Stimulant Medications in Children and Adolescents: A Big Problem for Little People?
|Pub Date:||Tuesday, April 22, 2008|
|Authors:||Christena H. Benson, RN, MPH D and Woodrow Benson, MD, PhD|
Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving stimulant drugs: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation 2008: published online before print April 21, 2008, 10.1161/CIRCULATIONAHA.107.189473.
Attention deficit hyperactivity disorder (ADHD) is estimated to affect 4% to 5% of the pediatric population, but the prevalence may be higher in children with heart disease. Numerous studies have identified that ADHD has substantial morbidity, including academic, occupational and interpersonal failure, sexual promiscuity and increased risk of cigarette smoking, criminality and motor vehicle accidents. Stimulant medications, such as methylphenidate and amphetamines, have been used to effectively treat this disorder for more than 30 years in both the United States and abroad. Global use of ADHD medications rose threefold from 1993 through 2003, whereas global spending (U.S. $2.4 billion in 2003) rose ninefold. In the United States, use of these medications increased fourfold in the decade, beginning in the mid 1980's, but appears to have leveled off in the most recent decade. The scope of the problem is illustrated by estimates that currently in the United States these medications are prescribed for approximately 2.5 million pediatric patients annually.Given the sympathomimetic qualities of the stimulant medications, it is not surprising that minor changes in heart rate and blood pressure have been reported. However, when use of these medications was previously reviewed by the Council on Cardiovascular Disease in the Young in 1999 [3,4], no specific cardiovascular monitoring was recommended; though, since that time, important issues have surfaced necessitating a second look at this problem. Awareness of ADHD in both the general pediatric population, as well as in children with underlying cardiac conditions, has continued to increase. There have been public concerns about the side effects and toxicities of medications in general but especially of stimulant medications in children. However, the major concerns have stemmed from reports of sudden cardiac death (SCD) in children taking these medications. Despite the low prevalence, the emotional effect of SCD in a child, on the family, and the community is disproportionately large (high-grief death) due in part to the youth, apparent good health, and lost potential. The recent recommendation for a "Black-Box Warning" (a type of warning that appears on the package insert for prescription drugs that may cause serious adverse effects) has added considerably to anxiety regarding safety of these medications.
In this issue of Circulation, Vetter and associates provide a timely and comprehensive overview of ADHD in the general population and in children with heart disease, and they give a detailed account of the regulatory issues that have surfaced since 2005. The authors review etiology, risk factors, and prevention of SCD in the young. As part of the assessment of efforts to prevent SCD in the pediatric population, the authors provide informative updates of worldwide initiatives focusing on universal electrocardiogram (ECG) screening and the role of ECG and echocardiography in preparticipation screening of athletes. The report also provides a comprehensive update on pharmacotherapy of ADHD, including cardiovascular side effects.
Based on this background, the authors develop guidelines, patterned after recommendations, to screen for SCD risk. In the case of risk assessment for stimulant medication use, the proposed guidelines are based on Level of Evidence C (consensus opinion of experts, case studies, or standard of care). Specific recommendations include review of systems with focused questions to determine symptoms of palpitations, presyncope or syncope, additional medication, and family history. Assessment of SCD risk also includes physical examination. The screening strategy is designed to identify the common causes of SCD in the young, which include hypertrophic cardiomyopathy (HCM), long Q-T syndrome (LQTS), Wolff-Parkinson-White syndrome (WPW) and Marfan syndrome (MFS). To increase the likelihood of identifying significant cardiac conditions known to be associated with SCD, the group recommends that all patients have an electrocardiogram prior to commencing stimulant medications.Like motherhood and apple pie, prevention of SCD, especially in the young, is championed by most. Risk assessment is an important component of the preventive strategy. Reservations regarding risk assessment are usually related to expense and concerns about sensitivity (the extent to which at-risk individuals can be identified) and specificity (mislabeling normal individuals as affected). These latter concerns have certainly been true for the ECG [7-9] and are the basis for Maron et al. to conclude that mass ECG screening of competitive athletes was not feasible. In regard to expense, Vetter et al. argue "The use of selective ECG screening in this population is felt to be medically indicated and of reasonable cost."
The authors of this AHA Scientific Statement are to be congratulated for their thorough review of ADHD, the pharmacotherapy of ADHD medications, and stimulant medication associated SCD. Nonetheless, it remains unclear whether the risk for SCD is actually higher in patients receiving stimulant medications than it is in the general pediatric population. From a practical standpoint, the rarity of this problem means that it may be impossible to develop evidence-based guidelines for cardiovascular monitoring of children and adolescents receiving stimulant drugs. The Agency for Healthcare Research and Quality (AHRQ) and the FDA, are funding a retrospective study being coordinated by Vanderbilt University to perform a review of data of 500,000 children and adults to determine whether medications used to treat ADHD increase cardiac-risk factors. More data defining cardiac risk may help to frame the scope of the problem.
The guidelines proposed in the paper by Vetter and colleagues serve a useful purpose to bring an important concern to the forefront. Certainly, in pediatric patients known to have heart disease, a comprehensive and thoughtful diagnostic and surveillance strategy is mandatory. However, since most stimulant medications are prescribed by general and subspecialty pediatricians, psychiatrists, and family practitioners, for the proposed guidelines to become a standard of care, a consensus involving the providers who prescribe these medications and their respective professional organizations should be sought.
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-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association. --