Drug therapy is effective when approached appropriately, with best results occurring when used in conjunction with counseling or behavioral therapy.
Central nervous system (CNS) stimulants is first line therapy for adults and children with ADHD; these drugs work best when used in conjunction with behavioral therapy. Beginning with a low dose and increasing until optimal improvement in symptoms is seen without side effects, with immediate-release drugs tried first. The first dose is given before school, for children; a second dose, if needed, given after school; transdermal patches are worn for 9 hours, and then removed. CNS stimulants work by enhancing the release and blocking the reuptake of dopamine and norepinephrine in presynaptic nerve cells.
Increasing levels of these neurotransmitters enhances executive functions, increases inhibition, improves attention, and allows for better focus. Boosting these neurotransmitters dampens the “noise” patients with ADHD experience, allowing them to focus and concentrate. Stimulants can help with self-control, aggression, and productivity; but may not help with reading skills, social skills, or academic achievement.
Side effects include headache, stomachache, loss of appetite, weight loss, insomnia, and irritability.
Children’s weight and height should be monitored, due to the occurrence of growth suppression.
To minimize side effects, children are given a therapeutic holiday – stopping the drug when school is not in session.
Cardiac abnormalities are rare but serious with the use of CNS stimulants. All CNS stimulants are C-II medications and have the potential for abuse and addiction. C-II medications are not given refills.
Drugs that Affect the Autonomic Nervous System
Most drugs that affect the autonomic nervous system are used to control blood pressure and heart rate.
Adrenergic inhibitors block alpha and beta receptors; adrenergic agonists stimulate alpha and beta receptors.
Alpha and beta receptors are found in the heart and blood vessels; stimulation can cause increased heart rate, vasoconstriction, and elevated blood pressure. Activation of alpha receptors also delays bladder emptying. Blocking these receptors causes opposite affects.
Alpha blockers are primarily used to treat hypertension (high blood pressure); useful in men with benign prostatic hyperplasia (BPH) – a condition where the prostate enlarges with age. They are also used to relieve urinary urgency and frequency associated with BPH.
Side effects of alpha blockers include: headache, dizziness, nausea, and fatigue/tiredness; patients should avoid driving until they know how the medication will effect them. Rare side effects is males experiencing priapism – erection lasting more than 4 hours. Significant hypotension and heart palpitations can happen with the first few doses; symptoms are dizziness, lightheadedness, and fainting.
Patients should not drive or undertake hazardous tasks for 12-24 hours after their first dose.
Drinking alcohol can intensify hypotensive effects and should be avoided when possible.
Beta blockers are used for hypertension, angina (chest pain), and arrhythmias. Class II of antiarrhythmic agents is made up entirely of beta blockers.
Research and low costs support the use of beta blockers, making them an attractive and frequent choice for treating high blood pressure. Also recommended for heart attack patients because these drugs reduce oxygen demands and stress on the heart; which can be helpful in prevention of subsequent heart attacks.
Cardioselective beta blockers inhibit only beta-one receptors; useful for angina and certain arrhythmias without causing bronchoconstriction. Less common uses include prophylaxis for migraines and mild anxiety; ophthalmic formula used to treat glaucoma.
Common side effects include headache, dizziness, lightheadedness, nausea, and fatigue/weakness; patients should avoid driving until they know how the medication will effect them; there is an increased incidence of depression. Sometimes the heart rate can slow too much and exacerbate cardiac conditions such as angina, arrhythmia, and heart failure. Patients experiencing difficulty breathing, night coughing, or swelling of extremities should seek medical attention right away.
Blocking beta-two receptors constricts airways in the lungs in addition to lowering blood pressure; this can be harmful to patients with asthma or COPD.
Patients should not stop taking beta blockers suddenly as this could result in severe cardiac problems, like heart attack, angina, or arrhythmia.
Diabetic patients should use beta blockers with caution because these drugs can inhibit the usual signs and symptoms of a reaction to low blood sugar.
Propranolol (Inderal) and Metoprolol (Lopressor, Toprol) should be taken with food.
Patients taking beta blockers for high blood pressure should avoid over the counter decongestants because they can raise blood pressure.
Adrenergic agonists stimulate the autonomic nervous system to produce sympathetic activity, like increased heart rate, bronchodilation, and elevated blood pressure.
These drugs can stimulate the heart to start beating again, open constricted airways, raise blood pressure when large amounts of blood have been lost, and constrict blood vessels to treat swelling during sinus infections and severe allergic reactions.
Adrenergic agonists are sympathomimetics because they mimic the effect of stimulating the sympathetic nervous system. Used in respiratory distress, allergic reactions, and sinus congestion; ophthalmic versions are used to treat glaucoma. Many have a vasopressor action, which increases the heart rate and blood pressure; used for cardiac arrest and shock situations.
Epinephrine is used in severe allergic reactions as a sympathomimetic agent; it opens airways and constricts blood vessels to treat swelling. Used for anaphylactic reactions, where swelling and closure of airways is possible, but not for simple hives, rash, or itching allergies.
Epinephrine and phenylephrine are used topically as decongestants in the nose to reduce sinus swelling.
Epinephrine in an IV is used during surgery to support blood pressure and respiration.
Side effects include headache, excitability, fast heart rate, restlessness, and insomnia; rare is arrhythmia.
These medications, in IV form are mixed only as needed, and are done so with dextrose not normal saline.
Patients should be counseled by the pharmacist on how to inject epinephrine using an autoinjector.
Anticholinergic side effects can be exerted by many drugs blocking cholinergic activity in the parasympathetic system. It may cause dry mouth, dry eyes, constipation, and urinary retention; rising blood pressure.
Opioid pain medications and bladder spasticity agents are drugs with significant anticholinergic side effects.
Ginkgo biloba may benefit patients with early Alzheimer's disease, but there are some serious side effects (bleeding, seizures, coma). Study results do not show dramatic improvement in memory or thinking; many patients take ginkgo biloba to prevent Alzheimer’s.
Patients taking warfarin (Coumadin) or aspirin should not take ginkgo biloba without medical supervision; it interacts with several prescription medications, particularly anticonvulsants.
Dietary supplements that contain ephedra, also called ma huang, were banned in 2004 from being sold in the U.S.
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