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Monthly NewsNote
February 2004
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A REVIEW OF NON-STIMULANT MEDICATIONS FOR THE TREATMENT OF ATTENTION DEFICIT DISORDER
While stimulants such as Ritalin are usually the first medications used in
the treatment of ADD, there are several non-stimulants that are also useful.
This NewsNote will discuss a number of these medications so that the reader
will understand what is available.
Strattera became available about a year ago. The dose is related
to weight, and the capsule is usually taken once a day, seven days a week. Since
this medication is always in the system, it will be active all the time, including
early morning and late at night. This is an advantage when compared to the shorter
acting stimulants. Strattera must be taken with food and usually takes two or
three weeks to become effective. The most frequent side effects described by
my patients are a reduced appetite and trouble sleeping.
In my experience, the results have been mixed. A few children have responded
extremely well and are functioning quite nicely on Strattera alone. A larger
number found it too weak, and are using a combination of a stimulant and the
Strattera. For about half of my patients, the medication has been ineffective
or caused significant side effects and so they are not using it at all.
Wellbutrin is a medication with many uses including ADD and
depression. Wellbutrin is helpful in about 40% of those I have treated for ADD
with the medication. It is taken every day, and often takes two weeks to become
effective. There are few side effects, most of which are intestinal. It is not
a first choice drug for ADD in most cases because it is fairly slow to work,
and does not work as often as we would like. However, if the patient is depressed
it is an excellent choice to be combined with a stimulant.
Cylert is a medication that is similar to the stimulants,
but not a controlled drug. Many of us used Cylert regularly when a stimulant
could not be used, and the results were generally good. A number of years ago
a few cases of serious liver toxicity were reported, and the FDA placed Cylert
in its dreaded black box. Therefore, doctors are afraid to use it for medico-legal
reasons. However, the drug is still available, and if parents educated to the
dangers of Cylert sign a release, it can be used. Several patients of mine have
chosen to remain on Cylert. Liver function tests are done regularly, and they
are doing very well.
Tenex and Clonidine are two medications that
can be helpful, particularly for the explosive or aggressive components of ADD.
The chief side effect is tiredness, and this can be very significant. Most children
do adjust and the tiredness disappears, but it can take several weeks. These
are not medication for the treatment of adults because they are used to reduce
blood pressure in the adult age group.
Tricyclic Antidepressants, including Tofranil, Norpramin
and Pamelar are among the first non-stimulants used and can
be very effective. Because there are possible cardiac side effects, a cardiogram
is generally done before the medication is started.
Finally, Provigil was brought out several years ago, primarily
for use in narcolepsy, a sleep disorder. A few small studies report that teachers
describe an improvement in behavior when a child takes 300 mg. in the morning.
Sleep disturbance was the main side effect reported. I don’t think there
is enough evidence to support its use in ADD at this time, but I’ll follow
the research.
There are many options for the treatment of ADD in addition to the stimulants.
While they may not be as effective, they are often useful on their own when
a stimulant cannot be used. In addition, some work well together with a stimulant
when there is a particular aspect of the condition that is not responsive to
stimulant treatment.
Information on the stimulants can be found in earlier Monthly NewsNotes. Methylphenidate
is discussed in the Note of January 2003 and Amphetamines in the Note of February
2003.
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