December 19, 2000
Cox News Service
If Winnie-the-Pooh does indeed need drugs to treat attention deficit hyperactivity disorder (ADHD), as recommended by a group of Canadian pediatricians last week, the bear couldn't have been diagnosed at a better time.
He would join millions of children with ADHD - up to 15 percent of all children, by some estimates - who now face an array of pharmaceutical choices beyond Ritalin, once the only drug option. Several new drugs on the market not only ease the symptoms of hyperactivity, inattentiveness and impulsiveness but, in some cases, restore patients' privacy.
Most of the front-line drugs used to treat attention deficit are stimulants, which change the balance of chemicals in the brain so that children with the disorder can concentrate better. Traditionally the stimulants' effect has been short-lived, requiring that patients take several pills a day in order to remain focused. In recent years that has changed, with the development of several new, longer-lasting drugs - and even a skin patch - that do not require repeated doses.
For example, Concerta, approved by the Food and Drug Administration in August, is a new time-release version of methylphenidate, the main ingredient in Ritalin. Unlike the older, short-acting Ritalin tablets, which usually must be taken at four-hour intervals, Concerta lasts 12 to 14 hours, which allows children to take their medication at home before going to school and not need a second dose during class. That helps eliminate the social stigma that some ADHD children might face, from classmates or school employees, because of their medical condition.
"There are kids who get too embarrassed to take their medication at school," said Dr. Leslie Rubin, director of the Marcus Center for Developmental Medicine and Emory University's Division of Developmental Pediatrics. "It's a very real issue."
In addition, Noven Pharmaceuticals plans on releasing Methypatch, a skin patch, within two years. The patch, worn under the clothes, delivers methylphenidate directly through the skin into the bloodstream. And because the medication doesn't go through the digestive system, the company says, smaller doses will be needed.
But it's too early to tell whether these new entries will have a lasting effect, doctors say. Although they beat more traditional medications for convenience and privacy, they still must show over time that they work as well as Ritalin, introduced in 1956.
Ritalin, the prescription of choice in almost 70 percent of children's ADHD cases, is often chosen because it has a solid record of safety and doesn't linger in the body for long. And it doesn't take weeks to find out whether a patient is responding to treatment; doctors and parents often see improvement within an hour of a child's taking the pill.
But as more children are given Ritalin, more parents and others have become concerned about its side effects and its frequent social stigma. Some children on Ritalin become zombielike - although doctors say that clearly means it's not working - and lose their appetite. And, as children age, many become resistant to treatment, often because of real or perceived stigmatization at school or elsewhere.
The second most popular ADHD drug, Adderall, introduced four years ago, is competing well against Ritalin, mostly because it usually works well and a single dose lasts seven to eight hours. Its main drawbacks are that it's expensive for those without a pharmaceutical benefits plan and it's an amphetamine that can be addictive.
But the market for ADHD drugs continues to grow. Studies show that between 3 percent and 6 percent of schoolchildren are taking some kind of medication for attention deficit, and that number is likely to rise as science becomes more sophisticated in identifying individuals with the condition.
Nationally, doctors recommended in 1999 that almost 7.7 million youngsters under 18 be placed on Ritalin or Adderall, almost a 23 percent increase from 1995, according to IMS Health, a pharmaceutical tracking firm. For another 2.1 million children, doctors recommended antidepressants known as selective serotonin reuptake inhibitors (SSRIs), such as Prozac - a 73.9 percent jump since 1995.
The rising demand means that drug companies will keep looking for newer, better ways to treat ADHD. "We're going to see new medications in the future," Rubin predicted. "The market is just too significant to ignore."
But what did the pediatricians whose diagnosis was published in the Canadian Medical Association Journal recommend for the lovable, huggable bear? A low dose of Ritalin.
A glance at the three main drugs used for treating ADHD, all of which are stimulants:
Ritalin: Introduced in 1956. Main ingredient is methylphenidate, with a duration of four to six hours. Notable advantage: Fast-acting, with doctors often able to monitor behavioral changes within an hour. Common side effects: loss of appetite, nervousness, trouble in sleeping, dizziness, drowsiness, headache, nausea and stomach pain.
Adderall: Approved by the Food and Drug Administration in 1996. A combination of four amphetamines, including Dexedrine, with a duration of seven to eight hours. Notable advantage: Because of its longer duration of action, it can replace Ritalin in some patients, ending the need for a "noon" dose of medication. Common side effects: restlessness, dizziness, insomnia, headache, dryness of the mouth, weight loss, diarrhea, constipation and other gastrointestinal disturbances.
Concerta: Approved by the FDA this year. Main ingredient is methylphenidate. Notable advantage: duration of 12 to 14 hours. Common side effects: headache, upper respiratory tract infection, stomachache, vomiting, loss of appetite, sleeplessness, increased cough, sore throat, sinusitis and dizziness.
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