Alternative pharmacological strategies for adult ADHD treatment: a systematic review

ABSTRACT

Adult Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent psychiatric condition associated with high disability and frequent comorbidity. Current standard pharmacotherapy (methylphenidate and atomoxetine) improves ADHD symptoms in the short-term, but poor data were published about long-term treatment. In addition a number of patients present partial or no response to methylphenidate and atomoxetine. Research into the main database sources has been conducted to obtain an overview of alternative pharmacological approaches in adult ADHD patients. Among alternative compounds, amphetamines (mixed amphetamine salts and lisdexamfetamine) have the most robust evidence of efficacy, but they may be associated with serious side effects (e.g. psychotic symptoms or hypertension). Antidepressants, particularly those acting as noradrenaline or dopamine enhancers, have evidence of efficacy, but they should be avoided in patients with comorbid bipolar disorder. Finally metadoxine and lithium may be particularly suitable in case of comorbid alcohol misuse or bipolar disorder.

Keywords:

• Adults
• Attention Deficit Hyperactivity Disorder (ADHD)
• Pharmacological Treatment
• Efficacy
• Amphetamines
• Antidepressants
• Metadoxine
• Lithium

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Key issues

• Adult ADHD is a prevalent condition associated with important social dysfunction (criminal behavior, substance abuse and poor job performance).

• Methylphenidate and atomoxetine have improved outcome of adult ADHD patients, but they are not always tolerated, there are few data of efficacy in the long-term and a number of non-responders.

• Amphetamines have the most robust evidence of efficacy, but serious side effects such as psychotic symptoms.

• Antidepressants have some evidence of efficacy, but they should be carefully prescribed for the frequent comorbidity with bipolar disorder in adult ADHD patients.

• Metadoxine and lithium might be useful therapeutic options if data of effectiveness will be confirmed by large-sample placebo-controlled studies.

• Modafinil did not show a clear efficacy in improving symptoms of patients with ADHD.

• Future research should help clinicians to prescribe ‘personalized treatments’ for adult ADHD patients and fulfill current unmet needs.

• Wider therapeutic options will limit potential drug interactions or worsening of medical/psychiatric conditions in comorbidity with adult ADHD.