compulsory, but if it is advisable to complete cardiologic study to rule out the presence of cardiac pathology in patients with a family history heart. ( The American Academy of Pediatric Cardiology recommended in this case an electrocardiogram and echocardiogram ).
The duration of treatment depends on each patient. You can practice tests suspension, but not before the year. It can be done by lowering the dose in half for a week and assessing the evolution without medication, with school review without knowingly two consequent weeks. However treatments are long lasting, being rare patients who can withdraw the medication in the first year of treatment.
psychostimulants are drugs to be administered daily, without suspending the holidays, as before was done in a time with less knowledge of side effects. ("ADHD is a disorder that affects life, not just school" ;), moreover, the current known effects of methylphenidate, from recent work by P. Shaw, modification of brain architecture facillitando and stimulating their maturation, determine the need for treatment
The most common side effects include decreased appetite and insomnia. Current publications (Spencer TJ et al 2006 and Pliszka SR et al 2006 and Biederman et al 2010) confirm that methylphenidate does not diminish the stature of clinically significant way.
Other side effects include anxiety, restlessness, nervousness, headache, motor stereotypies, tics, increased heart rate and blood pressure, being much more rare psychosis and mania induced by the drug ( Wolraich et al. 2007).
When we manage psychostimulant must understand that there are still attitudes of distrust of psicofarmacos, with false ideas, erroneous beliefs and prejudices that often prevent adequate therapeutic compliance. Parents think that cause addiction and dependency, which alter the personality of the child or adolescent or conversely that psychostimulants are the solution to all your problems. It is essential to point out all these aspects with the family, and that compliance with the prescription depends on them. Finally do not forget that drugs are used in pediatric clinic for more than 60 years ago.
Atomoxetine
tomoxetine formerly Atomoxetine is a selective inhibitor of the reuptake of norepinephrine. Initially investigated as an antidepressant, low efficiency pose the search of another therapeutic strategy, so that its application was oriented ago over ten years to treat attention deficit disorder and hyperactivity.
The mechanism of action of atomoxetine is not known in depth. Perhaps it is related to the selective inhibition of reuptake of norepinephrine, increasing the activity of norepinephrine and its role in balancing the regulation of noradrenergic and dopaminergic neurotransmission associated with the disorder, according neurobiological studies and pharmacological supporting the hypothesis that ADHD is also a noradrenergic disorder that is essential to achieve a balance between the noradrenergic and dopaminergic activity.
quantitative neuroimaging studies in animal models show that atomoxetine binds more effectively to"locus"associated with fronto-subcortical areas of high presence of noradrenergic neurons that control attention and motor behavior system.
Atomoxetine can be used from six years of age. Los although rare side effects are:headache, stomach pain, decreased appetite, dizziness and vomiting. It is important to control blood pressure and heart rate, but follow-up studies, these values return to normal on withdrawal of treatment, likewise atomoxetine does not alter the QT interval of the ECG.
In summary Atomoxetine is a selective inhibitor of the reuptake of norepinephrine which has been approved by the Food and Drug Administration American to treat attention deficit disorder with hyperactivity that has shown efficacy in clinical trials of short duration in children and adolescents.
Other drugs used in Spain with ADHD
adrenergic agents:Clonidine, Guanfacine (2015 )
Antidepressants:Antidepressants triciclcos:Reboxetine, Bupropion
Amphetamines:Lisdexamfetamine (2014 )
fatty acids:Omega 3 (DHA and EPA)
Finally, it is important to note that in future revisions DSM is raised to the various subtypes of ADHD are also identify clinical variables that meet specific psychopharmacological treatments. ( Martin A. et al 2007, Martin et al 2010).