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ADHD: An update on our armamentarium

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Prof Renata Schoeman, a psychiatrist in private practice with a special interest in cognitive disorders such as ADHD, recently presented on the condition.   

ADHD is a neurodevelopmental disorder with a complex aetiology, multiple genetic and environmental risk factors, and a small individual effect. Diagnosis (DSM-V, APA, 2013) is based on inattention, hyperactivity and impulsivity, present across time and place, inconsistent with developmental levels, and which cause significant impairment. 

It is not solely a manifestation of oppositional behaviour, defiance, hostility, or a failure to understand and is not due to other causes.  

MANAGEMENT 

Treatment should always include: therapy, educational/ occupational support, addressing potential stressors and lifestyle changes (physical exercise, a healthy diet, good sleeping habits, limiting screentime). Use a behavioural programme in the following situations: If symptoms are mild or moderate, with minimal impairment, diagnosis is uncertain, patient/parents reject medication as a treatment option, or urgent response is not required. In other cases, use pharmacotherapy. 

Treatment choice depends on patient profile (preference, requirements and comorbid conditions), medication profile (mechanism of action, duration of action, abuse potential, side-effect profile and toxicity in overdose). There needs to be a balance of efficacy and tolerability, which must be monitored.   

Adcock Ingram has announced the introduction of two new treatments for ADHD, Medikinet Modified Release (MR) and Amfexa.  

Medikinet MR is a novel long-acting methylphenidate (MPH) that provides effective control of core ADHD symptoms throughout the academic day with a single daily dose. Each pellet-containing capsule comprises 50% immediate release (IR) MPH and 50% extended release (ER) MPH. It’s MR is designed to maintain therapeutic plasma levels for a period of approximately eight hours and a treatment response through the afternoon without the need
for a midday dose.   

The capsule may be opened and sprinkled onto food for ease of administration. It is registered for children six years or older, adolescents and adults. 

Amfexa tablets contain dexamfetamine sulfate, and is a new, short-acting amphetamine for the treatment of ADHD in children and adolescents. Studies have shown that being able to offer dexamphetamine to patients with ADHD who have an inadequate response to MPH can significantly increase the response rate and improve symptom control. 

In clinical studies, after the first dose of Amfexa in the morning, patients reported an average onset of action of 36 minutes and an average duration of action of 6.5 hours. It is simple to titrate by increasing the dose weekly, and 61% of patients required three or fewer weekly titration steps to achieve optimal dosing. In the US, amphetamines are authorised for the treatment of ADHD since 1994 as first-line treatment. However, they are classified as reserve because of the higher addiction potential. Amphetamines should be used if there is no or no sufficient effect by using methylphenidate, or considerable adverse effects appear. The advantage is precise titration (5mg snap tablet, dose 5-10mg/d, max 20mg/d). 

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