Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.
- Cortese S Center for Innovation in Mental Health, Academic Unit of Psychology, and Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK; Solent NHS Trust, Southampton, UK; New York University Child Study Center, New York, NY, USA; Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.
- Adamo N Department of Child and Adolescent Psychiatry, King's College London, and Institute of Psychiatry, Psychology and Neuroscience, and National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre, London, UK.
- Del Giovane C Institute of Primary Health Care, University of Bern, Switzerland.
- Mohr-Jensen C Department of Child and Adolescent Psychiatry, Aalborg Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark.
- Hayes AJ Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.
- Carucci S Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Sciences, University of Cagliari and "A Cao" Paediatric Hospital, "G Brotzu" Hospital Trust, Cagliari, Italy.
- Atkinson LZ Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.
- Tessari L Department of Child and Adolescent Psychiatry and Psychotherapy, Bolzano, Italy.
- Banaschewski T Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim and University of Heidelberg, Mannheim, Germany.
- Coghill D Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia; Division of Neuroscience, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK; Murdoch Childrens' Research Institute, Melbourne, Vic, Australia.
- Hollis C Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, NIHR MindTech MedTech and In-vitro Diagnostic Cooperative, and Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan (CANDAL), Institute of Mental Health, University of Nottingham, Nottingham, UK.
- Simonoff E Department of Child and Adolescent Psychiatry, King's College London, and Institute of Psychiatry, Psychology and Neuroscience, and National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre, London, UK.
- Zuddas A Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Sciences, University of Cagliari and "A Cao" Paediatric Hospital, "G Brotzu" Hospital Trust, Cagliari, Italy.
- Barbui C WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy.
- Purgato M WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy.
- Steinhausen HC Department of Child and Adolescent Psychiatry, Psychiatric University Clinic Zurich, Zurich, Switzerland; Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland; Child and Adolescent Mental Health Centre, Capital Region Psychiatry, Copenhagen, Denmark; Department of Child and Adolescent Psychiatry, University of Southern Denmark, Odense, Denmark.
- Shokraneh F Cochrane Schizophrenia Group, Division of Psychiatry and Clinical Psychology, School of Medicine, University of Nottingham, Nottingham, UK; Research Center for Modeling in Health, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
- Xia J Systematic Review Solutions, and Nottingham Health China, University of Nottingham, Ningbo, China.
- Cipriani A Department of Psychiatry, University of Oxford, and Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK. Electronic address: andrea.cipriani@psych.ox.ac.uk.
- 2018-08-12
Published in:
- The lancet. Psychiatry. - 2018
Adolescent
Adrenergic alpha-2 Receptor Agonists
Adult
Attention Deficit Disorder with Hyperactivity
Bupropion
Central Nervous System Stimulants
Child
Clonidine
Dose-Response Relationship, Drug
Humans
Methylphenidate
Network Meta-Analysis
Randomized Controlled Trials as Topic
English
BACKGROUND
The benefits and safety of medications for attention-deficit hyperactivity disorder (ADHD) remain controversial, and guidelines are inconsistent on which medications are preferred across different age groups. We aimed to estimate the comparative efficacy and tolerability of oral medications for ADHD in children, adolescents, and adults.
METHODS
We did a literature search for published and unpublished double-blind randomised controlled trials comparing amphetamines (including lisdexamfetamine), atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with each other or placebo. We systematically contacted study authors and drug manufacturers for additional information. Primary outcomes were efficacy (change in severity of ADHD core symptoms based on teachers' and clinicians' ratings) and tolerability (proportion of patients who dropped out of studies because of side-effects) at timepoints closest to 12 weeks, 26 weeks, and 52 weeks. We estimated summary odds ratios (ORs) and standardised mean differences (SMDs) using pairwise and network meta-analysis with random effects. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool and confidence of estimates with the Grading of Recommendations Assessment, Development, and Evaluation approach for network meta-analyses. This study is registered with PROSPERO, number CRD42014008976.
FINDINGS
133 double-blind randomised controlled trials (81 in children and adolescents, 51 in adults, and one in both) were included. The analysis of efficacy closest to 12 weeks was based on 10 068 children and adolescents and 8131 adults; the analysis of tolerability was based on 11 018 children and adolescents and 5362 adults. The confidence of estimates varied from high or moderate (for some comparisons) to low or very low (for most indirect comparisons). For ADHD core symptoms rated by clinicians in children and adolescents closest to 12 weeks, all included drugs were superior to placebo (eg, SMD -1·02, 95% CI -1·19 to -0·85 for amphetamines, -0·78, -0·93 to -0·62 for methylphenidate, -0·56, -0·66 to -0·45 for atomoxetine). By contrast, for available comparisons based on teachers' ratings, only methylphenidate (SMD -0·82, 95% CI -1·16 to -0·48) and modafinil (-0·76, -1·15 to -0·37) were more efficacious than placebo. In adults (clinicians' ratings), amphetamines (SMD -0·79, 95% CI -0·99 to -0·58), methylphenidate (-0·49, -0·64 to -0·35), bupropion (-0·46, -0·85 to -0·07), and atomoxetine (-0·45, -0·58 to -0·32), but not modafinil (0·16, -0·28 to 0·59), were better than placebo. With respect to tolerability, amphetamines were inferior to placebo in both children and adolescents (odds ratio [OR] 2·30, 95% CI 1·36-3·89) and adults (3·26, 1·54-6·92); guanfacine was inferior to placebo in children and adolescents only (2·64, 1·20-5·81); and atomoxetine (2·33, 1·28-4·25), methylphenidate (2·39, 1·40-4·08), and modafinil (4·01, 1·42-11·33) were less well tolerated than placebo in adults only. In head-to-head comparisons, only differences in efficacy (clinicians' ratings) were found, favouring amphetamines over modafinil, atomoxetine, and methylphenidate in both children and adolescents (SMDs -0·46 to -0·24) and adults (-0·94 to -0·29). We did not find sufficient data for the 26-week and 52-week timepoints.
INTERPRETATION
Our findings represent the most comprehensive available evidence base to inform patients, families, clinicians, guideline developers, and policymakers on the choice of ADHD medications across age groups. Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD. New research should be funded urgently to assess long-term effects of these drugs.
FUNDING
Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the UK National Institute for Health Research Oxford Health Biomedical Research Centre.
The benefits and safety of medications for attention-deficit hyperactivity disorder (ADHD) remain controversial, and guidelines are inconsistent on which medications are preferred across different age groups. We aimed to estimate the comparative efficacy and tolerability of oral medications for ADHD in children, adolescents, and adults.
METHODS
We did a literature search for published and unpublished double-blind randomised controlled trials comparing amphetamines (including lisdexamfetamine), atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with each other or placebo. We systematically contacted study authors and drug manufacturers for additional information. Primary outcomes were efficacy (change in severity of ADHD core symptoms based on teachers' and clinicians' ratings) and tolerability (proportion of patients who dropped out of studies because of side-effects) at timepoints closest to 12 weeks, 26 weeks, and 52 weeks. We estimated summary odds ratios (ORs) and standardised mean differences (SMDs) using pairwise and network meta-analysis with random effects. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool and confidence of estimates with the Grading of Recommendations Assessment, Development, and Evaluation approach for network meta-analyses. This study is registered with PROSPERO, number CRD42014008976.
FINDINGS
133 double-blind randomised controlled trials (81 in children and adolescents, 51 in adults, and one in both) were included. The analysis of efficacy closest to 12 weeks was based on 10 068 children and adolescents and 8131 adults; the analysis of tolerability was based on 11 018 children and adolescents and 5362 adults. The confidence of estimates varied from high or moderate (for some comparisons) to low or very low (for most indirect comparisons). For ADHD core symptoms rated by clinicians in children and adolescents closest to 12 weeks, all included drugs were superior to placebo (eg, SMD -1·02, 95% CI -1·19 to -0·85 for amphetamines, -0·78, -0·93 to -0·62 for methylphenidate, -0·56, -0·66 to -0·45 for atomoxetine). By contrast, for available comparisons based on teachers' ratings, only methylphenidate (SMD -0·82, 95% CI -1·16 to -0·48) and modafinil (-0·76, -1·15 to -0·37) were more efficacious than placebo. In adults (clinicians' ratings), amphetamines (SMD -0·79, 95% CI -0·99 to -0·58), methylphenidate (-0·49, -0·64 to -0·35), bupropion (-0·46, -0·85 to -0·07), and atomoxetine (-0·45, -0·58 to -0·32), but not modafinil (0·16, -0·28 to 0·59), were better than placebo. With respect to tolerability, amphetamines were inferior to placebo in both children and adolescents (odds ratio [OR] 2·30, 95% CI 1·36-3·89) and adults (3·26, 1·54-6·92); guanfacine was inferior to placebo in children and adolescents only (2·64, 1·20-5·81); and atomoxetine (2·33, 1·28-4·25), methylphenidate (2·39, 1·40-4·08), and modafinil (4·01, 1·42-11·33) were less well tolerated than placebo in adults only. In head-to-head comparisons, only differences in efficacy (clinicians' ratings) were found, favouring amphetamines over modafinil, atomoxetine, and methylphenidate in both children and adolescents (SMDs -0·46 to -0·24) and adults (-0·94 to -0·29). We did not find sufficient data for the 26-week and 52-week timepoints.
INTERPRETATION
Our findings represent the most comprehensive available evidence base to inform patients, families, clinicians, guideline developers, and policymakers on the choice of ADHD medications across age groups. Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD. New research should be funded urgently to assess long-term effects of these drugs.
FUNDING
Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the UK National Institute for Health Research Oxford Health Biomedical Research Centre.
- Language
-
- English
- Open access status
- hybrid
- Identifiers
-
- DOI 10.1016/S2215-0366(18)30269-4
- PMID 30097390
- Persistent URL
- https://folia.unifr.ch/global/documents/106922
Statistics
Document views: 13
File downloads:
- fulltext.pdf: 0