Pregnancy

• Risk Category C [some animal studies show adverse effects; no controlled studies in humans]

• There is a greater risk of premature birth and low birth weight in infants whose mothers take d-amphetamine during pregnancy

• Infants whose mothers take d-amphetamine during pregnancy may experience withdrawal symptoms

• Use in women of childbearing potential requires weighing potential benefits to the mother against potential risks to the fetus

✽ For ADHD patients, d-amphetamine should generally be discontinued before anticipated pregnancies

Breast Feeding

• Some drug is found in mother’s breast milk

✽ Recommended either to discontinue drug or bottle feed

• If infant shows signs of irritability, drug may need to be discontinued

AMPHETAMINE (D): THE ART OF PSYCHOPHARMACOLOGY

Potential Advantages

• May work in ADHD patients unresponsive to other stimulants

• Established long-term efficacy of immediate-release and spansule formulations

Potential Disadvantages

• Patients with current or past substance abuse

• Patients with current or past bipolar disorder or psychosis

Primary Target Symptoms

• Concentration, attention span

• Motor hyperactivity

• Impulsiveness

• Physical and mental fatigue

• Daytime sleepiness

• Depression

Pearls

✽ May be useful for treatment of depressive symptoms in medically ill elderly patients

✽ May be useful for treatment of post-stroke depression

✽ A classical augmentation strategy for treatment-refractory depression

✽ Specifically, may be useful for treatment of cognitive dysfunction and fatigue as residual symptoms of major depressive disorder unresponsive to multiple prior treatments

✽ May also be useful for the treatment of cognitive impairment, depressive symptoms, and severe fatigue in patients with HIV infection and in cancer patients

• Can be used to potentiate opioid analgesia and reduce sedation, particularly in end-of-life management

• Some patients respond to or tolerate d-amphetamin better than methylphenidate and vice versa

• Some patients may benefit from an occasional addition of 5–10 mg of immediate-release d-amphetamine to their daily base of sustained-release Dexedrine spansules

✽ Despite warnings, can be a useful adjunct to MAOIs for heroic treatment of highly refractory mood disorders when monitored with vigilance

✽ Can reverse sexual dysfunction caused by psychiatric illness and by some drugs such as SSRIs, including decreased libido, erectile dysfunction, delayed ejaculation, and anorgasmia

• Atypical antipsychotics may be useful in treating stimulant or psychotic consequences of overdose

• Taking with food may delay peak actions for 2–3 hours

• Half-life and duration of clinical action tend to be shorter in younger children

• Drug abuse may actually be lower in ADHD adolescents treated with stimulants than in ADHD adolescents who are not treated

Suggested Reading

Fry JM. Treatment modalities for narcolepsy. Neurology. 1998;50(2 Suppl 1):S43–8.

Greenhill LL, Pliszka S, Dulcan MK, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002;41 (2):S26–49.

Jadad AR, Boyle M, Cunningham C, Kim M, Schachar R. Treatment of attention-deficit/hyperactivity disorder. Evid Rep Technol Assess (Summ) 1999;(11):i–viii, 1–341.

Stiefel G, Besag FM. Cardiovascular effects of methylphenidate, amphetamines, and atomoxetine in the treatment of attention-deficit hyperactivity disorder. Drug Saf 2010;33(10):821–42.

Vinson DC. Therapy for attention-deficit hyperactivity disorder. Arch Fam Med. 1994;3:445–51.

Wender PH, Wolf LE, Wasserstein J. Adults with ADHD. An overview. Ann N Y Acad Sci. 2001;931:1–16.

AMPHETAMINE (D,L)

AMPHETAMINE (D,L): THERAPEUTICS

Brands

• Adderall

• Adderall XR

see index for additional brand names

Generic?

Yes

Class

• Stimulant

Commonly Prescribed for

(bold for FDA approved)

• Attention deficit hyperactivity disorder (ADHD) in children ages 3–12 (Adderall)

• Attention deficit hyperactivity disorder (ADHD) in children ages 6–17 and in adults (Adderall XR)

• Narcolepsy (Adderall)

• Treatment-resistant depression

How the Drug Works

✽ Increases norepinephrine and especially dopamine actions by blocking their reuptake and facilitating their release

• Enhancement of dopamine and norepinephrine actions in certain brain regions (e.g., dorsolateral prefrontal cortex) may improve attention, concentration, executive function, and wakefulness

• Enhancement of dopamine actions in other brain regions (e.g., basal ganglia) may improve hyperactivity

• Enhancement of dopamine and norepinephrine in yet other brain regions (e.g., medial prefrontal cortex, hypothalamus) may improve depression, fatigue, and sleepiness