Highlights from 2023 NEI Congress: Sessions on ADHD
Presented by David W. Goodman, MD, LFAPA
Thursday, November 9, 2023

Arousing Discussion: Differentiating Stimulant Medications for ADHD
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity that negatively impact daily functioning. Stimulant medications like methylphenidate and amphetamine are commonly prescribed to help manage ADHD symptoms. These medications work by increasing levels of the neurotransmitters dopamine and norepinephrine in the brain, which play key roles in executive functioning, focus, organization, and impulse control.

As of this date, stimulants are available in over 30 preparations. At the 2023 NEI Congress, Dr. David Goodman delivered a presentation on differentiating the pharmacological and clinical profiles of stimulant medication formulations used to treat ADHD.

The two major classes of stimulant compounds, methylphenidates and amphetamines, have slightly different mechanisms of action. While methylphenidate works by blocking the dopamine and norepinephrine transporters, amphetamines compete for reuptake at the dopamine and norepinephrine transporters and also cause reverse transport through the vesicular monoamine transporter VMAT2 (Figure 1). In effect, both these classes of medication cause an increase in dopamine and norepinephrine levels.

Studies on efficacy and tolerance indicate that methylphenidate might be preferable for children/adolescents, and amphetamine for adults with ADHD.

Short, intermediate, and long-acting preparations of both methylphenidate and amphetamine are available in different delivery systems like beads, osmotic release and dissolvable tablets. Dr. Goodman emphasized that extended release and prodrug formulations can provide longer duration, slower onset, and reduced potential for abuse.

Dr. Goodman also shared an important recent update by the FDA pertaining to stimulant misuse, specifically that the FDA is now requiring updates to the Boxed Warning for prescription stimulants to include up-to-date warnings on harms of misuse and abuse.

When prescribing any stimulant for ADHD, Dr. Goodman said it is essential clinicians carefully assess and document any risk factors for misuse, diversion, or substance use disorders. Regularly monitoring consistency of daily use and potential medication stockpiling can also help minimize risks. While stimulants remain highly effective pharmacotherapies for managing ADHD, judicious prescribing and vigilant follow-up could help ensure these medications are used appropriately and safely.

The Other Meds: Nonstimulant Treatment Options for ADHD
For decades, stimulant medications like methylphenidate and amphetamines have been the mainstay of pharmacotherapy for ADHD. They work by increasing levels of dopamine and norepinephrine in the brain, which improves attention, impulse control and regulation of activity levels.

However, stimulants do have their limitations. Some individuals may not achieve optimal symptom control or tolerate the side effects of stimulants. Issues like insomnia, appetite suppression, irritability and rebounds when the medication wears off are common. The U.S. Food and Drug Administration (FDA) has also expressed concern about the potential for stimulant misuse and abuse, especially among adolescents and young adults. These drawbacks of stimulant medications have led to growing interest in nonstimulant medications for ADHD, either as monotherapy or as an adjunct to stimulants.

At the 2023 NEI Congress, Dr. Goodman delivered a presentation on nonstimulants as treatment options for ADHD, with a focus on assessing the pharmacological and clinical profiles of the different nonstimulant medications used to treat ADHD and tailoring the selection of nonstimulant medication to the individual patient’s presentation, personal goals and preferences for therapy.

In his presentation at the 2023 NEI Congress, Dr. Goodman presented in detail about the FDA-approved nonstimulant medications for ADHD (Figure 2, as well as off-label medications used for ADHD, including bupropion, modafinil, desipramine and memantine. As we learn more about the neurobiology of ADHD, nonstimulants are likely to play an expanding role in treatment. Their favorable safety profile makes them an attractive first-line or concomitant option to stimulants for managing ADHD across the lifespan.

Source:
David W. Goodman, MD, LFAPA. Arousing Discussion: Differentiating Stimulant Medications for ADHD. Presented November 11 at the 2023 NEI Congress, Colorado Springs, CO.

David W. Goodman, MD, LFAPA. The Other Meds: Nonstimulant Treatment Options for ADHD Presented November 11 at the 2023 NEI Congress, Colorado Springs, CO.

To Learn More: The recording of these presentations, as well as all of the other presentations from the 2023 NEI Congress, will be available as Encore Presentations for NEI Members.