Okay, we’re assuming, number one, that you have done a good job diagnosing ADD or ADHD, and that ADHD is the primary diagnosis, far out-shadowing any comorbid problems that may also be present. And number two, we are assuming that you, the patient, and the parents (if the patient is under age) have all agreed that now is the time for a medication trial.
While Strattera is desperately trying to muscle in on the action, most psychiatrists who are serious about licking ADHD favor a one-two punch involving a right hook with methylphenidate, followed, if necessary, by an upercut with amphetamine.
Why do most of us start with a methylphenidate-based drug? Primarily because it’s tolerated better than amphetamine, an impression that isn’t based solely on clinical lore. The major study to look specifically at side effects randomized 125 children (average age was 9) to either Dexedrine (0.15 mg/kg) or Ritalin (0.3 mg/kg). Ritalin was dosed twice as high because several studies have shown that it is half as potent as Dexedrine. While there were few actual dropouts in either group due to side effects, Dexedrine caused more insomnia and irritability than Ritalin. Both of them suppressed appetite equally (Pediatrics 1997; 100:662- 666).
At any rate, once you’ve decided to start with a methylphenidate, you still have plenty of irksome choices ahead of you, because there are now eleven versions of methylphenidate crowding the market. (To make all this information more manageable, we provide a detailed chart on page 2.)
Regular short-acting methylphenidate is, of course, available in generic form and generally is the cheapest option. You can prescribe brand name “Ritalin” if you prefer, but someone’s going to pay a lot more for it. There is also the “branded generic,” Methylin, which is basically a generic with a fancy name and fancy marketing. Branded generics are often no more expensive than “generic” generics, and some drug stores will preferentially stock these versions, possibly because of a special financial deal with the company.
The big news in the world of short-acting methylphenidate preparations is that there are now two child-friendly versions: Methylin CT (chewable tablet) and Methylin Oral Solution. No longer do you have to crush tablets and sprinkle them over food for kids who hate swallowing pills.
Focalin is simply the dextroisomer of methylphenidate. The only published head-to-head study showed it to be identical to Ritalin in efficacy, though it lasted a little longer (J Am Acad Child Adolesc Psychiatry 2004; 43:1406-14). Some clinicians find it helpful as a thirdline stimulant if everything else has failed, but beyond that it appears to be little more than an enantiomer marketing gimmick by Novartis.
Intermediate-acting methylphenidate comes in three versions. Ritalin SR was the original, and is available generically. Metadate ER is the branded generic of methylphenidate SR, and is essentially identical to Ritalin SR; they are both methylphenidate molecules mixed into a wax matrix. Methylin ER, also a branded generic, offers methylphenidate mixed into a hydrophilic polymer, which, according to the manufacturer, may yield an advantage in terms of being more continuously released than its competitors – but who really knows?
The long acting versions of methylphenidate are dominated these days by Concerta, which probably lasts longer than either Metadate CD or Ritalin LA. Some very experienced clinicians we’ve spoken to, however, have the impression that it’s harder to convert patients from a given dose of shortacting methylphenidate to Concerta. According to these anecdotal reports, a more seamless conversion can be made to either Ritalin SR or LA. In the absence of comparative studies, take this with a grain of salt.
Both Metadate CD and Ritalin LA are capsules filled with beads, so they can be sprinkled over food for kids. Both contain anywhere from 30% (Metadate CD) to 50% (Ritalin LA) of their beads in immediate release form, providing an extra stimulant punch in the morning, if that’s what your patient needs.
If methylphenidate doesn’t work or isn’t tolerated, you’ll move on to the amphetamine preparations. In this category, the choices are, thankfully, more limited. You have dextroamphetamine and its branded generics, such as Dexedrine and Dextrostat. You’d do the DEA a big favor by not prescribing Desoxyn to anybody, because it is the prescription version of crystal meth, a particularly euphoric type of speed that is the scourge of emergency rooms, which are treating addicts at an increasing rate, especially in the West and Midwest.
For intermediate and long-acting coverage, Shire’s Adderall (available in both IR and XR forms) has saturated the journal ads and CME Programs. Whether it really is any better than dirtcheap Dexedrine SR is not clear, as Dr. Diller discusses in this month’s interview. Recently, Canada withdrew it from the market because of 12 deaths supposedly linked to it, but TCR’s review of this topic gives Adderall a clean slate (see “Adderall and Death: It’s Team FDA versus Team Canada,” in this month’s issue).
Finally, what’s shaking with Strattera (amoxetine)? Very little. We’re still waiting for double blind studies comparing it with stimulants, and the impression in the trenches continues to be that responses tend to be less dramatic. However, for kids who experience lots of irritability on stimulants, it’s a good second-tier agent. And it’s always nice to have a tool with a different mechanism of action from the stimulants–recall that Strattera bumps up norepinephrine rather than dopamine.
TCR VERDICT: A 1-2-3 punch: Ritalin, Dexedrine, Strattera