Up to half of all children with ADHD continue to meet the criteria at adul age. Dysfunction in adults can be considerable.They will have more rates of antisocial, addictive, mood, and anxiety disorders compared with controls. There is not much data to make conclusions on best medication approaches in Adult ADHD. Stimulants have the risk of abuse and diversion.There is some suggestion that Atomoxetine have similar response rates in young and older adults.
Todd M. Durell et al report the results of the first multicenter, double-blind, placebo-controlled medication trial conducted in young adults (18-30 years old) with at least moderate degree of ADHD. Those with depression, PTSD, Psychosis or Substance use disorder were excluded.Study was condusted in USA and Puerto Rico.Participants randomized to atomoxetine began treatment with 40 mg/d for a minimum of 7 days. This was increased to 80 mg/d for a minimum of 7 days. At or after week 8, the dose could be increased to the maximum of 100 mg/d depending on prescribers assessment of the need.Primary outcome measure was the change in mean scores on the 18 item Conners’ Adult ADHD Rating Scale: Investigator-Rated: Screening Version (CAARS-Inv:SV). Total score range from 0-54.
445 participants were randomized to treatment, and 385 received at least 1 dose of study drug. Half of the 220 participants randomized to atomoxetine and 58% of the 225 participants randomized to placebo completed the study.The most common reasons for early discontinuation were lost to follow-up (n = 97), participant decision (n = 54), and adverse events (n = 27) .
Atomexetine was statistically superior to placebo on the outcome measure. Atomoxetine group showed an improvement of (-13.6) of on the CAARS Total ADHD Symptoms score. The effect size indicate moderate effect .Quality of life measures also showed greater improvement in treatment group. The discontinuation rate due to an adverse event for patients receiving atomoxetine was 10%. Nearly 5% of males reported erectile dysfunction. Nausea, decreased appetite,irritability and dry mouth were the other reported side effects.
These results are similar to those from previous atomoxetine trials. It is important to note that the poor completion rate in this study . It is interesting that ADHD symptom improvement did not lead to significantly lower substance use. As in many psychiatric trials, substantial number of subjects in placebo group also responded.
Conclusion: Results from this study provide evidence that atomoxetine 40 to 100 mg/d is superior to placebo in treating young adults (aged 18 to 30 years) with ADHD and that it is safe to prescribe them.
Comment: Atomoxetine prescription even in adults need a very cautious approach. Cardiac status needs to be assessed prior to prescription.There are rare reports of hepatic disorders and hence patients should be educated to recognise these symptoms. Emergence or worsening of depression, irritability, aggression and suicidal ideations need careful monitoring.
Summary of the article:
Atomoxetine treatment of attention-deficit/hyperactivity disorder in young adults with assessment of functional outcomes: a randomized, double-blind, placebo-controlled clinical trial.Durell TM, Adler LA, Williams DW, Deldar A, McGough JJ, Glaser PE, Rubin RL, Pigott TA, Sarkis EH, Fox BK.
J Clin Psychopharmacol. 2013 Feb;33(1):45-54.