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Psych- ADHD

Primary Care Corner with Dr. Geoffrey Modest: ADHD drugs and Priapism

22 Dec, 13 | by EBM

see below from the FDA.  not just methylphenidate, but also seems to be an issue with  non-stimulant drug atomoxetine. sounds like it can be severe: average age 12.5 and 2 needing surgical intervention.

geoff

Safety Announcement

[12-17-2013]  The U.S. Food and Drug Administration (FDA) is warning that methylphenidate products, one type of stimulant drug used to treat attention deficit hyperactivity disorder (ADHD), may in rare instances cause prolonged and sometimes painful erections known as priapism. FDA continues to monitor the safety of drugs after they are approved, and, based on a recent review of methylphenidate products, we have updated the drug labels2 and patient Medication Guides to include information about the rare but serious risk of priapism. Patients who take methylphenidate and develop erections lasting longer than four hours should seek immediate medical treatment to prevent long-term problems with the penis.  If not treated right away, priapism can lead to permanent damage to the penis.

Priapism can occur in males of any age and happens when blood in the penis becomes trapped, leading to an abnormally long-lasting and sometimes painful erection. Younger males, especially those who have not yet reached puberty, may not recognize the problem or may be embarrassed to tell anyone if it occurs.  All male patients and their caregivers should be taught the signs and symptoms of priapism and the importance of seeking immediate medical treatment if it occurs.

Methylphenidate products are among the medicines that can be used to treat ADHD. One of the most common childhood brain disorders, ADHD can continue through adolescence and adulthood and causes symptoms such as difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity. Medications such as methylphenidate used to treat ADHD benefit patients with the disorder by increasing focus, reducing impulsivity, and improving overall social functioning. Therefore, patients who have been prescribed a methylphenidate product should not stop taking it without first talking to their health care professionals. Table 1 lists methylphenidate products marketed in the United States.

In our review, the median age of patients taking a methylphenidate product who experienced priapism was 12.5 years (range 8 to 33 years). In a few patients, priapism occurred after an increase in the dosage of methylphenidate, but priapism has also occurred under other conditions, such as during short periods of time when the drug was stopped temporarily, when there was a longer than typical time between doses, or after stopping the drug permanently. Two patients required surgical intervention; one required shunt placement, and the other had to have needle aspiration of the corpus cavernosum.

The risk of priapism may cause some health care professionals toconsider switching patients to the non-stimulant drug Strattera (atomoxetine), another drug used to treat ADHD; however, atomoxetine has also been associated with priapism in young children, teenagers, and adults. Priapism appears to be more common in patients taking atomoxetine than in patients taking methylphenidate products. Health care professionals should be cautious when considering changing patients from methylphenidate to atomoxetine.

Amphetamine products are also used to treat ADHD, and we have received reports of priapism in four patients taking an amphetamine product.  However, whether the amphetamine products caused the  priapism is uncertain, because all of these patients had been taking other medications that are thought to cause priapism. Therefore, we cannot conclude that the use of amphetamine products can result in priapism.

Primary Care Corner with Dr. Geoffrey Modest: “The Selling of Attention Deficit Disorder” (from the NYT)

16 Dec, 13 | by EBM

the NY times had a front-page story on “the selling of attention deficit disorder”, one of a recent series of health care expose-type articles (see http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?nl=todaysheadlines&emc=edit_th_20131215&_r=0). their basic points:

–dramatic increase in diagnosis (made in 15% of high school aged children!! — second only to  asthma — with # of kids on meds increasing from 600K to 3.5M in past 20 years)

–increase in meds coincides with intensive drug company campaign to publicize syndrome and promote pills as therapy, including widespread advertising to parents/kids: using celebrities on TV to promote diagnosis, defining ADHD to include “childhood forgetfulness and poor grades as grounds for medication, that, among other benefits, can result in ‘schoolwork that matches his intelligence’ and ease family tension”, “subsidized 50,000 copies of a comic book that tries to demystify the disorder and uses superheroes to tell children, ‘medicines may make it easier to pay attention and control your behavior'”.

–(my comment): part of issue is that DSM-5 has broadened diagnosis of ADHD, expanding the age of diagnosis (used to be that dx had to be made by age 7, now it’s 12), and lowering the definition of when a kid is “impaired” but without specifics on the definition of degree of impairment, eg mild, moderate, severe). BMJ has a good editorial comment on DSM-5, noting that many more people diagnosed, lack of specific definitions of severity though 87% of those diagnosed in 2010 ended up on meds (though per DSM-5 those with only mild to moderate sx should have nonmedication behavioral approach), and 78% !!!! of the work group advisors for DSM-5 redefinition of ADHD had links to drug companies (see http://dx.doi.org/10.1136/bmj.f6172)

–drug company now targeting “adult ADHD” for publicity blitz, using popular musicians and the campaign: “it’s your ADHD — Own It”, and an on-line instrument which NY Time poll found that 1/2 of 1000 participants got result of either “ADHD possible or ADHD may be likely”. the Times comments on a psychiatrist promoting concept that ADHD is a lifelong disorder requiring life-long therapy (he received $45K from drug companies from 2010-2011). also, part of ad campaign is that since ADHD runs in families, parents of ADHD kids may need therapy. as an aside, there was a funny comment in the lancet several years ago in an editorial about adult ADHD (which they saw as basically a credible diagnosis in the U.S. and not the U.K.), where a U.S. med student was asked what was “normal” for patient, with the response that that happened when the physician did not look hard enough…..

–dr. joseph biederman, a child psychiatrist at harvard and MGH whose studies were frequently cited by drug companies, was involved in 2008 senate investigation on his research, which was subsidized by drug companies, and he was paid $1.6M in speaking and consulting fees.

–and, by the way, the name “Adderall” comes from ADD for all”

so, there are clear cases of ADHD in kids — i have treated many kids with severe dysfunction from ADHD with some pretty remarkable results.  the point is not to deny the existence or appropriate therapy to those kids in need. but there are clear adverse effects (not a benign drug as promoted by drug companies, but with potential for addiction and, though unusual, can have very severe adverse effects, such as psychosis/hallucinations, suicide). the extensive drug company blitz clearly led to dramatic profits for the drug company, akin to the drug-company sponsored “pain as the fifth vital sign” helped promote the widespread use of opiates, as per prior blog posts.

geoff

 

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