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Customize ADHD drugs to facets of the disorder. (Expert Advice on Dosing, Timing).

MONTEREY, CALIF. -- Tailoring medication to the specific components of attention-deficit hyperactivity disorder is key Dr. Margaret C. McBride said at a meeting sponsored by the American Academy of Pediatrics.

For example, clonidine (Catapres) and guanfacine (Tenex) are useful in treating hyperactivity, tics, and sleep disorders in children, but they should not be prescribed for inattention and distractibility, she noted at the meeting, which was also sponsored by the American Academy of Pediatrics California Chapter 1.

Dr. McBride, professor of pediatrics at Northeastern Ohio Universities in Akron, offered these tips for treating patients diagnosed with one or more components of attention-deficit hyperactivity disorder (ADHD):


These drugs should be considered when either the child's academic performance is below expectation based on cognitive abilities, or the child's self-image is suffering because he or she is getting in trouble often and symptoms of attention deficit, impulsivity, or hyperactivity appear to be contributing factors.

* Remember to dose with the duration of action in mind. This is especially true when using stimulants. With a duration of 3-4 hours, methylphenidate (Methylin or Ritalin) is shorter acting than Meradate ER or Ritalin SR, which last 5-7 hours; dextroamphetamine (Dexedrine), which lasts 4-6 hours; Dexedrine Spansules, which last 6-8 hours; and Concerta, which lasts 12 hours. Longer- and shorter-acting stimulants can be combined to avoid rebounding and to better cover the demands of the school day.

* Minimize weight loss and slower growth. To do this, give stimulants after breakfast and lunch or a snack. Minimize weekend and late afternoon dosing, and encourage nutritious and high-calorie evening or bedtime snacks.

* Avoid sleep disturbances. Provide the smallest dose in the late afternoon or add clonidine to avoid sleep disturbances due to rebounding at bedtime.

* Start the initial dose on Saturday during a trial of medication. If there are to be two doses in the day, overlap the next dose with the end of the effect of the preceding dose.

* Medicate with comorbidities in mind. Stimulants may worsen anxiety in patients with obsessive-compulsive disorder, but they can help some children with ADHD and mental retardation, Dr. McBride said. Stimulants also can benefit some children with comorbid hyperactivity and autism, and they usually do not aggravate seizures in most children with epilepsy or epileptiform EEGs.

* Recognize that tics are not necessarily a contraindication. Although stimulants may exacerbate tics in 33%-50% of children with tics, there is no evidence that they ultimately change the natural history of tics.

[alpha]2-Adrenergic Agonists

This class of drugs includes clonidine in tablet form or transdermal patch, and guanfacine. They are effective at treating impulsivity and hyperactivity but not distractibility and shortened attention span.

* Titrate slowly to dose. This will avoid sleepiness and significant hypotension.

* Remember to taper off when stopping medication. This will avoid clinically significant rebound hypertension.

* Reduce sleepiness. Give clonidine tablets in frequent, small doses. Also, clonidine and guanfacine should be started at bedtime.

* Wait for the full effect. The full effect of clonidine and guanfacine on impulsivity and hyperactivity may not be seen for 45 weeks; they have little effect on distractibility or shortened attention span.
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Title Annotation:attention-deficit hyperactivity disorder
Author:Donohue, Maureen
Publication:Pediatric News
Date:Feb 1, 2002
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