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Übersichtsarbeiten/Overview articles

Medikamentöse Behandlungsalgorithmen bei Aufmerksamkeitsdefizit-Hyperaktivitätsstörungen unter Berücksichtigung spezifischer Komorbiditäten

Published Online:December 28, 2009https://doi.org/10.1024/1422-4917.a000002

Abstract

Hintergrund: Die Aufmerksamkeitsdefizit-Hyperaktivitätsstörung (ADHS) geht mit einer Vielzahl unterschiedlicher Komorbiditäten einher, die sich zum Teil als Komplikation und in Folge der Kernsymptomatik, aber auch parallel zusammen mit der Grunderkrankung entwickeln können. Eine wichtige Säule im Rahmen des multimodalen Konzepts zur Behandlung der ADHS stellt die medikamentöse Behandlung, v. a. mit Psychostimulanzien, dar. Verschränkt mit psychotherapeutischen und psychosozialen Maßnahmen bewirkt eine Stimulanzienmedikation in vielen Fällen einen zufriedenstellenden Rückgang der Hauptsymptome des Störungsbildes und kann hierdurch auch zu einer Verminderung der Komorbiditäten führen. Gelingt dies nicht ausreichend, dann sollten medikamentöse Behandlungsstrategien mit anderen Substanzen überlegt werden, die zunehmend als Alternative oder in Kombination mit den Stimulanzien die komorbiden Symptome positiv beeinflussen. Fragestellung: Der vorliegende Beitrag gibt eine Übersicht der medikamentösen Behandlungsoptionen für verschiedene Komorbiditäten, d. h. affektive Störungen, aggressive Verhaltensstörungen sowie Ticstörungen. Besondere Beachtung kommt dabei der Möglichkeit kombinierter Behandlungsmöglichkeiten mit Psychostimulanzien zu. Darüber hinaus werden in Form von Algorithmen Vorschläge zu medikamentösen Behandlungsstrategien unterbreitet, die sich an den im Vordergrund stehenden klinischen Leitsymptomen orientieren. Methodik: Auf der Basis einer Medline-Recherche erfolgt eine kritische Übersicht der evidenzbasierten Literatur und praktischer Erfahrungen. Ergebnisse: Im Ergebnis bewirkt der individuell titrierte Einsatz von Stimulanzien zur Behandlung der Kernsymptome der ADHS oft zugleich einen zufrieden stellenden Rückgang der komorbiden Symptome. Stehen diese aber zunehmend im Vordergrund des klinischen Beschwerdebildes, kann der Einsatz von Antidepressiva oder Neuroleptika zur primären oder gleichberechtigten Behandlungsoptionen werden. Schlussfolgerung: Gegenstand der Diskussion muss v. a. sein, dass die gewählten Substanzen zumeist keine Zulassung zur Behandlung bei Kindern in Deutschland besitzen, dass Wirksamkeitsnachweise für dieses Altersspektrum fehlen, häufiger mit Nebenwirkungen zu rechnen ist und v. a. für die Kombination mit Stimulanzien nur sehr wenige Daten vorliegen.


Algorithms for the medical treatment of Attention-Deficit/Hyperactivity Disorder with specific co-morbidities

Background: In clinical practice Attention Deficit Hyperactivity Disorder (ADHD) is a challenge for diagnostic and therapeutic effort due to a number of co-morbidities, e.g., depression, anxiety disorders, Tourette Syndrome and impulsive aggression that can be a complication or a result of the core symptoms or evolve parallel to the basic disorder. The therapeutic strategies incorporate a multimodal access with a combination of psychosocial, psychotherapeutic and medical measures. The combination of various medical substances for an effective treatment of these co-morbidities, especially Serotonin-Reuptake Inhibitors (SSRIs) and atypical neuroleptics with psychostimulants has substantially reduced the occurrence of the main symptoms of the disorder in many cases and thus can also lead to a decrease in the occurrence of co-morbidities. Where this strategy fails to suffice, it is recommended to consider medical treatment strategies in combination with other substances that alternatively or in combination with psychostimulants increasingly positively influence co-morbid symptoms. Objective and method: Based on a Medline literature search we report the results of combined medical approaches for an effective medical treatment of the ADHD core symptoms accompanied by serious co-morbid symptoms. Hereby we focused on the above cited disorders. Combined treatment options that include psychostimulants are considered in particular. Moreover, recommendations for medical treatment strategies oriented to the clinical cardinal symptoms are presented in the form of algorithms. Evidence-based literature and practical experience are critically reviewed. Results: In most cases it will be sufficient to begin the treatment with a psychostimulant because co-morbid symptoms also will be significantly reduced. However, if the latter are in the foreground of the clinical picture, antidepressants or neuroleptics are to be considered as primary or equivalent treatment options. Conclusions: Since in Germany most of the substances discussed are not licensed for use in paediatric treatment, proofs of efficacy in children are lacking. One also must reckon with the frequent occurrence of side effects. Finally, little data exist on treatments that include the use of psychostimulants.

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