Tag Archives: methylphenidate

Quick Hits: FDA Approves New Antibiotic, ADHD Med, and Opioid Use in Depressed Patients

The FDA has approved Baxdela (delafloxacin), a fluoroquinolone antibiotic that is used to treat acute bacterial skin and skin structure infections (ABSSSI). The drug is available as a tablet or intravenous injection. Labeling for the drug includes a “black box” warning due to serious adverse and potentially irreversible reactions that have been associated with fluoroquinolones, such as tendinitis and tendon rupture, peripheral neuropathy and central nervous system effects. In trials, the most common adverse reactions in patients observed were nausea, diarrhea, headache, elevations of the enzyme transaminase, which can indicate liver damage, and vomiting. Posted June 19, 2017. Via Melinta Therapeutics.

A new once-daily treatment for attention deficit/hyperactivity disorder (ADHD) has won FDA approval. Mydayis, a stimulant for patients 13 years and older, contains the same active ingredients as Adderall (amphetamine/dextroamphetamine), but lasts for up to 16 hours compared to up to 6 for Adderall and 12 for Adderall XR. Adderall and Adderall XR are both available as a generic. Like other stimulant medications, such as methylphenidate (Ritalin, Concerta, Daytrana), Mydayis has a “black box” warning because it has a high chance for abuse and can cause physical and psychological dependence. Posted June 20, 2017. Via Shire.

Patients with low back pain who also suffer from depression are more likely to be given opioids that are prescribed at higher doses. This is problematic, since patients with depression are at a higher risk of misuse and overdose of opioids. Researchers examined data on opioid prescriptions from 2004-2009 and found that those with low back pain who also had depression were twice as likely to be prescribed an opioid than those without depression. And over a year, they typically got more than twice the usual dose, according to the study published in the journal Pain Reports. The authors noted more study is needed to determine the risks and benefits of prescribing such powerful painkillers to those who are depressed. Posted June 20, 2017. Via University of Rochester Medical Center.

Can 6 Questions Diagnose Adult ADHD? Probably Not.

I had a terrible time writing this blog today. While I was working, I was texting my sister, making a dentist appointment and helping my kid with his homework. I was restless and kept jumping to my feet for a glass of water or to let the cat out. Even when my blog was done, I couldn’t relax. There were just too many things on my mind. Thank goodness my husband made the doctor’s appointment for our child’s school physical. I kept forgetting.

Sound familiar? Be careful before you say yes. I just demonstrated plenty enough traits to qualify for a diagnosis of ADHD. Distraction, restlessness, trouble unwinding, putting things off until last minute and depending on others to keep my life in order. With that story and the recollection of tardiness as a child and I, too, could get a lifetime prescription for Ritalin, a powerful stimulant and popular ADHD drug

But hold the trigger. Distraction can be a symptom of depression, which is more serious and life threatening than ADHD. Restlessness could be a symptom of an overactive thyroid. See where I’m going?

The medical definition of ADHD has changed several times in the past decade and it seems to get broader each time. Now the World Health Organization has devised a list of 6 questions that, they claim, accurately identifies those adults with ADHD.

What are the questions like? Here are a couple. How often do you have difficulty unwinding and relaxing when you have time to yourself? How often do you depend on others to keep your life in order and attend to details?

Possible responses are never, rarely, sometimes, often or very often. Each response has a different numerical value. Higher overall scores indicate a strong likelihood of ADHD.

The medical definition of ADHD has been changed several times over the last decade and it seems to get broader each time.

When the teachers at my child’s school asked that I put him on Ritalin, I took him for neuro-psych testing. It was lengthy, intense and expensive. I think we paid about $3,500 (many school systems will pay for the testing) and it took 4 interviews/testing sessions with my child and multiple interviews with his teachers to make a full diagnosis. The outcome? There was some evidence of ADHD. But more importantly, we learned that my child had previously undiagnosed and undetected learning disabilities. By addressing those disabilities with behavioral therapy, he improved and became successful. In his case, no need for Ritalin

I feel like a conspiracy theorist, but I’m not alone in questioning why the diagnosis for ADHD has become so simple and broad. As reported on NPR, Alan Schwarz, the author of the book ADHD Nation and a former investigative reporter for The New York Times, has investigated the ties between pharmaceutical companies and doctors.

“The 6-question screening instrument that was endorsed by the World Health Organization was devised by doctors with a very long history in ADHD research,” he says. “These are, generally, men who have been enriched by the pharmaceutical industry in order to churn out research and churn out things like this that merely expand the ADHD market.

“What we’ve seen over the past 10 [to] 20 years is a constant enthusiasm on the part of the ADHD lobby to get more and more adults to consider the possibility that they, too, have ADHD,” Schwarz says.

If you have a symptom — or 3 — that you think is ADHD that is keeping you from being able to work or enjoy life then go ask your doctor. But self-diagnosing reminds me of the old saying, “The lawyer who represents himself has a fool for a client.”

Do Your Psychiatric Drugs Keep You Up at Night?

If you take a medication for a psychiatric condition, you may have experienced troubled sleep — insomnia, daytime sleepiness, or any other numbers of sleep-related disorders. I have treated patients with myriad sleep difficulties who take antidepressants, antipsychotics and even medications to treat attention deficit/hyperactivity disorder (ADHD).

While no one wants to experience a poor night of sleep, it’s important to recognize whether the sleep problem you are having is a result of a side effect of a drug (or drugs) you are taking, or something completely independent of medication. That is why if you are on psychiatric medication – or any drug for that matter – and you find yourself having difficulty catching some Zs, it’s important to talk to your primary doctor, who may change your medication or refer you to a sleep specialist for further evaluation. In many cases, the benefits of a drug may outweigh the sleep-deficit side effects. Your physician can work with you to minimize the impact of them.

However, it’s a good idea to know what some of the sleep-related side effects are that have been reported with different types of drugs which act upon the brain. Let’s start with antidepressants. The most commonly prescribed ones are known as SSRIs (selective serotonin reuptake inhibitors) and have names including Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine). Complaints of both insomnia and daytime sleepiness have been reported in patients with depression on SSRIs. Prozac’s impact on sleep has been the most widely studied. Interestingly, it has been shown to have both a sedating and energizing effect depending on the individual. Prozac can also cause decreased sleep efficiency, awakenings during the night, and interrupted REM (rapid eye movement) sleep, an important period during the sleep cycle that allows a person to dream vividly.

Antidepressants and Vivid Dreams

Another class of antidepressants, SNRIs (serotonin norepinephrine reuptake inhibitors), are known to cause sleep problems similar to those in SSRIs, as well as vivid dreams. Common SNRIs are Effexor (venlafaxine), Pristiq (desvenlafaxine) and Cymbalta (duloxetine).

Treatment with Effexor has also been associated with a condition known as dyskinesia that is characterized by occasional movement of one’s limbs, repetitive and involuntary movements of the extremities – typically the legs – usually during or just before falling asleep. There have also been cases where these involuntary movements have been seen a week after a person stopped taking Effexor.

One antidepressant, Wellbutrin (bupropion), has been associated with insomnia. However, studies that have examined electrical activity of the brain in patients taking bupropion indicate the drug actually increases REM sleep time.

It’s important to recognize whether the sleep problem you are having is a result of a side effect of a drug (or drugs) you are taking, or something completely independent of medication.

Antipsychotics are usually prescribed for schizophrenia and other psychotic disorders, though they are also prescribed for bipolar disorder and to supplement antidepressants in the treatment of depression. One of the most popular antipsychotics, Seroquel (quetiapine), has been associated with faster sleep onset and longer overall sleep time. A typical antipsychotic, Clozaril (clozapine) has also been associated with improving sleep onset and sleep time.

RLS (restless legs syndrome) can ruin a good night’s sleep and antipsychotics and antidepressants have been known to lead to cause it. The strong urge that RLS causes to uncontrollably move one’s legs can make it hard to sleep, lead to sleeplessness, irritability and depressed mood. Remeron (mirtazapine), an older, atypical antidepressant, is most likely to cause RLS. A case study found that RLS appeared to be provoked in patients on a low-dose of Seroquel. Interestingly, some evidence has shown that Wellbutrin may actually help to alleviate RLS.

Lifestyle Changes May Help Curb Sleep-Related Side Effects

However, you might find relief from RLS through lifestyle changes and/or taking certain vitamins. For example, going to the bed at the same time every night and getting up at the same time each morning can help. Also, there are some indications that a lack of some vitamins and minerals, such as iron, folic acid, magnesium, and vitamin B, can contribute to RLS.

Not surprisingly, insomnia and delayed sleep onset are associated with stimulants such as Adderall and Ritalin (methylphenidate), that are used in the treatment of ADHD. However, the effect of Ritalin on sleep may depend on the amount of time a child has been on the drug and when the medication is given. There have also been reports of children having difficulty falling asleep as they are being weaned off the medication.

Sleep is an important part of staying healthy and feeling good. Again, if you feel you are experiencing sleep issues as a result of medication, speak to your doctor without delay. Sleep-related side effects due to drugs impact relatively few patients. And if it ends up your sleep problems are not drug-related, the good news is there are steps you can take to rectify the situation. Changes in sleep hygiene and even in your bedroom environment can provide some of the most effective improvements, as can making sure you are getting enough sleep in the first place. As we are in the middle of Sleep Awareness Week, I recommend visiting the National Sleep Foundation’s website for more helpful tips.

This piece is based on an article, Adverse Effects of Psychotropic Medications on Sleep, published in the journal Psychiatric Clinics of North America in 2016.

80% of Kids Undergoing ADHD Treatment Receive Stimulant Meds

An increasing number of children are visiting their doctor for treatment of attention deficit/hyperactivity disorder (ADHD), and along with it, the number of prescriptions for drugs, particularly stimulants, used to treat the condition.

New data from the Centers for Disease Control and Prevention found that in 2013, an average of 6.1 million visits to a physician, pediatrician or psychiatrist by children between the ages of 4 and 13 were for diagnosed ADHD. That accounts for 6% of all doctor visits by that population. In 2003, that figure was 4%.

Whether more kids actually have ADHD or are being misdiagnosed with the disease is up for debate.

The CDC data brief also found that 8 out of 10 ADHD doctor visits for those aged between 4 and 12 resulted in a prescription for a stimulant drug, such as Adderall (amphetamine/dextroamphetamine), Ritalin (methylphenidate) and Focalin (dextroamphetamine). A similar rate was found for ADHD visits for those aged between 13 and 17.

The new research also showed that boys were twice as likely to visit a doctor for ADHD as girls. The figure for boys is 147 visits per 1,000 compared with 62 per 1,000 for girls.

ADHD and Homework: Skip the Stimulants in Favor of Behavioral Interventions

Behavioral interventions are better than stimulant medication in helping children with ADHD (attention deficit/hyperactivity disorder) with completing homework.

Researchers enrolled 75 children with ADHD who took part in an 8-week summer school session. The children ranged in age from 5 to 12 years old. The students were given either a long-acting stimulant or a behavioral intervention that included both report cards for kids and training for parents on how to help their kids with homework.

In the stimulant group, physicians took about 2 weeks to determine the correct drug dose to give them. After that, for another 3 weeks, those students were given either a stimulant or placebo. For the last 3 weeks, those who were on a stimulant switched to a placebo, and vice versa. The stimulant given was methylphenidate, which is known under the brand names Ritalin, Daytrana and Concerta.

In the behavioral therapy group, students took part in six 2-hour group sessions for the first 2 weeks, and then individual sessions lasting 30 minutes over the following 2 weeks.

Children who received behavioral treatment were able to finish between 10% and 13% more homework and assignments, and the work was also 8% more accurate than that of the children who received a stimulant only, the researchers reported in the Journal of Consulting and Clinical Psychology. Medication had no significant impact on homework performance.

The authors note this translates to children who received behavioral treatment getting an average grade of C compared to an average grade of F for those who didn’t get the intervention.

Drug Classifications, Schedule I, II, III, IV, V

The FDA has been overseeing drugs in the US since the beginning of the 20th century. In 1970 the FDA released the following drug classifications, or drug schedules, under the Controlled Substance Act (CSA). The drug classificaton schedules organize drugs into groups based on risk of abuse or harm. Those drugs with high risk and no counterbalancing benefit are banned from medical practice and are Schedule I drugs.

From the Drug Enforcement Administration Office of Diversion Control:

Definition of Controlled Substance Schedules

Drugs and other substances that are considered controlled substances under the Controlled Substances Act (CSA) are divided into five schedules.  An updated and complete list of the schedules is published annually in Title 21 Code of Federal Regulations (C.F.R.) §§ 1308.11 through 1308.15.  Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States, their relative abuse potential, and likelihood of causing dependence when abused.  Some examples of the drugs in each schedule are listed below.

Schedule I Controlled Substances

Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.

Some examples of substances listed in Schedule I are: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“Ecstasy”).

Schedule II/IIN Controlled Substances (2/2N)

Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.

Examples of Schedule II narcotics include: hydromorphone (Dilaudid), methadone (Dolophine), meperidine (Demerol), oxycodone (OxyContin, Percocet), and fentanyl (Sublimaze, Duragesic).  Other Schedule II narcotics include: morphine, opium, and codeine.

Examples of Schedule IIN stimulants include: amphetamine (Dexedrine, Adderall), methamphetamine (Desoxyn), and methylphenidate (Ritalin).

Other Schedule II substances include: amobarbital, glutethimide, and pentobarbital.

Schedule III/IIIN Controlled Substances (3/3N)

Substances in this schedule have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.

Examples of Schedule III narcotics include: combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin), products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine), and buprenorphine (Suboxone).

Examples of Schedule IIIN non-narcotics include: benzphetamine (Didrex), phendimetrazine, ketamine, and anabolic steroids such as Depo-Testosterone.

Schedule IV Controlled Substances

Substances in this schedule have a low potential for abuse relative to substances in Schedule III.

Examples of Schedule IV substances include: alprazolam (Xanax), carisoprodol (Soma), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion).

Schedule V Controlled Substances

Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics.

Examples of Schedule V substances include: cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC, Phenergan with Codeine), and ezogabine.

 

5 Ways to Minimize Side Effects of Your Child’s ADHD Meds

While there is a relatively scant amount of research examining the benefits or the risks of stimulant medication -– the most common type of drug used to treat ADHD –- over the long term, many parents and doctors may decide that a stimulant (along with continuing cognitive therapy) might be the most effective way to treat your child.

But addressing ADHD first through non-medical means is best practices and in many cases makes using drugs unnecessary. Here is an article on how children can be treated for ADHD through non-pharmaceutical interventions. However, there are times when medication is part of an appropriate treatment plan.

Although stimulants have benefits, they also have a wide array of side effects. However, these side effects can potentially be minimized with a few pieces of helpful information.

1. Find the Right Medication

There are 2 basic lines of stimulant medication: those derived from methylphenidate (e.g, Ritalin) and those derived from dextroamphetamine (e.g., Adderall). Although they are very similar medications, they are not the same, and any given child may do much better on one than the other. There is no reliable way to predict whether your child would do better on one than the other. There is new genetic testing that may help predict your child’s reaction to stimulants, but so far it cannot distinguish between the 2 lines.

The absolute key to successful treatment with minimal side effects is communication, communication, communication!

Even within a given line, there can be significant differences between how your child reacts to one or another. As an example, Focalin (dexmethylphenidate) can be effective when there are unacceptable reactions to Concerta (methylphenidate), or vice versa, despite the fact that both are derived from methylphenidate.

2. Find the Right Dosage

Like most psychotropic medication, there is no single dose that will be effective for each patient. The expected dose is generally based on a child’s size, but there are dramatic differences in how children metabolize these medications. There are college students in my practice doing very well on the minimal possible dose of Concerta, for example, while there are 10-year-olds who need twice that much.

The correct dose is the smallest dose that produces the desired effect without causing unacceptable side effects. In some cases, no such dose exists. In other words, even the smallest dose that is effective causes side effects that cannot be tolerated. Then another medication must be tried. Most clinicians would suggest that an acceptable side effect is appetite loss at lunchtime only. An unacceptable one is depression or irritability. However, it is the patient and patient’s parents who are the final determiners of what is an acceptable side effect and what side effects make the drug benefits not worth it.

3. Nutrition and Lifestyle

If you are not taking care of all the nutritional and lifestyle factors that can influence ADHD, then I recommend doing so before trying drugs. These include proper nutrition, adequate sleep and adequate exercise. Continue to make sure school accommodations (as outlined in a 504 plan in any public school) are up to date and being carried out. If you feel that you might need help in parenting your child effectively, seek the proper guidance.

4. Non-pharmaceutical Interventions

There are some other non-pharmaceutical interventions that should be continued even while taking medication. Some of these would include taking fish oil, zinc and iron when indicated, as I discussed in a prior article for MedShadow. Continuing these interventions can reduce the amount of medication necessary to be effective and thus make the difference between successful and unsuccessful treatment.

5. Communication

Over and above these factors, the absolute key to successful treatment with minimal side effects is communication, communication, communication! As parents you are the hub of a network that is crucial to your child’s success.

You and your child must talk to each other to be as clear as possible about positive and negative effects. This communication will be as much by observation of behavior as by what your child is actually telling you.

You and his or her teachers must be in constant touch to be as clear as possible about the effects of the treatment while the child is at school. For the majority of parents, this is the major time that the medication is active, so this is crucial.

You must give your medical provider as much feedback as possible to help determining changes in dosage or medications. Beware the health care provider who gives you a prescription and tells you to come back in 4 to 6 months without any interim contact. This is unlikely to lead to a positive result.

Although I believe many children with ADHD can do well without stimulant or other medication, there are some children for whom it is truly necessary. Following the above guidelines will help increase the chances of successful treatment.