Methylphenidate (Ritalin) is effective in the shortterm treatment of attention deficit/hyperactivity disorder (ADHD) (strength of recommendation [SOR]: A, multiple randomized control trials). Though the immediate-release preparation is the best studied of methylphenidate formulations, extended-release methylphenidate (Concerta) has similar benefits, with a dosing regimen that may better suit an adolescent lifestyle (SOR: B, based on extrapolation of 1 randomized controlled trial and expert opinion)

Leach, Laura

Mott, Timothy F.

University of Missouri: MOspace

Madden KP, Hamilton S. Recombinant tissue-type plas-minogen activator (Alteplase) for ischemic stroke 3 to 5hours after symptom onset. The ATLANTIS Study: a ran-domized controlled trial. Alteplase Thrombolysis forAcute Noninterventional Therapy in Ischemic Stroke.JAMA 1999; 282:2019–2026.7. Practice advisory: thrombolytic therapy for acuteischemic stroke—summary statement. Report of theQuality Standards Subcommittee of the AmericanAcademy of Neurology. Neurology 1996; 47:835–839.8. Hirsh J, Dalen J, Guyatt G; American College of ChestPhysicians. The sixth (2000) ACCP guidelines forantithrombotic therapy for prevention and treatment ofthrombosis. American College of Chest Physicians. Chest2001; 119(1 Suppl):1S–2S.9. Bravata DM, Kim N, Concato J, Krumholz HM, Brass LM.Thrombolysis for acute stroke in routine clinical prac-tice. Arch Intern Med 2002; 162:1994–2001.10. Katzan IL, Furlan AJ, Lloyd LE, et al. Use of tissue-typeplasminogen activator for acute ischemic stroke: theCleveland area experience. JAMA 2000; 283:1151–1158.11. Katzan IL, Hammer MD, Furlan AJ, Hixson ED, NadzamDM; Cleveland Clinic Health System Stroke QualityImprovement Team. Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: aCleveland update. Stroke 2003; 34:799–800.■ CLINICAL COMMENTARY:Respect the accepted inclusion andexclusion criteria for using thrombolyticsAcute ischemic stroke has always posed thedilemma of giving treatment that may be eitherbeneficial or harmful. Now the stakes of suc-cess or failure are dramatically higher. Familyphysicians must be knowledgeable about treat-ment options, as the 3-hour window for usingrtPA after symptom onset is a diagnostic andlogistic challenge for physicians and staff. Our radiology colleagues help by using theunenhanced head CT to exclude lesions thatmimic ischemic infarct and to confirm that truestroke victims do not have identifiable infarc-tion greater than one third of the middle cere-bral artery territory. Clinicians involved in thertPA decision must know and respect fully andwithout deviation the accepted inclusion andexclusion criteria for using thrombolytics foracute ischemic stroke, to promote recovery andminimize death and disability due to intracra-nial hemorrhage.John Richmond, MD, University of Texas SouthwesternFamily Practice Residency Program, DallasIs methylphenidate useful for treating adolescents with ADHD?■ EVIDENCE-BASED ANSWERMethylphenidate (Ritalin) is effective in the short-term treatment of attention deficit/hyperactivitydisorder (ADHD) (strength of recommendation[SOR]: A, multiple randomized control trials).Though the immediate-release preparation isthe best studied of methylphenidate formulations,extended-release methylphenidate (Concerta) hassimilar benefits, with a dosing regimen that maybetter suit an adolescent lifestyle (SOR: B, basedon extrapolation of 1 randomized controlled trialand expert opinion).■ EVIDENCE SUMMARYThe subjects of most ADHD medication studieshave been school-age children. Most childrenwith ADHD will have symptoms persisting intoteenage years, and methylphenidate has beenincreasingly prescribed for them.1,2 Various systematic reviews and meta-analyses havedemonstrated the effectiveness of short-termmethylphenidate in the treatment of adolescentswith ADHD.3–5 Most participants in these studiesare males aged <13 years. Therefore, any conclu-sions about the effectiveness of methylphenidatein older adolescents must be inferred.The most comprehensive systematic reviewfound 8 well-controlled crossover trials with anaverage sample size of 24.8 (range, 9–48).6 Theaverage duration of the studies was 6 weeks.The majority of the participants were whitemales with a mean age of 13 years. Each studyshowed statistically significant improvementfrom treatment with methylphenidate. Averageeffect sizes were calculated for 3 domains:ADHD symptoms (0.94), social behavior (1.06),and academic performance (1.25). Effect sizeswere calculated using a modified Cohen’s d,which is the difference between the treated andC L I N I C A L  I N Q U I R I E SAUGUST 2004 / VOL 53, NO 8 · The Journal of Family Practice 659C O N T I N U E DJFP_08.04_CI_final  7/21/04  9:25 AM  Page 659C L I N I C A L  I N Q U I R I E SC O N T I N U E D660 AUGUST 2004 / VOL 53, NO 8 · The Journal of Family Practiceuntreated means divided by the standard devia-tion in the untreated condition. It is difficult totranslate these changes in effect size into clini-cally meaningful outcome measures, althoughone rule of thumb estimates an effect size of 0.8is moderate to large. Of the 3 studies that reported the proportionof subjects with clinically significant improve-ment, the modal result was about one half show-ings improvement with methylphenidate. Of trialsassessing dosing levels, <50% found significantdifferences between “low” and “high” doses.However, the researchers did not give their defini-tion of low and high doses. Also, diminishing clin-ical improvement was noted with highermethylphenidate doses. A single study on the once-daily stimulantpreparation, extended-release methylphenidate,shows statistically significant improvement inadolescent ADHD.7 In this multicenter, random-ized, double-blind, placebo-controlled trial of 177adolescents, subjects were given placebo (n=87)or extended-release methylphenidate (n=90) attitrated doses from 18 mg/d to 72 mg/d.Following a subsequent 2-week randomizationphase, clinical investigators found extended-release methylphenidate significantly superior toplacebo (P=.001) on the ADHD scale. Subjectsalso rated it significantly superior to placebo(P=.001) on the Conners-Wells’ Self-ReportScale. Mean dose and average age were notreported. This study has been presented as anabstract and is not yet published.■ RECOMMENDATIONS FROM OTHERSThe American Academy of Child and AdolescentPsychiatry (AACAP) supports the prescribing ofmethylphenidate in adolescents with ADHD.8Given the unique psychosocial, environmental, andscheduling challenges of adolescence, the AACAPmentions extended-release methyl-phenidate as“well-suited for treatment of adolescents.” Timothy F. Mott, MD, Navy Hospital Pensacola FamilyPractice Residency, Pensacola, Fla; Laura Leach, MLIS,Carolinas Healthcare System, Charlotte AHEC, Charlotte, NC■ CLINICAL COMMENTARY:Patients with childhood ADHD usuallybenefit from continuing their medicationAdolescents must face the challenge of becom-ing more organized and independent to be suc-cessful in middle school and high school. Thosewith childhood ADHD may have a particularlydifficult transition, and will usually benefit fromcontinuing to take their stimulants. Some ado-lescents, who were not previously identified ashaving ADHD, may declare themselves at thisage due to school performance issues. Carefulevaluation and treatment of these patients willcontribute to their success. Physicians should use the lowest effectivedose of methylphenidate, as the studies seem toindicate that higher dosages do not improve per-formance in adolescents. Teens often preferlong-acting preparations, which obviate theneed to take medication at school. The studiesreviewed do not define long-term academic orvocational success, which is a more importantoutcome than symptom control for adolescents. Lisa Johnson, MD, Providence St. Peter’s FamilyPractice Residency, Olympia, WashREFERENCES1. Safer DJ, Zito JM, Fine EM. Increased methylphenidateusage for attention deficit disorder in the 1990s. Pediatrics1996; 98:1084–1088.2. Fischer M, Barkley RA, Edelbrock CS, Smallish L. Theadolescent outcome of hyperactive children diagnosed byresearch criteria: II. Academic, attentional, and neuropsy-chological status. J Consult Clin Psychol 1990;58:580–588.3. Klassen A, Miller A, Raina P, Lee SK, Olsen L. Attention-deficit hyperactivity disorder in children and youth: aquantitative systematic review of the efficacy of differentmanagement strategies. Can J Psychiatry 1999;44:1007–1016.4. Schachar R, Jadad AR, Gauld M, et al. Attention-deficithyperactivity disorder: critical appraisal of extended treat-ment studies. Can J Psychiatry 2002; 47:337–348.5. Schachter HM, Pham B, King J, Langford S, Moher D.How efficacious and safe is short-acting methylphenidatefor the treatment of attention-deficit disorder in childrenand adolescents? A meta-analysis. CMAJ 2001;165:1475–1488.6. Smith BH, Waschbusch DA, Willoughby MT, Evans S. Theefficacy, safety, and practicality of treatments for adoles-cents with attention-deficit/hyperactivity disorder(ADHD). Clin Child Fam Psychol Rev 2000; 3:243–267.JFP_08.04_CI_final  7/21/04  9:25 AM  Page 660C L I N I C A L  I N Q U I R I E SAUGUST 2004 / VOL 53, NO 8 · The Journal of Family Practice 663■ EVIDENCE SUMMARYNo studies of inhaled beta-agonists have been con-ducted with patients who have an explicit diagno-sis of acute cough due to URI. While some clini-cians feel a distinction between URI and acutebronchitis should be made, there is significantoverlap between these diagnoses in clinical prac-tice, as well as in the available studies. A systematic review looking at beta-agonistsfor acute bronchitis included the clinical diag-noses of both acute bronchitis and acute coughbecause a standard definition of bronchitis islacking.1 Only two trials in this review examinedinhaled beta-agonists. When results from thesetrials were combined for the outcome of produc-tive cough at 7 days, inhaled beta-agonistsshowed no benefit. However, the authors notethat details of the individual trials may help toclarify the effect of inhaled beta-agonists.One trial, a randomized controlled trial ofadult patients with acute bronchitis in 2 com-munity-based family practices, compared 23patients receiving albuterolin a multidoseinhaler (MDI) with 23 patients receiving place-bo inhaler.2 Patients were also randomized toreceive erythromycin or placebo tablets.Patients with pneumonia or a history of asthmaor chronic obstructive pulmonary disease(COPD) were excluded. At 7 days, 61% ofpatients in the albuterol group reported coughcompared with 91% in the control group (P=.02,NNT=3). No statistically significant differencewas seen in productive cough or night cough.Smokers responded to inhaled albuterol similar-ly to nonsmokers. Erythromycin had no effecton cough and side effects were similar amongall groups.The other trial was a randomized controlledtrial of 80 adults with cough due to acute respi-ratory infection; it compared fenoterol aerosol 4times daily with placebo.3 Inhaled fenoterol isnot available in the US but is similar toalbuterol. This study showed no difference incough at 7 days (relative risk [RR]=0.83; 95%confidence interval [CI], 0.52–1.30). In a sub-group analysis, however, smokers and thosewheezing on initial exam had lower overallsymptom scores when treated with fenoterol.■ RECOMMENDATIONS FROM OTHERSWe were unable to find any guidelines on theuse of albuterol via MDI for cough from bron-chitis or URIs. ■ CLINICAL COMMENTARY:Inhaled beta-agonists may aid symptoms;other outcomes may not be improvedEven without a history of lung disease,patients presenting with cough due to acuterespiratory illness and with evidence of air-flow obstruction (wheezing) appear to receivesymptom relief from inhaled beta-agonists.Smokers may be another subgroup who bene-fit from treatment. However, importantpatient-oriented outcomes (such as reducedneed for over-the-counter medicines, generalwell being, and return to work) do notimprove. If using inhaled albuterol to treatacute cough in practice, one must also con-sider the financial costs and adverse effectsassociated with treatment.Mary Maniscalco Stephens, MD, MPH, EastTennessee State University, Johnson City, TN;Joan Nashelsky, MLS, Family Practice Inquiries Network,Inc, Iowa City, IAREFERENCES1. Smucny J, Flynn C, Becker L, Glazier R. Beta2-agonists foracute bronchitis (Cochrane Review). In: The Cochrane Library,Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.2. Hueston WJ. Albuterol delivered by metered-dose inhalerto treat acute bronchitis. J Fam Pract 1994; 39:437–440. 3. Melbye H, Aasebo U, Straume B. Symptomatic effect ofinhaled fenoterol in acute bronchitis: a placebo controlleddouble-blind study. Fam Pract 1991; 8:216–222.With beta-agonists, outcomes suchas need for OTC medications andreturn to work do not improveJFP_08.04_CI_final  7/21/04  9:25 AM  Page 663

Is methylphenidate useful for treating adolescents with ADHD?

Abstract

Similar works

Full text

Available Versions

University of Missouri: MOspace