[Portraits describing pharmacological and non-pharmacological interventions for attention deficit hyperactivity disorder (ADHD) in Quebecers 25 years of age and under]
Brassard J, Breton MC, Daigle JM, Guay H, Moreault B, Tremblay É, Turgeon M
Record ID 32018001014
French
Original Title:
Portraits décrivant les interventions pharmacologiques et non pharmacologiques entourant le trouble du déficit de l'attention avec ou sans hyperactivité (TDAH) chez les Québécois de 25 ans et moins
Authors' objectives:
The drugs approved by Health Canada for the treatment of attention deficit disorder with or without hyperactivity (ADHD) include psychostimulants, atomoxetine and guanfacine extended release. According to the data presented in the latest edition of the Canadian Rx Atlas, in Québec, total per-person expenditures associated with drugs specific to ADHD are twice what they are in the rest of Canada [Smolina and Morgan, 2014]. The Minister of Health and Social Services asked INESSS to shed light on this situation, which is described as troubling. The Minister indicated that he wanted to obtain an overview of the use of drugs specific to the treatment of ADHD in Québec. INESSS chose to carry out a systematic review of the good practice recommendations regarding the optimal pharmacological treatment of this disorder with the ultimate objective of comparing them with the overview’s findings.
Authors' results and conclusions:
RESULTS: The information search led to the identification of three clinical practice guidelines of good methodological quality: a French guideline, a Spanish guideline and an American guideline. The American guideline states that primary care physicians are authorized to diagnose ADHD, while the French and Spanish guidelines stipulate that only professionals specializing in ADHD may diagnose this disorder. In this regard, in France, the recommendations even mention referring to a medical specialist [HAS, 2014]. All three guidelines state that the type of physician who makes the diagnosis may also prescribe medication. In France, although the initial prescription and the annual renewals are reserved for medical specialists, the other renewals can be made by any physician, who can also modify the dosages. The Spanish and American guidelines recommend either a pharmacological treatment specific to ADHD or behavioural interventions as first-line therapy in 6- to 18-year-olds. In Spain, the nonpharmacological approaches nonetheless seem to be preferred for patients with mild ADHD. According to a French document published after the clinical practice guideline, pharmacological therapy should be used on a second-line basis in France. The availability of drugs specific to ADHD and their therapeutic role differ considerably from one country to another. The European guidelines mention methylphenidate (and atomoxetine in Spain). In the United States, there is no preference among the approved drugs, psychostimulants and non-psychostimulants. Children under 6 years of age are covered in only one guideline, the American guideline, which mentions only 4- and 5-year-olds and which states that methylphenidate could be used on a second-line basis if behavioural therapies fail. The French and American guidelines state that the pharmacotherapy could be monitored by a primary care physician. Some of the components of this monitoring mentioned in the Spanish and French guidelines are the treatment’s effectiveness, the presence of adverse effects, and the patient’s heart rate, blood pressure, height and weight. In Canada, clinicians use the Canadian ADHD Resource Alliance (CADDRA) guideline. It was identified through the literature search strategy but was considered to be of less good methodological quality and was therefore not selected for the systematic review. For INESSS, it is important to examine the local tools used by Québec clinicians. It was from this perspective that the recommendations in the CADDRA guideline were consulted.
The Canadian guideline states that the professionals who diagnose ADHD, start pharmacological treatment and monitor it can be primary care physicians or medical specialists. On the subject of the role of pharmacotherapy in the therapeutic arsenal, the CADDRA guideline recommends a pharmacological treatment specific to ADHD or behavioural interventions on a first-line basis and mentions the advantages of multimodal therapy. More specifically, for children aged 6 to 12 years, the drugs recommended on a first-line basis are long-acting psychostimulants. Short- and medium-acting psychostimulants and atomoxetine and guanfacine are second-line options. In adolescents and adults, the recommendations are the same, except with regard to guanfacine, which is not recommended in these age groups. With regard to the components of pharmacotherapy monitoring, the Canadian guideline recommends, among other things, monitoring the treatment’s effectiveness, the patient’s physical health and vital signs, adverse effects, family functioning, personal and family well-being, and putting in place behaviour management and therapy strategies.
CONCLUSION: After it finished collecting the information in the good clinical practice recommendations and the contextual data, INESSS concluded that the role of pharmacotherapy in the therapeutic arsenal for ADHD varies substantially from one clinical guideline to another (and, therefore, from one country to another), as do the steps taken by the primary care physician in making a diagnosis of ADHD and in starting and monitoring the treatment.
Authors' methods:
A systematic review of the clinical practice guidelines, consensus conferences and health technology assessment reports published between 2010 and 2015 was conducted for the purpose of identifying recommendations regarding the optimal pharmacological treatment of ADHD published by different national and international authorities. The literature search was performed in the MEDLINE (PubMed) and Embase (OvidSP) databases and in the grey literature. The methodology used to carry out this systematic review is in accordance with INESSS’s production standards.
Details
Project Status:
Completed
Year Published:
2017
English language abstract:
An English language summary is available
Publication Type:
Other
Country:
Canada
Province:
Quebec
MeSH Terms
- Attention Deficit Disorder with Hyperactivity
- Attention Deficit and Disruptive Behavior Disorders
- Methylphenidate
- Atomoxetine Hydrochloride
- Child
- Adolescent
- Young Adult
Keywords
- Hyperactivity
- Attention Deficit Disorder in adolescents
- Psychosocial services
Contact
Organisation Name:
Institut national d'excellence en sante et en services sociaux
Contact Address:
L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name:
demande@inesss.qc.ca
Contact Email:
demande@inesss.qc.ca
Copyright:
Gouvernement du Québec
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.