LOS ANGELES – A few key questions must be answered before starting children on ADHD stimulants to protect them from the small but real risk the drugs pose of sudden cardiac death, according to Dr. James J. McGough.
Has the child ever fainted while exercising? Is there a family history of early sudden death? Does the child have any known cardiac abnormalities? Is there a click or murmur on physical exam?
"If you get a ‘yes’ to any of [those questions], that is the time to refer," Dr. McGough of the division of child and adolescent psychiatry at the University of California, Los Angeles, said at a psychopharmacology update sponsored by the American Academy of Child & Adolescent Psychiatry.
An "EKG is reasonable, if you want it," he added; a recent study showed a small benefit prior to stimulant treatment (Circulation 2010;121:1329-37).
In general, the sudden death risk with ADHD stimulants is low, on par with the "risk of sudden death [at] Saturday morning soccer," Dr. McGough said. Still, "this is something where you really do need to be thoughtful," he said.
An audience member asked whether he thought the arrhythmia risk increased when alpha2-adrenergic agonists (clonidine or guanfacine, for example) are used with stimulants to increase ADHD control, or for other reasons.
"We will be able to answer that," Dr. McGough said, because he and his colleagues are completing a 200-child ADHD study of that and other questions. But in the meantime, "I would not have those concerns," he said.
In fact, Dr. McGough and his colleagues use the combination "commonly. I think it is a really good treatment," he said.
Dr. McGough noted that he has treated children with cardiac abnormalities, with the help of a pediatric cardiologist. "I had one boy who could not function without stimulants. He has an aortic outflow obstruction. The parents and the boy knew the risk, [and] we were very careful. So you can do it, but you should get the further work-up," he said.
Once cardiac issues are dealt with, ADHD treatment starts with methylphenidate or amphetamines. "There’s nothing to direct you one way or the other. If [patients] fail one, it suggests you try the other class. I can think of no good reason to prescribe an amphetamine and a methylphenidate in the same kid," Dr. McGough said.
To maintain effect, "you need to keep the [drug] blood level rising" throughout the day, he said.
That’s possible with immediate-release formulations if they are given every few hours, but extended-release medications save the hassle. Because of that, "I would never start with immediate-release stimulants," Dr. McGough said.
The conference moderator, Dr. Gabrielle Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook, objected to the comment.
She noted that sometimes children do not respond to extended-release medications but do respond to immediate-release formulations. In addition, sometimes children are unable to tolerate ascending blood levels and become toxic; with immediate-release stimulants, you can often tell in the office whether the drug will work.
Dr. McGough acknowledged the concerns but said he still prefers to initiate treatment with extended-release products.
"What I typically do is send people out with usually around 30 small-dose, extended-release tablets [and instructions to] take one a day for 5 days; two a day for 5 days; and three a day for 5 days," then return for re-evaluation, he said. "That’s how I do it, and it’s effective for me."
Dr. McGough had a tip about one long-acting medication in particular: Adderall XR. "You only get 10-12 hours of benefit from it, but the actual half-life is much longer," he said. As a result – and especially if doses are increased to maintain effect – the drug can build up in children’s systems.
Eventually, a wall might be hit where the drug no longer seems to work. The problem is that children "have this swamp of amphetamine doing nothing for [them]. You’ve got to ramp up out of that before you get effect," Dr. McGough said.
Once the dosage is above 30 mg/day and the child is still nonresponsive, consider that "maybe they’re getting too much medicine. Let their bodies clear out, and start again on a lower dose," he suggested.
Should stimulants fail even with proper dosing, nonstimulants are the next step for ADHD management. "Research suggests atomoxetine, but I think we could now move the alpha2-agonists up [to be] equal with that, because there’s evidence those medicines work," Dr. McGough said.