The Use of Ritalin as a cure for ADHD Essay

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The Use of Ritalin as a cure for ADHD

Ritalin or ‘Methylphenidate’ is a sympathomimetic agent that indirect acts by stimulating the central nervous system.  It facilities the release dopamine and nor epinephrine at the pre-synaptic neurons, and in this way responsible for changing the level of several substances in the brain.  The drug tends to affect the dopaminergic function.  The drug is utilized in several neurological and psychiatric disorders such as attention-deficit/hyperactivity disorder and narcolepsy.

ADHD is a mental disorder seen usually in young children in whom it may be very difficult to control and is characterized by inattention and hyperactivity.  The condition is more often seen preschool age or beyond this (average age of 7 years).  Narcolepsy is neurological disorder in which the individual becomes excessively sleepy during daytime and fall into attacks of sudden sleep.  For the treatment of ADHD, Ritalin is the most often administered medication in ADHD.  Ritalin is also administered to treat tiredness and depression that does not arise from narcolepsy.

The other conditions in which Ritalin are administered include depression following the development of AIDS or Strokes (especially in the recovery of stroke); elders with a general medical problem, etc.  However, in these conditions it has been found that the standard antidepressants can be much beneficial to the patient, and the only advantage Ritalin would be having over other drugs, that the symptoms are relieved much faster.  The drug may be life-saving in several circumstances as it helps to relieve the depressive symptoms quickly and improve the condition of the patient.  The other conditions in which Ritalin is administered includes:-

  • Apathy (especially when it is serious following a general physical disorder )
  • AIDS-dementia
  • Traumatic brain injury with depressive symptoms
  • Cancer patients with cognitive slowing
  • Patients admitted opioids having developed somnolence
  • Adults with depression in whom the usual antidepressants have not worked
  • Tourette’s syndrome (Dodson, 2001, & Moore, 2004)

            Ritalin is available in several forms including:-

  • Chewable tablets
  • Liquid solutions
  • Extended-release tablets
  • Long-acting tablets – releases the drug over a long period of time (Dodson, 2002)

            Ritalin consumed in the form of chewable tablets or solution is given 2 to 3 times a day, about 30 minutes before food.  Before going to bed, the individual should consume one tablet.  Longer-acting forms of Ritalin are usually consumed once daily in the mornings, before food.  After the tablet has been consumed, the individual should consume a glass of water (as the tablet can swell and block the throat leading to several complications such as breathing problems).  Longer-acting forms of Ritalin are not available in the form of chewable tablets, and hence do not swell up when consumed.  The psychiatrist would usually prescribe lower dosage of the drug and then slowly increase the dosage over a week (Dodson, 2001, & Moore,

            Ritalin is available in the form of immediate acting and long-acting preparations.  The half life of the immediate acting forms is 2 to 6 hours, producing their effect within 2 hours.  The long acting form produces its effect in 3 to 8 hours, and has a half-life of 3 to 6 hours.  The liver helps to convert the Ritalin into an inactive form known as ‘ritalinic acid’.

  The over dosage effects of Ritalin are similar to that of amphetamine.  In order to combat over dosage, clonazepam is administered to help curb the agitation and the high blood pressure levels.  Besides, lorazepam is administered to help control seizures.  Some of the signs of over dosage include sleeplessness, headache, irritability, agitation, seizures, tremors, palpitations, etc.  As titration for other stimulants such as amphetamine is usually not required, the chances of over dosage usually do not appear, and hence amphetamine is usually preferred (Dodson, 2001, & Moore, 2004).

            Ritalin is usually available as 2.5, 5, 10 and 20 mg preparations.   The doses of Ritalin need to be carefully titrated to ensure that the beneficial effects are optimum and the side-effects are minimal.  The patient’s treatment has to be carefully monitored for the positive and the negative effects of the drug, and accordingly the dosage has to be increased, decreased, or even stopped.  The patient is started on 2.5 mg of Ritalin every 4 hourly.  It may be increased by another 2.5 mg for the next 1 to 3 days.  When the dosage is increased, the attending psychiatrist should clearly observe an improvement in the behavioral symptoms, impulse control, mood stability, improved functioning of the patient, etc.

  Certain side-effects such as anorexia are not a serious problem and would appear whenever the dosage is increased.  As the dosage of the drug is increased by 2.5 mg, the patient would not notice any improvement in the symptoms of ADHD, but there would be an increase in the side-effects.  Under such a circumstance, the psychiatrist should consider administering the previous lower dosage for the next few years.

This is known as the ‘optimal dosage’ of Ritalin, and usually tolerance to the drug does not develop.  The process of administering Ritalin to get the exact dosage required for the patient is known as ‘trial and error titration’.  Frequently, this process is very difficult and may cause several inconveniences for the patient including difficulty in repeated visits to the psychiatrist, constant monitoring, serious side-effects, etc.  The maximum dosage of the drug should not be more than 60 mg per day (Dodson, 2002).

            A patient consuming Ritalin should observe certain precautions.  As the drug is a strong base, there are chances that it would not be absorbed by the intestines in case food acidic in nature is consumed (such as ascorbic acid).  The individual should avoid several foods including citrus fruits, sodas, vitamin C preparations, etc, one hour before and after administering the drug.

It has been utilized over 30 years, and studies have shown that with long-term administration, no serious problems develop.  Several other studies have shown that first-line stimulants including Ritalin can protect the individual from developing ADHD.   However, the rate of side-effects and symptoms of over dosage are higher with Ritalin compared to other stimulants such as amphetamine (Dodson, 2001 and Jefferson, 2004).

            Ritalin has also the potential of worsening drug abuse.  In patients suffering from alcohol abuse, drug abuse, etc, the drug should be preferably avoided, as there is the risk that the patient would misuse even this substance.  Ritalin is also known to cause dangerous interactions with several substances including TCA, MAOI, warfarin, phenotoin sodium, Phenobarbital, phenylbutazone, etc.  The drug can raise the levels of TCA’s in the body to over 100% (causing potential toxic effects) and with MAOI it can provoke a hypertensive crisis.  With guanetidine, the drug is known to reduce the antihypertensive effect Ritalin (Dodson, 2001 and Jefferson, 2004).

            Ritalin can cause several side-effects when consumed.  Some of the less serious side-effects include:-

  • Confusion
  • Insomnia (especially when consumed at night)
  • Nausea
  • Fainting
  • Vomiting
  • Anorexia
  • Diarrhea
  • Stomachache
  • Weight loss
  • Headache
  • Weakness
  • Tiredness
  • Dysmenorrhea (Medline Plus, 2007)

            Some of the side-effects of Ritalin which are more serious and need immediate attention includes:-

  • Chest pain
  • Dyspnea
  • Breathlessness
  • Palpitations
  • Rise in the blood pressure levels
  • Worsening of schizophrenia symptoms
  • Chorea (very rare cases)
  • Growth retardation (especially for children with long-term administration – children should be administered the drug before the closure of the epiphysis, so that catch-up growth can occur)
  • Excessive tiredness
  • Tremors
  • Dizziness
  • Blurring of the vision
  • Speech problems
  • Aggressiveness
  • Agitation
  • Anxiety
  • Abnormal thoughts
  • Hallucinations
  • Tics (should not be an absolute contraindication in case it develops)
  • Depression
  • Fever
  • Sore throat
  • Depression
  • Easy bruising
  • Joint disorders
  • Hives
  • Skin rashes
  • Itching
  • Difficulty in swallowing (Medline Plus, 2007)

            There are several issues with the use of Ritalin.  Many practitioners do not prefer using Ritalin as the drug is not only unsafe and unreliable, but also comes in doses that may be difficult to triturate for the patient individually.  Even if the dosage is reduced, the sustained effect would be lost.  For these reasons, several practitioners are considering using long-acting drugs such as amphetamine.  About 5 studies conducted have clearly demonstrated that amphetamine is much better in treating the core symptoms of ADHD compared to Ritalin.  Unless the symptoms have to be reduced immediately, Ritalin seems to be effective (Dodson, 2001 and Jefferson, 2004).

            Some of the drugs that can be utilized as alternatives to Ritalin are Pemoline and amphetamine.  Amphetamine is given in doses of 5, 10, 20 and 30 mgs, whereas pemoline is given in doses of 75 to 100 mg daily.  Studies have shown that pemoline can produce its effects only after 3 weeks of administration.  However, pemoline has several disadvantages including hepatotoxicity and drowsiness in children.

About 20 cases of hepatotoxicity have been recorded throughout the world following pemoline administration.  For this reason pemoline is not administered as a first-line treatment for ADHD in children.  The hepatotoxicity followed by the liver damage occurs so quickly, that liver functions tests conducted routinely are unable to detect it.  Hence, liver function tests need to be conducted more often.  Pemoline is usually required in people with substance abuse, and those who tend to consume repeated doses of Ritalin (Dodson, 2001 and Jefferson, 2004).

            Ritalin works by raising the level of the dopamine neurotransmitter present in the brain.  This neurotransmitter is related to attention, pleasure and movement.  Once the levels of dopamine are raised, the symptoms of ADHD are also reduced.  If the dopamine levels are raised all of a sudden then there are chances that euphoria, addiction and dependence develops.

 In a study conducted by Arnold et al (2000), clear differences were seen between Ritalin and amphetamine.  Both the drugs helped to raise the level of dopamine in the brain.  In patients suffering from ADHD, 27 responded well to Ritalin, 48 to amphetamine and 72 to both.  The range of side-effects were also different, with Ritalin producing the more serious ones compared to amphetamine.  Thus is found that Amphetamine was a better and more effective stimulant in the treatment of ADHD compared to Ritalin (Arnold et al, 2000 and NIDA, 2008).

            There are several problems with Ritalin including amphetamine including:-

  • Greater range of side-effects
  • Less effectiveness of the drug compared to amphetamine
  • Problems in titrating the drug
  • Repeated administration of the drug
  • Potential interactions with other drugs
  • Problems with acidic foods
  • Problems associated with patients suffering from drug abuse.

            For these reasons, other stimulants such as amphetamines are preferred over Ritalin.  Several studies have shown the potential problems of Ritalin in comparison with other drugs.  Hence, psychiatrist should consider administering other drugs for children suffering from ADHD.  The only advantage ADHD has over other drugs is that it acts immediately and can be utilized in acute situations.  This should not however be a factor for considering long-term administration of the drug.

 

References:

David P. Moore and James W. Jefferson. Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. St. Louis: Mosby, 2004.

National Institute of Drug Abuse. “NIDA InfoFacts: Stimulant ADHD Medications – Methylphenidate and Amphetamines.” 2008. NIDA. 22 July 2008. http://www.liu.edu/cwis/cwp/library/workshop/citmla.htm

LE Arold. “Methylpheniade Vs. amphetamine, Comparative Review.” Journal of Attention Disorders. 3.4: 200-211. (2000). http://jad.sagepub.com/cgi/content/abstract/3/4/200

Medline Plus. “Methylpheniade.” 2008. Medline Plus Drug Information. 22 July 2008. http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682188.html

William W. Dodson. “Attention Deficit–Hyperactivity Disorder.” Jacobson: Psychiatric Secrets, 2nd ed. Ed. Jacobson. Hanley and Belfus, 2001.

 

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