Attention Magazine June 2018

Jake is a happy third grader who has ADHD. He takes a stimulant medication that helps him focus, and both his parents and his teacher have noticed an improvement in his behavior, academics, and relationship with classmates. However, the pharmacy just informed Jake’s parents that his medication is on backorder, and they are not sure when the medication will once again be available.

Maria is in middle school and, for the past three years, her ADHD has been successfully treated with a stimulant medication. When her parent changed jobs and had to change insurance companies, Maria’s parents discovered that Maria’s ADHD medication was no longer covered by their new insurance plan.

IN RECENT YEARS, MANY NEW STIMULANT FORMULATIONS have been approved by the FDA for treatment of ADHD. These new formulations vary in their duration of benefit, and many offer new ways that the medication is administered or “delivered.” In addition to tablets and capsules, we now have short- and long-lasting stimulant medications available as liquids and chewable tablets. In addition, we have two other unique delivery systems that are able to provide extended benefit. For example, oral disintegrating tablets dissolve quickly when placed under the tongue, and medication patches can be applied to the skin and the medication is then absorbed through the skin.

Although this expanded range of stimulant medication options has been a significant benefit for many families, challenges arise when families are unable to get the medication that they think is best for themselves or their child. Unfortunately, this is not an uncommon circumstance, and there are a range of reasons why patients may struggle to get the medication that they want. For example, as in the instance above with Jake, some medications become unavailable due to “production issues.” This has been especially problematic of recent for patients who were benefiting from treatment with Quillivant XR (a liquid version of methylphenidate).

Medication shortages are occasionally a problem at the end of each calendar year because of production limits imposed by the Food and Drug Administration (FDA). Families may have difficulty accessing a specific medication even when there are no production issues. For example, in some instances, an insurance company may change which medications are included within its formulary, or it may change the pricing or approval process for certain medications. These changes can sometimes impose hardships to families if they are no longer able to get (or afford) a previously accessible medications. Lastly, as in Maria’s case above, when families change health insurance coverage (oft en in conjunction with a change of jobs), a previously covered medication may no longer be an option through the family’s new healthcare plan.

Tips for finding medication in times of shortage

If a family’s local pharmacy does not have their ADHD medication of choice, they may consider contacting other local pharmacies. Many of the large retail pharmacy chains are able to check their computer system to see if any other nearby locations have the medication you want. If this strategy is not successful, you should contact several of the independently owned pharmacies near your home or work location. A third option is to contact the manufacturer of the medication you are seeking. In some cases, the manufacturer’s website for the medication may be able to provide you with information about availability; if not, you can call the manufacturer directly for help in finding the medication.

Consider priorities when choosing the right alternative medication

If the medication of choice is no longer available, families will likely need to consider trying a different medication. In these instances, consideration should be given to what are the priorities in selecting an alternative stimulant formulation—is it the medication’s means of administration, its duration of action, or its costs? The accompanying table shows all of the FDA-approved medications organized by means of administration and duration of benefit. Keep in mind that a combination of long-acting and short-acting medications is sometimes needed to achieve the desired duration of benefit or clinical response.

Additional considerations

● Although generic medications are usually less expensive, this is not always the case. Insurance companies may negotiate a more financially advantageous arrangement with a particular drug manufacturer, and thus a brand name medication may indeed be cheaper than a generic formulation. The accompanying table also shows which formulations are available as generics.

● In some instances, it may be helpful to use a medication in a manner that is off label—in a way not formally approved by the FDA. In some cases, this can be as simple as using a dose that has not been FDA-approved—such as using a 7.5mg dose when 5mg is too low and 10mg is too strong. In other instances, this can mean crushing a short-acting tablet or cutting a transdermal patch. Although these off-label uses of stimulants are not FDA approved, they are generally safe and effective. Nonetheless, you should discuss with your healthcare provider whenever you are considering using a medication in an off-label manner.

● For many of the newest stimulant formulations, manufacturers offer patient savings coupons to reduce a patient’s out-of-pocket costs. These can generally be accessed online at the manufacturer’s website for that medication or from your healthcare provider. Pharmacists may also have information about available discounts.

● Some insurance companies may require a patient’s healthcare provider to fill out a prior authorization approval form to explain and justify why a particular medication formulation is needed. It is oft en easiest to get approval for insurance coverage for a non-preferred ADHD medication if you have already tried one or more formulary formulations without success.

● If you find yourself having to pay out of pocket for a medication, families may want to consider switching to a different pharmacy. The pharmacies associated with some discount retailers (such as Costco) oft en offer medication at a lower price than some chain or small retail pharmacies.

Nonstimulants

If you are unable to find a stimulant formulation that provides you with the same benefits as a previously successful treatment regimen, you may wish to consider trying a nonstimulant medication in addition to (or instead of) a stimulant medication. Nonstimulants such as atomoxetine and extended-release formulations of guanfacine and clonidine generally provide some round-the-clock benefit; this means that they may provide some symptom control at times when a replacement stimulant may not be as effective (such as early mornings and evenings). Moreover, in some cases, addition of a nonstimulant may allow you to use a lower dose of a stimulant medication—which may then also result in fewer side effects from the stimulant medication.

Conclusion

It is important that families recognize that there is often more than one suitable medication for an individual with ADHD. If families work with a healthcare provider who is comfortable prescribing many different ADHD stimulant formulations and if families keep an open mind about trying different medication options, they will likely benefit from a “happy accident.” In other words, families that try one or more alternate medication regimens will often discover that there is another medication formulation or regimen that is as good (and possibly even better) than their previous medication regimen.

EDITOR’S NOTE: There is an excellent chart on stimulant medications that is available in the PDF version of this article. Be sure to check it out.

Andrew Adesman, MD, is chief of developmental and behavioral pediatrics at the Steven and Alexandra Cohen Children’s Medical Center of New York in New Hyde Park. Adesman is board certified in pediatrics, neurodevelopmental disabilities, and developmental and behavioral pediatrics, and is associate professor of clinical pediatrics at the Albert Einstein College of Medicine. Anna Krevskaya, MD, is a board-certified developmental-behavioral pediatrician in Lake Success, New York. She is affiliated with Long Island Jewish Medical Center and Southside Hospital.