Abstract
This issue of the journal contains two important articles on pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD). One investigates the pharmacokinetics of a novel formulation of methylphenidate (MPH) and suggests a new frontier in precision dosing; the other looks at the comparative effectiveness of MPH and a plant-based alternative.
First, Liu et al. add to the literature describing HLD200, an MPH formulation that provides immediate, delayed, and extended release of the compound. The authors write that HLD200 “was specifically designed to provide ADHD control that starts upon awakening and lasts into the evening,” achieved using the specific formulation and an evening dosing schedule. This same formulation was shown to be effective in treating ADHD symptoms and functional impairment in the morning among youth with ADHD aged 6–12 years in a recent study published in this journal (Pliszka et al. 2017).
In this article the authors describe the pharmacokinetics of this formulation. “Delayed onset was consistent across 20- and 100-mg doses and was not affected by evening or morning food intake,” they write. In addition, “larger doses resulted in proportionally higher plasma MPH concentration, which allows clinicians to titrate doses with relatively predictable outcome.”
Second, Baziar et al. describe a 6-week randomized double-blind study (n = 54) of MPH versus saffron capsules (Crocus sativus). This Iranian group acknowledges that their results are preliminary but report a remarkable treatment effect of saffron when evaluated using the ADHD Rating Scale-IV, teacher and parent versions. “This 6-week course of treatment with saffron showed the same efficacy as methylphenidate in children with ADHD,” the authors write, and “the frequency of side effects was not significantly different between the saffron and MPH groups.”
The authors draw attention to the 30% of patients who “do not respond to stimulants or cannot tolerate their side effects” as an impetus for developing and testing alternative medication treatments, including herbal medicine like the one studied here. Based on these results, they conclude, “larger controlled studies with longer treatment periods” are necessary and warranted.
In addition, I would like to highlight the work of Schoemakers et al. These Dutch investigators report on a retrospective chart study of relative increase in BMI z-score among patients aged 8 to 13 years prescribed either risperidone or aripiprazole. The authors conclude that there is no significant difference in the weight gain associated with these two antipsychotic medications, a finding that is contrary to those previously reported in the literature.
The authors do find, however, that youth prescribed aripiprazole had a significantly higher BMI at the outset of treatment when compared with youth prescribed risperidone. This suggests a possible effect of the belief among clinicians that aripiprazole is a “safer” choice for patients wherein weight gain is a concern. Schoemakers et al. conclude that “aripiprazole should not be favored over risperidone in children and adolescents when based solely on the degree of weight gain.”