Lecture Notes: Combination Medications for ADHD

Speaker: Dr. John Cru

Introduction

• Topic: Combination medications for ADHD.
• Format: Take-home message followed by main content.
• Interaction: Questions can be submitted in comments.

Key Points

1. Combination Medications:

   • Refers to combining different pharmacologic agents.
   • Not discussing the combination of talking therapies and medications.
   • Common practice, although not FDA-approved for combined use.
   • Most research is descriptive, with some randomized controlled studies.

2. FDA Stance:

   • No ADHD medications approved for combination use by the FDA.
   • Medications approved as solo agents.

3. Research Evidence:

   • Some evidence supporting combination therapy (e.g., atomoxetine + stimulant, guanosine + stimulant).
   • Evidence shows potential enhanced benefits without increasing side effect risks.

Main Talk: Rationale for Combination Medications

1. Need for Combination:

   • Stimulants provide substantial relief, but not complete relief for most.
   • ADHD involves neurochemical and brain circuitry issues.

2. Mechanism and Effects:

   • Combining stimulants with non-stimulants for stronger or synergistic effects.
   • Different classes of drugs target different pathways (dopamine, norepinephrine, Alpha 2 receptors).

3. Augmentation Needs:

   • Stimulants vary in duration, some may require short-acting stimulants for specific tasks.
   • Additional agents like atomoxetine may cover time gaps.

4. Side Effect Management:

   • Addressing common stimulant side effects (e.g., insomnia, tics).
   • Use of sleep agents or sedating antidepressants when necessary.

5. Comorbid Conditions:

   • ADHD often coexists with other conditions (e.g., depression, PTSD).
   • Additional psychoactive agents may be required for these conditions.

Research and Studies

• 2009 Study: 18,000 ADHD individuals in the US; various combination therapy rates.
• 2015 Study: 200,000 children in the US, comparison of commercial insurance vs Medicaid.
• 2021 Study in Korea: Smaller sample, distinctions due to regional medication restrictions.

Benefits and Limitations of Combination Therapy

• Atomoxetine + Stimulant: Some studies show improvements, no increased side effects.
• Guanosine + Stimulant: Improvements in inattentiveness, no pharmacokinetic interactions.

Supplements and ADHD

• Little Research: Fish oil, Ginkgo, ginseng show potential benefits.
• St. John's Wort: No additional benefits when combined with stimulants.

Personal Clinical Observations

• More than half of Dr. Cru's ADHD patients on combination therapy.
• Common combinations: Stimulants with non-stimulants for various reasons.

Guidelines for Combining Medications

1. Target Symptoms: Clearly define what symptoms are targeted for improvement.
2. Use of ADHD Scales: Track symptomatic improvements through standardized scales.
3. Dosing: Start with low doses and monitor results, focusing on symptomatic relief and side effects.

Specific Scenarios for Combination Therapy

• High tolerance to stimulants, coverage for gaps, anxiety management, etc.

Conclusion

• Encouragement to use this information for healthier, happier outcomes.
• Availability for questions and further discussions in comments or Q&A sessions.