Both alpha-2 adrenergic agonists and stimulants were associated with improvement in attention-deficit/hyperactivity disorder (ADHD) in preschool children in a retrospective study, although the two treatments had different adverse effect profiles. "These findings indicate that medications like guanfacine may play a helpful role in treating young children with ADHD," Dr. Elizabeth Harstad of Boston Children's Hospital told Reuters Health by email. "But future research is needed to better understand this role and more critically evaluate effectiveness and side effects, given that our data were collected retrospectively." "Although this study is focused on medications when they are used," she added, "it is important to note that behavioral interventions are recommended as first-line treatment for young children with ADHD, and behavioral interventions should be used for all young children with ADHD." As reported in JAMA, Dr. Harstad and colleagues reviewed electronic health records for 497 preschool-age children with ADHD receiving alpha-2-adrenergic agonists or stimulants at seven U.S. outpatient developmental-behavioral pediatric practices. The median age was 62 months at ADHD medication initiation, and 82% were males. For the initial treatment, 35% of children were given alpha 2-adrenergic agonists (guanfacine or clonidine) for a median of 136 days and 65% were prescribed stimulants (methylphenidate or amphetamine) for a median of 133 days. Sixty-six percent of children who started on alpha-2-adrenergic agonists and 78% of those who initiated stimulants reported improvement. Only daytime sleepiness was more common in children receiving alpha-2-adrenergic agonists versus stimulants (38% vs. 3%); however, several adverse effects were reported more commonly for stimulants compared with alpha-2-adrenergic agonists, including moodiness/irritability (50% vs. 29%), appetite suppression (38% vs. 7%), and difficulty sleeping (21% vs. 11%). The authors state, "Further research, including from randomized clinical trials, is needed to assess comparative effectiveness of alpha-2-adrenergic agonists (versus) stimulants." Dr. Tanya Froehlich of Cincinnati Children's Hospital Medical Center in Ohio, author of a related editorial, told Reuters Health by email that because of the differing side effect profiles, "the study suggests that clinicians may consider methylphenidate first when a child's difficulties center on hyperactivity and impulsivity, while guanfacine may be a good option when children have significant irritability, moodiness, or sleep difficulties coexisting with their ADHD, although this needs to be confirmed." "Use of alpha agonists like guanfacine is increasing in the preschool age group (because) many parents and providers are reluctant to try stimulant medications in preschool children, even though we have robust evidence from prior studies that methylphenidate is generally effective and safe in this age group," she said. "In addition," she noted, "since long-acting guanfacine was FDA-approved for use in older children with ADHD, families and clinicians have become increasingly comfortable with its use - although it should be noted that the short-acting formulation generally used to treat preschoolers is not FDA-approved for ADHD." Further, she said, "methylphenidate is also not FDA-approved to treat ADHD in this age group, but is FDA-approved for the treatment of children aged six years and up." —Marilynn Larkin Source
