Activity

Activity ID

5918

Expires

July 1, 2022

Format Type

Journal-based

CME Credit

1

Fee

$30

CME Provider: JAMA Pediatrics

Description of CME Course
Abstract

Importance:
Evidence on the titration of stimulant medications for attention-deficit/hyperactivity disorder (ADHD) is lacking. However, this lack of evidence has not prevented medication guidelines from specifying apparently arbitrary dose limitations, which could discourage clinicians from titrating methylphenidate to higher and, perhaps for some patients, more efficacious doses.

Objective:
To determine the evidence on dose titration and adverse events associated with dose titration of stimulants for ADHD.

Data Sources:
MEDLINE from 1946, Embase from 1974, and PsycINFO from 1806 through April 1, 2019, were searched to identify relevant articles.

Study Selection:
The inclusion criteria were that (1) the study was conducted on children up to 18 years of age; (2) children had a diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, or hyperkinetic disorder according to the International Classification of Diseases codes; and (3) the dose of methylphenidate was determined by titration.

Data Extraction and Synthesis:
The PRISMA guidelines for abstracting data and assessing data quality and validity were followed. Quality assessment was undertaken using the Jadad scoring system. Statistical analysis was undertaken using a random-effects model.

Main Outcomes and Measures:
The outcomes of interest were (1) the doses used in published clinical trials, (2) the clinical justification given by researchers for their selected dose range, and (3) the adverse effects associated with methylphenidate when the dose is established by titration.

Results:
A total of 11 randomized clinical trials and 38 cohort studies were analyzed. The randomized clinical trials involved 1304 participants treated with methylphenidate and 887 controls; the 38 cohort studies included 5524 participants. Maximum doses of methylphenidate ranged from 0.8 to 1.8 mg/kg/d. Some studies detailed their method of titration, including starting dose, titration interval, increment dose, and maximum dose. Not all of these studies reported justification for the chosen dose range. Common adverse effects of methylphenidate included insomnia (odds ratio, 4.66; 95% CI, 1.99-10.92; P? A range of maximum doses for methylphenidate was recommended in clinical studies; no discernable scientific justification for any particular dose was given. Reports of life-threatening adverse events were absent; further studies of the efficacy, tolerability, and safety of methylphenidate titrated purely on clinical grounds, without reference to any set maximum dose, are needed.

Disclaimers
1. This activity is accredited by the American Medical Association.
2. This activity is free to AMA members.

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More Information
Commercial Support?
No

NOTE: If a Member Board has not deemed this activity for MOC approval as an accredited CME activity, this activity may count toward an ABMS Member Board’s general CME requirement. Please refer directly to your Member Board’s MOC Part II Lifelong Learning and Self-Assessment Program Requirements.

Educational Objectives

To determine the evidence on dose titration and adverse events associated with dose titration of stimulants for attention-deficit/hyperactivity disorder (ADHD).

Keywords

Adverse Drug Events, Attention Deficit/Hyperactivity Disorders, Child and Adolescent Psychiatry, Clinical Pharmacy and Pharmacology, Headache

Competencies

Medical Knowledge

CME Credit Type

AMA PRA Category 1 Credit

Additional Information

doi:10.1001/jamapediatrics.2019.0905

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