Individualizing ADHD Treatment for Different Patient Populations

Theresa R. Cerulli, MD: One question I often get asked from patients and clinicians alike is: if the patient has more inattentive symptoms vs hyperactive symptoms, do we treat those differently and choose different medications for those populations? Another question I get asked is: do you treat younger patients vs older patients differently in terms of your choice of medications?

I don’t know about all of you, but I don’t think in those terms. It certainly isn’t that certain medications work better for inattentive or hyperactive-impulsive symptoms. If they’re FDA approved, they hopefully work on all symptomatology. But it’s about what we’ve been discussing: finding the right fit for that particular patient, not grouped by age, gender, methylphenidate responders, or amphetamine responders. Sometimes family history can guide you a little, but it seems as though ADHD [attention-deficit/hyperactivity disorder] is such a heterogeneous condition that you have to take each patient as an individual. That has been my experience. What are other thoughts?

I’ll add one last thing. More than how to approach it, historically, there are statistics that more pediatric patients seem to end up on methylphenidate products, and more adults seem to end up on amphetamine products. Just because it’s a higher percentage doesn’t mean it’s better efficacy. That’s my sense. It was just the way the prescribing habits evolved over time. As Andy said, the amphetamines were a bit harsher at times and more potent. In young children, they might have been harder to tolerate in the original short-acting form.

Andrew Cutler, MD: Right.

Theresa R. Cerulli, MD: We tended to reach more for the methylphenidate products, so that’s historically the practice. Then the adults did a little better on the amphetamines in terms of tolerability. But I don’t think there’s better efficacy in either direction. That’s the pattern I’ve seen with prescribing.

Andrew Cutler, MD: I have a slightly different take, Theresa. First, let me address the comments about methylphenidate in younger patients, and amphetamine in older. You’re absolutely right that it’s a bit of a tolerability issue in younger children. As I said, amphetamines tend to be more potent as far as appetite suppression, which is a big issue with children and less of an issue with adults. There’s also irritability and insomnia. There’s a historical reason for amphetamines in adults: up until recently, we haven’t had truly long-acting methylphenidates, and the amphetamines were the first ones approved for adults. There’s the mixed amphetamine salt XR [extended release], the 2-beaded one. But there’s also now a 3-beaded one that lasts longer, and then lisdexamfetamine [LDX]. We also have the mixed amphetamine salt XR liquid, and now the tablet, which is very exciting. Some of that is the issue.

But as far as thinking about younger vs older patients, I have a different take. There are certain things we have to consider as people age. In the older adolescent and younger adult patients—especially college age—I’m a little worried about abuse, misuse, and diversion. That may affect things. Also, as Mike said, he had a patient who went away to college. That presents certain challenges as far as maintaining them on medication.

As people get older, I’m worried about medical comorbidities and concomitant medications—especially cardiovascular issues—so I’m going to be a lot more careful using something with a really up-and-down PK [pharmacokinetic] curve when I’m really worried about blood pressure peaks and heart rate peaks and elevation. There are certain considerations that we might also take into account. The duration of the day and the types of activities the person has might change what we do.

Theresa R. Cerulli, MD: Thanks, Andy. Does anyone else want to weigh in before we move to a couple of very specific new options in the field of ADHD?

Birgit H. Amann, MD, PLLC: I’m so glad we have so many more options approved in adults. Because in the beginning of my practice, it was so common to have a pharmacy phone and say, “Do you realize your patient is over 18 years old and you’re still treating ADHD?” That was because pretty much all of the products out at that time didn’t have an adult indication.

Theresa R. Cerulli, MD: Then insurance wouldn’t pay for a medication if it wasn’t approved by the FDA for adults. We’ve come a long way. We still have some unmet needs in the field, but we’ve certainly come a long way.

Andrew Cutler, MD: Historically, there were only 4 stimulants approved for adults. There were the dexmethylphenidate extended release, and the methylphenidate OROS [osmotic-release oral system] preparation. Neither of those address the duration that adults need. They wear off too soon. Then we had the mixed amphetamine salt double-bead, and lisdexamfetamine. That played into this amphetamine vs methylphenidate story.

Michael Feld, MD: I’ll add one final thing. A lot of primary care providers who treat a lot of these children believe that methylphenidate is more like a McDonald’s vs a Starbucks. But when we look at the 2 extended-release forms that Andy just talked about—the double-bead mixed amphetamine salts, and LDX—a lot of children didn’t tolerate that. There was a tolerability issue, so I honestly think, and we’re going to talk about the liquid XR delivery but also the new tablet, and the other company that has the ODT [orally disintegrating tablet] in a little different microparticle delivery.

That has been a game changer for me to get children onto amphetamine products, because I find them kinder and gentler. You ideally get to be more of yourself on it and hopefully a little less appetite suppression; not everyone tolerates it. Then you get the easier drop-off at the end of the day with enough length of action and less IR [immediate-release] augmentation, so these children don’t have to take an IR medication as often as they previously did. That has been a game changer. As Andy said, with the 2 prior long-acting methylphenidate products, the beaded dexmethylphenidate product, you couldn’t get through the workday. If you were an adult, you were getting on IR augmentation. With the OROS delivery, because of its delivery system, you don’t always get the same length of action, but you have a very slow start to the day.

Andrew Cutler, MD: That’s right.

Michael Feld, MD: You often have to reverse augment an adult with an IR methylphenidate. The point is that these new methylphenidate delivery systems have opened up for me to tell adults to try it. A lot of adults don’t like how they feel on an amphetamine, so why not give them a methylphenidate challenge? I have many more adults on methylphenidate in the last 5 years than I did for the 25 years leading up to that.

Andrew Cutler, MD: I agree.

Michael Feld, MD: It’s completely about the biotechnology.

Theresa R. Cerulli, MD: Dr Feld, you may be a leader and trendsetter in the field here, shifting some of the adult patients to methylphenidates more than amphetamines, which isn’t the typical prescribing practice.

Michael Feld, MD: I probably have a higher percentage of adults on methylphenidate and a higher percentage of children on amphetamine. I don’t know the data, but I’m sure I do. Because they come to me, and I change them. They come to me because they aren’t tolerating an amphetamine, and I say, “Let’s try a methylphenidate.” If a child isn’t doing well on methylphenidate, I say, “We now have cool amphetamine products that we can try.” As a specialist, it’s easy to become that way because we often improve on what the patient didn’t do well with before they came to us.

Theresa R. Cerulli, MD: I’m so glad you joined our panel and have been able to give that perspective. That’s wonderful.

Michael Feld, MD: I’m glad to be part of this. You know how much I like you guys.

Transcript edited for clarity