Die medikamentöse Behandlung der Aufmerksamkeitsdefizit-Hyperaktivitätsstörung im Kindes- und Jugendalter mit Amphetaminpräparaten
Abstract
Einleitung: Die wichtigsten Psychostimulanzien in der Behandlung der Aufmerksamkeitsdefizit-Hyperaktivitätsstörung stellen Methylphenidat und Amphetaminsalze dar. Fragestellung: In der vorliegenden Arbeit werden die pharmakologischen Charakteristika von Amphetaminpräparaten zusammengefasst. Außerdem werden die Wirksamkeit und mögliche Nebenwirkungen im Vergleich zu Methylphenidat erläutert. Methodik: Die Arbeit basiert auf einer Medline-Recherche. Eingang fanden kontrollierte Studien und Metaanalysen zwischen 1980 und 2011. Verwendete Suchwörter waren Amphetamin, Amphetaminsalze, Lisdexamphetamin, kontrollierte Studien und Metaanalysen. Ergebnisse und Diskussion: Amphetaminpräparate weisen gegenüber Methylphenidat einige pharmakologische Besonderheiten auf, indem sie neben der Dopamin-Wiederaufnahmehemmung auch die Freisetzung von Dopamin und Noradrenalin bewirken. Die klinische Wirksamkeit von Amphetaminpräparaten ist so gut wie die von Methylphenidat und das Nebenwirkungsspektrum als vergleichbar einzuschätzen. Bei ausbleibender Therapieresponse auf Methylphenidat kann vor dem Übergang auf eine Substanz zweiter Wahl durch den Einsatz eines Amphetaminpräparates die Ansprechrate auf Psychostimulanzien optimiert werden. Da potentiell bei nicht vorgeschriebener Einnahme im Erwachsenenalter eine erhöhte Missbrauchsgefahr von herkömmlichen Amphetaminpräparaten feststellbar ist, könnte darüber hinaus dem Propharmakon Lisdexamphetamin eine wichtige Bedeutung zukommen aufgrund einer robusten klinischen Wirksamkeit, eines besseren Wirkprofils und möglicherweise geringeren Missbrauchsgefahren. Schlussfolgerungen: Amphetaminpräparate sind eine wichtige Ergänzung zu Methylphenidat in der Behandlung der Aufmerksamkeitsdefizit-Hyperaktivitätsstörung. Unklarheit besteht derzeit über eine differentielle Behandlungsindikation in Abhängigkeit der Symptomkonstellation und möglicher Komorbiditäten.
Introduction: Psychostimulants (methylphenidate and amphetamines) are the drugs of first choice in the pharmacological treatment of children and adolescents with attention deficit hyperactivity disorder (ADHD). Objective: We summarize the pharmacological characteristics of amphetamines and compare them with methylphenidate, special emphasisis being given to a comparison of effects and side effects of the two substances. Finally, we analyze the abuse and addiction risks. Methods: Publications were chosen based on a Medline analysis for controlled studies and meta-analyses published between 1980 and 2011; keywords were amphetamine, amphetamine salts, lisdexamphetamine, controlled studies, and metaanalyses. Results and Discussion: Amphetamines generally exhibit some pharmacologic similarities with methylphenidate. However, besides inhibiting dopamine reuptake amphetamines also cause the release of monoamines. Moreover, plasma half-life is significantly prolonged. The clinical efficacy and tolerability of amphetamines is comparable to methylphenidate. Amphetamines can therefore be used if the individual response to methylphenidate or tolerability is insufficient before switching to a nonstimulant substance, thus improving the total response rate to psychostimulant treatment. Because of the high abuse potential of amphetamines, especially in adults, the prodrug lisdexamphetamine (Vyvanse) could become an effective treatment alternative. Available study data suggest a combination of high clinical effect size with a beneficial pharmacokinetic profile and a reduced abuse risk. Conclusions: In addition to methylphenidate, amphetamines serve as important complements in the psychostimulant treatment of ADHD. Future studies should focus on a differential comparison of the two substances with regard to their effects on different core symptom constellations and the presence of various comorbidities.
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