From the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, Massachusetts General Hospital.
MIT Integrated Learning Initiative, Department of Brain and Cognitive Sciences, and McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA.
J Clin Psychopharmacol. 2021;41(3):310-314. doi: 10.1097/JCP.0000000000001374.
PURPOSE/BACKGROUND: This study aimed to evaluate the frequency of needing to switch the initial treatment of a stimulant to the alternative family in newly referred, medication-naive adults with attention-deficit/hyperactivity disorder (ADHD) initiating treatment with stimulants.
METHODS/PROCEDURES: Subjects were 49 unmedicated adults (18-45 years old) with Diagnostic and Statistical Manual of Disorders (Fifth Edition) ADHD who initiated treatment with a stimulant. Before the clinical assessment with an expert clinician, participants completed the Adult Self-Report, Behavior Rating Inventory of Executive Function-Adult Version, Emotional Dysregulation Subscale of the Barkley Current Behavior Scale-Self-report, and Mind Wandering Questionnaire. The rate of switching was examined using information from the electronic medical record for up to three clinical follow-up visits. Comparisons were made between those who did and did not need to switch on baseline demographic and clinical characteristics.
FINDINGS/RESULTS: Sixty-seven percent of ADHD patients were initially prescribed a methylphenidate product, and 33%, an amphetamine product. Forty-one percent of ADHD patients needed to switch from their initially prescribed stimulant family within 90 days of initiating treatment because of poor tolerability. Whereas the rate of switching was significantly higher in those initially prescribed methylphenidate, the rate of patients who required changes in formulation (long- to short-acting and vice versa) or additional antianxiety or antidepressant treatment ("strugglers") was higher in those taking amphetamine. Switchers were more impaired on the Adult Self-Report Intrusive scale, whereas nonswitchers were more impaired on the Behavior Rating Inventory of Executive Function Inhibit and Task Monitor scales. However, these findings were small and of unclear clinical significance.
IMPLICATIONS/CONCLUSIONS: Forty-one percent of medication-naive adults with ADHD initiating stimulant treatment required a switch from the initially prescribed stimulant family to the alternative one because of poor tolerability. Switching could not be adequately predicted by baseline demographic or clinical characteristics. These findings call for improved efforts to help identify predictors of response to stimulant treatment in adults with ADHD to avoid unnecessary delays in identifying a safe and effective treatment for these patients.
目的/背景：本研究旨在评估新诊断、未经药物治疗的注意力缺陷多动障碍（ADHD）成年患者在开始使用兴奋剂治疗时，需要将初始治疗药物从一种兴奋剂转换为另一种兴奋剂的频率。
方法/程序：研究对象为 49 名未经药物治疗的（18-45 岁）患有 DSM-5 诊断的 ADHD 成年患者，他们开始接受兴奋剂治疗。在接受专家临床评估之前，参与者完成了成人自评量表、执行功能行为评定量表成人版、Barkley 当前行为量表-自我报告的情绪调节分量表和思维漫游问卷。通过电子病历信息，在最多三个临床随访就诊时，检查了转换率。在基线人口统计学和临床特征方面，比较了需要和不需要转换的患者。
结果/发现：67%的 ADHD 患者最初被开了哌甲酯产品，33%的患者被开了安非他命产品。41%的 ADHD 患者在开始治疗后 90 天内需要从最初开的兴奋剂药物种类中转换，原因是耐受性差。虽然最初开哌甲酯的患者转换率明显更高，但需要改变剂型（长效至短效，反之亦然）或额外使用抗焦虑或抗抑郁药物的患者（“挣扎者”）比例更高，这些患者服用的是安非他命。转换者在成人自评量表的侵入性量表上得分更高，而非转换者在执行功能行为评定量表的抑制和任务监测量表上得分更高。然而，这些发现很小，且临床意义不明确。
意义/结论：41%的新诊断、未经药物治疗的 ADHD 成年患者在开始使用兴奋剂治疗时，需要将最初开的兴奋剂药物种类转换为另一种，原因是耐受性差。基线人口统计学或临床特征不能充分预测转换。这些发现需要我们努力提高识别成人 ADHD 对兴奋剂治疗反应的预测指标，以避免不必要地延迟为这些患者确定安全有效的治疗方法。
