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4yr
Optimizing ADHD Therapy

Most children are returning to onsite learning this year. While this is good news, it can bring back challenges to children diagnosed with attention deficit hyperactivity disorder (ADHD), their families, and their teachers.







One challenge of treating ADHD continues to be the onset and duration of action of the ADHD medications. According to the CDC, stimulants are the best known and most widely available treatments for ADHD with 70-80% of the children treated with them showing fewer symptoms. Short and long-acting stimulants are available with the treatment goal being to find the most efficacious drug that also causes the least bothersome side effects. Short-acting drugs are released immediately and last about 4 hours, while long-acting drugs are released over time and last up to 14 hours.







Although both types of stimulants reduce the symptoms of ADHD, they may start or wear off at inopportune times. For example, if a child receives a short-acting drug in the morning before school, its effect will likely disappear by the afternoon while they are still in school. Similarly, a child can be given a long-acting drug in the morning. This drug has the disadvantage of not kicking in until the child arrives at school, leaving breakfast and the morning routine chaotic, and still dealing with it wearing off around homework or bedtime. These problems can be stressful for the child, parents, and teachers as neither provides optimal coverage throughout the child’s waking hours.







How do you optimize onset and duration of action? What percent of your ADHD patients are prescribed both short-acting (immediate release, IR) and long-acting (extended release, ER) therapies?







CDC: Treatment of ADHD. Source, accessed September 10, 2021.



CHADD, “Peaks and Troughs: Uneven Medications & ADHD”, Attention Magazine Fall 2017 (source)



 


  • 4yr
    The choice and optimal treatment will depend on how long parents want the



















    meds to work , when is the most difficult time for the child , and whether child can swallow pill or need liquid,







    I have 50 percent taking long acting in am with short acting in noon , another 25percent have short acting alone and 25 percent take long acting alone
    After this information I will individualize treatment ,,
    Typically start with low dose long acting ( use to start ) with short acting) but not now ,,and use short acting in lunch or afternoon ,
    If I don’t know family well or any suspicion for diversion or abuse will prefer long acting vs short acting stimulant
  • 4yr
    I like the approach of a long acting stimulant in the morning and adding a short acting in the late afternoon to facilitate children getting their homework done and still allowing them to not interfere with sleep. This approach helps avoid children from needing dosing at school too.
  • 4yr
    I mostly treat transitional aged youth in the college setting. I prefer long-acting stimulants and usually choose between Concerta or Adderall XR as a first choice as monotherapy. Depending on response, I will make changes accordingly. For instance, if a patient needs longer-acting coverage, I may switch from Adderall XR to Vyvanse. For patients who are not consistent with taking medication, however, an immediate release formulation provides more flexibility, particularly because it won't be as likely to lead to insomnia if taken in the afternoon as compared to a longer acting agent. In cases where patients have a wearing-off effect too early, and this cannot be overcome by changing the dose or the agent, I will add an immediate release stimulant in the afternoon (around 12 pm). Less than 20% of my ADHD patients are on dual stimulants.
  • 4yr
    What adverse effects are you most concerned about and why?
  • 4yr
    I prefer to use long-short acting as needed, but strongly prefer genetics
  • 4yr
    I tend to start with Concerta and then if this is affecting sleep adversely, will try switching to Metadate CD, which has a slightly shorter duration of action.
  • 4yr
    Most of my elementary-age and adolescent patients respond best to an initial trial of long-acting methylphenidate, such as Concerta or Metadate CD. In my experience, the short-acting stimulants aren't nearly as effective as far as onset and it is tricky to make the twice daily dosing work with a school schedule and parent work schedule. Furthermore, the side effects at peak of medication for short-acting seem to be more bothersome for patients than with long-acting meds. So I hardly ever start with short-acting in my practice for all of these reasons. I try to avoid Adderall due to the small but noted potential for drug diversion or dependence in the teenage years, especially. I've also noticed more emotional lability with Adderall.
  • 4yr
    It depends on the schedule for the day, metabolism and insurance coverage of meds. I usually use a long acting first then see how long it lasts, any side effects and if additional coverage is needed/tolerated.
  • 4yr
    my preffrence for college student short acting stimulants .people needing coverage mainly adults working long hours start out with long acting in the am and before 4 pm add short acting to get smooth and long time sustain coverage
  • 4yr
    Consideration to be carefully given to young children and adolescents.
  • 4yr
    Best practice is to start with appropriate long acting and add short term as needed.
  • 4yr
    Since I see children and adolescents up to 21 years old my choice of meds varies widely and has to take into consideration ability to swallow pills, need for chewables or liquids and schedules. I generally prescribe stimulants but Strattera had its advantages for early AM coverage in its day. Needing immediate response and not having to wait 6 weeks for effect has necessitated the use of stimulants. I typically start with methylphenidates that are long acting except in the very young where I use short acting. I prefer them to amphetamines since they have less effect on appetite. As dictated by school demands as the long acting wear off I add short acting for homework, tutoring and sports. 50 % are on pure long acting and 20 % more are on both IR and LR. Stimulants give parents flexibility to not use on weekends. College students like short acting sometimes to manage just when needed fir class or studying as they may need meds for shorter blocks of time.
  • 4yr
    Combination treatment with long and short acting stimulants is the most effective pharmacological approach. Adding other meds as Guanfacin is somewhat helpful to some patients. Combining pharmacological and supportive therapy is a key. Skipping weekends is a rule in my practice.
  • 4yr
    50% of my patients likely have some combination of long acting and IR. Vyvanse is my choice for long acting amphetamine and Concerta for long acting methylphenidate. Mydais has very long action but I have limited clinical experience with it.
  • 4yr
    I typically start with a long acting stimulant formulation. Then add short acting/ IR if necessary. Some patients like the option of not always taking the IR or taking only the IR formulation on weekends. Haven’t found IR in mornings to be particularly effective.
  • 4yr
    It generally depends on the patient's age. If they are very young, ie/ 6 years old, I would start with a very small dose of IR Ritalin after breakfast and work it up to TID and then covert if well tolerated to a longer acting agent. For older patients, I generally lay the foundation with a long acting stimulant and if well tolerated but wears off during homework, I will add a booster dose. If mornings are very disruptive and the child is not underweight, starting the morning off with a very small dose of IR Ritalin can be helpful.
  • 4yr
    depends if history of SUD would prefer non stimulating initially however medications like vyvanse which is a pro drug are advantageous , others may benefit from a extended release followed by immediate. may consider adding clonidine or intuiniv as well
  • 4yr
    My approach will vary with the patient's particular symptoms, side effects, and age. Most of my high school and college patients will need the option of the short acting for the evening. If younger children have a lot of defiance and impulsivity, to the extent that they will be in trouble all evening, I will probably try a short acting. They are also great for withdrawal irritability. For the morning, I might ask the parents to give the pill while the kiddos are still in bed, so that when they really get up it will be working. It would be great if everyone would get a good breakfast, but we really don't want the patients hearing repeatedly that the parents are going to lose their jobs because of his/her behavior.
  • 4yr
    The best protociol is to start with a long acting stimulant and add a short one for optimum effect!
  • 4yr
    Looks very interesting. Not!
  • 4yr
    As a matter of routine practice I prescribe a long acting stimolant in the morning and add a short acting agent in the late afternoon around 4 or 5 to allow them concentrate on home work and at the same time make sure it does not interfere with approach has woked very well.
  • 4yr
    I usually start with long-acting methylphenidate in the morning, and add short-acting in the afternoon if needed. Various factors can change this general approach. For example, can the child swallow pills? A liquid or chewable stimulant might be more appropriate. How old is the child? I have found that many families prefer short-acting stimulants for younger children, since total dose is smaller. Does the child have medical conditions that make a stimulant less desirable, like poor weight gain or insomnia? Is the family opposed to using a stimulant? Last, but not least, cost varies wildly among different ADHD meds and depending on the insurance company. It is usually hard to predict how much a given medication will cost the family.
  • 4yr
    Long acting stimulants mostly. Short-acting in addition if needed
  • 4yr
    A combination of needed of short and long- term.
  • 4yr
    Most of my patients with ADHD are on stimulants. Most of them are on a long-acting med in the am on school days and most also have a prescription for a short-acting stimulant for as-needed use in the afternoon or on weekends for homework, projects, etc. Some parents aren’t happy about a second med initially but most find the usefulness of it over time.
  • 4yr
    I usually start with a long acting medication as a base and will add ashort acting version of the medication as a supplement to the treatment.
  • 4yr
    I probably have 30 percent of my patients that are on a combination on a long acting stimulant as well as an immediate release product. Typically this situation begins with a been on a long acting product but as their educational burden increases they find they are having trouble getting homework completed as their long acting med wears off. Often it is the parent who initiates starting the later short acting stimulant as either homework becomes a struggle or as afternoon sports delays the start of homework an immediate release becomes necessary.
  • 4yr
    I like to start low, start slow . Then on a follow up visit , ask mom and the patient about their individual needs and expectations . Then adjust accordingly . I usually start with an extended release tablet first thing in the am. The individual titration occurs next depending on when the medication seems to falter , at times even adding a dose through the school nurse later in the day whether before or after lunchtime . The next titration may come depending on homework , etc. Mostly , I try to engage patient and parents as part of the treatment to benefit all .
  • 4yr
    It’s best to individualize treatment and determine what’s best for each patient
  • 4yr
    A long acting version should provide steady state and time taking in morning with food may need to be adjusted. From there, assessing when it wears off will allow for question of if immediate release is required.
    Another approach would be some of the novel delivery systems where amount released is more variable.
    A still more novel approach would be desmethyphenidate formulations with a pro drug that allows for initial drug followed by a delayed activation to desmethylphenidate and thus a more desirable response.
  • 4yr
    I advise them to take as early as they can in the morning. If itis short acting they get may be 3 doses in a day. Some long acting still may have to be dosed twice a day. My dayis semms to last longer. jornayPM can be given previous night, occationally use patches. in 25-30 percent combine LA in AM and short acting in the evening. Also combine stimulants with non stimulants some times
  • 4yr
    In practice, it is a highly individualized approach that is needed to optimize efficacy, balanced against side effects and compliance. Many can take a once daily medication and do well in all areas. Most patients I see are more complicated and require quite a bit of fine tuning. Most take a long lasting stimulant each morning and something else as well- maybe an alpha 1 agonist to keep the stimulant dose down if had side effects on higher dose or could be a shorter lasting stimulant anytime from noon to 4 pm.

    Paying careful attention to onset of action and when effects wear off allows dosing to be carefully adjusted to cover most of the day.
  • 4yr
    i typically advise the patients to make sure that they eat in the morning before taking either the long or short acting version. I find that eating is likely to slow the release of the med so that they will get a more steady effect of the meds. I also ask that they eat a snack in mid morning to help with the breakdown of the meds. 80% of patients are on long acting and about 20 % are on the shorter acting brand of stimulants.

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