Case outcome: interim follow-up visits three to six months later

Lisdexamfetamine (Vyvanse) is increased to 40 mg/d to obtain better effectiveness and afternoon symptom control of ADHD

Parents will attempt to awaken the patient earlier to dispense this medication for better symptom control at breakfast-time and on his bus ride to school

There is no change in stature/height

School reports good ADHD symptom control, but notice that patient seems to be worried about eating habits, bathroom habits, and appears to be more obsessive in general

Sertraline (Zoloft) is started, fearing anxiety recurrence and in lieu of fluoxetine (Prozac)

• – It is started ideally to recapture an SSRI anxiolytic effect without the side effects of anorexia or enuresis

• – At 50 mg/d, anxiety symptoms normalize but secondary enuresis begins again

• – Sertraline (Zoloft) is lowered to 25 mg/d as a result; several weeks later, SSRI effectiveness was noted to return

He continues with good effectiveness from both medications and enuresis is resolved

Attending physician’s mental notes: follow-up visit, six months

Two out of two SSRIs have caused enuresis, but the current low-dose SSRI seems to be fairly effective in lowering his anxiety without this adverse effect

Increased stimulant dose has lowered his ADHD symptoms, improving his school performance, self-esteem, and lowered his parents’ frustration at home

Height and weight have not changed, so perhaps the previous weight loss was, in fact, due to SSRI fluoxetine (Prozac), which had been discontinued some time ago

Case outcome: interim follow-up visits eight to 12 months later

Toward the end of this interval, the patient appears to have lost 5 lbs

The parents ask for options outside the current medicine combination that might avoid weight-loss side effects

• – Pediatrician reports that he has now, in fact, fallen off the growth curve, is mildly concerned, and asks if medications can be switched or drug cessation offered over the summer

• – Drug cessation is not clinically warranted as the patient’s esteem will suffer due to his ADHD symptoms, which would begin interfering with peer relationships and ability to go to summer camps

• – The patient refuses to drink protein-enrichment shakes, but is allowed to eat and snack ad lib, but he fails to gain weight this way

Nonstimulant options are discussed and the patient is started on the ADHD-approved guanfacine-ER (Intuniv), an alpha-2 adrenergic receptor agonist, while the lisdexamfetamine (Vyvanse) is lowered to 30 mg/d in the hope of reversing the newest weight loss

Guanfacine-ER (Intuniv) dose is titrated up and lisdexamfetamine (Vyvanse) dose is lowered in the hope of fully replacing the stimulant eventually

• – The patient becomes sedated and sleepy at school on 3 mg/d of guanfacine-ER and exhibits an increase in his ADHD symptoms on the remaining lisdexamfetamine 10 mg/d

Case debrief

This patient may have a subsyndromal developmental disorder given his stereotypic behaviors, tactile sensitivity, and possibly genetic short stature

He suffered a mixture of GAD and OCD symptoms that have been fully treated with low-dose SSRIs

• – This treatment clearly caused enuresis, and while on SSRIs, his normal weight gain seemed inhibited

He suffered a moderate to severe number of ADHD symptoms, which were well treated once an adequate stimulant dose was achieved

• – This treatment in conjunction with SSRI use ultimately caused him to fall off his growth curve, instigating a change in medications away from the higher-dosed stimulant medication and SSRI combination

The patient is currently taking

• – Sertraline (Zoloft) 25 mg/d

• – Lisdexamfetamine (Vyvanse) 20 mg/d

• – Guanfacine-ER (Intuniv) 2 mg/d

He suffers no acute side effects and is functioning well at home and at school

He appears to be maintaining his weight and height on this regimen and his loss of stature and weight has halted for the time being

• – There appears to be benefit now with minimum side effects on low doses of three complementary medications in a rational polypharmacy approach

He functions better upon awakening and in the afternoons compared to using a stimulant alone to control his ADHD symptoms

He is less anxious, and it appears that guanfacine-ER has also augmented his SSRI response in this area

He has been sent for genetic testing to determine if he has a congenital stature disorder or a chromosomally based developmental disorder such as Williams’ syndrome