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Case Vignette: A 7-year-old female child was referred for poor concentration and reduced ‘interest’ in classes while the teacher was teaching. She would make careless mistakes while writing dictation, often coming home with incomplete notes. She would lose her things in school daily and would have difficulty sitting in one place for a long time with a lot of fidgetiness. She was also known to be hyperactive. The teachers would complain about her distractibility to the smallest of stimuli during teaching hours in class. Her IQ on Wechsler Intelligence Scale for Children was 115 and there were no other significant problems in her psychosocial history. Her father had a history of similar problems.
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This is a preparation of MPH that uses the spheroidal oral drug absorption system (SODAS). It is available as 10, 20, 30 and 40 mg capsules. It has bimodal release profile with 50% of the drug i.e. d,l-threo MPH releasing initially and the other 50% releasing after 3-5 hours. It thus provides 8-hour coverage. The side effect profile is mild too. A study has shown an effect size of 0.9 with this treatment and no major adverse effects (Biederman et al., 2003a).
Expert consensus recommends MPH as the first line medication to be used in a treatment algorithm for ADHD in children and adolescents (Greenhill et al., 2002a; Wolraich et al., 2010). In case of no response or partial response, optimising the doses, or switching to other agents is the recommended step. It is also worth addressing and assessing non-compliance issues and any co-morbid conditions. There are various preparations of MPH available and various delivery forms to facilitate dosages in a once-a-day format.
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ADHD pharmacogenetics may pave the way for development of novel treatments. Gene discovery may promote the discovery of new drug targets. Genotyping may lead to identifying patients who are more likely to show response to a particular drug and thus treatment failures can be minimised. The hope that arises out of this is that ADHD treatments will eventually improve through a more personalised and individualised approach, and personalised ADHD therapy shall soon move from the promise phase to a practical one (Stein and McGough, 2008) .
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Attention deficit hyperactivity disorder is a developmental disorder with an age onset prior to 7 years. Children with ADHD have significantly lower ability to focus and sustain attention and also score higher on impulsivity and hyperactivity. Stimulants, such as methylphenidate, have remained the mainstay of ADHD treatment for decades with evidence supporting their use. However, recent years have seen emergence of newer drugs and drug delivery systems, like osmotic release oral systems and transdermal patches, to mention a few. The use of nonstimulant drugs like atomoxetine and various other drugs, such as α-agonists, and a few antidepressants, being used in an off-label manner, have added to the pharmacotherapy of ADHD. This review discusses current trends in drug therapy of ADHD and highlights the promise pharmacogenomics may hold in the future.
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Overall, pharmacotherapy of ADHD in children is proven to be effective. There is an abundance of evidence in this context, especially for MPH and ATX. In contrast to many other drugs used by relatively large proportions of children, drugs for treating ADHD are licensed and on-label for children. Although ADHD medication is being increasingly used for adolescents and adults, not much is published on specific efficacy and safety issues in these age categories. In general, we may conclude that though stimulant use has increased over the years, there is a lack of studies on long-term effects of ADHD drugs in all ages. Since ATX is new and has been used on a relatively small scale, not much is known yet about its adverse events. This may at times bias the ATX – MPH choice discussion in favor of the first. There are few studies that provide a head on comparison between various drugs used in ADHD. Multiple studies with small and large number of subjects using different scales and methods, along with varying durations, make meta-analyses in ADHD an onerous task. Although MPH has been used for decades, physicians also need to be aware that rare and possibly severe adverse events might come up. Also, the increased longevity of ADHD medication use may give rise to new concerns, which stresses the importance of monitoring people who use this medication for such a long period.
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CITATION: De Sousa A, Kalra G. Drug Therapy of Attention Deficit Hyperactivity Disorder: Current Trends. Mens Sana Monogr 2012; 10: 45-69.