What are the implications of drug holidays for patients on stimulant therapy for Attention Deficit Hyperactivity Disorder (ADHD)?

From the Guidelines

Drug holidays from stimulant medications for ADHD patients are generally not routinely recommended but may be considered in specific situations, such as evaluating continued need for medication or managing side effects, as suggested by the most recent guideline evidence 1. When considering a drug holiday, it is essential to weigh the potential benefits against the risks of symptom reemergence and behavioral challenges. The decision to implement a drug holiday should be individualized, taking into account the patient's specific needs, symptom severity, and life circumstances.

Key Considerations

• Drug holidays may be appropriate for evaluating continued need for medication, managing side effects like appetite suppression or growth concerns, or during periods when symptom management is less critical 1.
• Implementing a drug holiday should be planned in advance with healthcare provider guidance, typically starting during a low-demand period like a school break 1.
• Parents and patients should monitor behavior changes during the break and maintain regular communication with their provider 1.
• No tapering is typically needed for stimulants as they don't cause physical dependence 1.
• The most recent guideline evidence suggests that stimulant medications can be effectively titrated on a 7‑day basis, but in urgent situations, they may be effectively titrated in as few as 3 days 1.

Important Factors

• The patient's response to stimulants is variable and unpredictable, and titration from a low dose to one that achieves a maximum, optimal effect in controlling symptoms without adverse effects is recommended 1.
• Parent and child education is an important component in the chronic illness model to ensure cooperation in efforts to achieve appropriate titration 1.
• Regular monitoring and follow-up are crucial to ensure the patient's symptoms are well-managed and to adjust the treatment plan as needed 1.

From the FDA Drug Label

Patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted Long-Term Suppression of Growth Careful follow-up of weight and height in children ages 7 to 10 years who were randomized to either methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic subgroups of newly methylphenidate-treated and non-medication treated children over 36 months (to the ages of 10 to 13 years), suggests that consistently medicated children (i.e., treatment for 7 days per week throughout the year) have a temporary slowing in growth rate (on average, a total of about 2 cm less growth in height and 2. 7 kg less growth in weight over 3 years), without evidence of growth rebound during this period of development.

Drug Holidays for Patients on Stimulant Therapy for ADHD may be necessary for patients who are not growing or gaining height or weight as expected.

• The decision to interrupt treatment should be based on careful monitoring of the patient's growth and weight.
• Growth suppression is a potential side effect of long-term stimulant therapy, and treatment interruption may be necessary to allow for catch-up growth.
• However, the FDA drug labels do not provide specific guidance on the duration or frequency of drug holidays for patients on stimulant therapy for ADHD 2 3.

From the Research

Drug Holidays for Patients on Stimulant Therapy for ADHD

• There is no direct evidence in the provided studies to support the concept of "drug holidays" for patients on stimulant therapy for ADHD.
• However, the studies suggest that stimulant therapy can have long-term beneficial effects and is well tolerated in adults with ADHD 4.
• The use of stimulant medications can potentially lead to small increases in blood pressure and heart rate, particularly with amphetamines, but no serious cardiovascular events have been reported 5.
• The current pharmacotherapy for ADHD is mainly based on stimulant medications, such as methylphenidate and amphetamines, and non-stimulant medications like atomoxetine 6.
• The effects of stimulant dose and dosing strategy on treatment outcomes in ADHD have been studied, and the results suggest that flexible titration of stimulants can lead to improved efficacy and acceptability 7.
• Combination therapy with atomoxetine and stimulants, such as methylphenidate, has been shown to be effective in reducing ADHD severity in some patients, particularly those who are treatment-resistant to monotherapy 8.
• However, more research is needed to fully understand the long-term effects of stimulant therapy and combination therapy in ADHD patients, including the potential benefits and risks of "drug holidays" 4, 5, 7, 8.