Drug holidays and attention deficit/hyPeractivity disorder

Christopher P.SZABO

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Drug holidays and attention deficit/hyPeractivity disorder

Christopher P.SZABO

The concept of‘drug holidays’(defined as "…the structured interruption of pharmacological treatment…"［1］)in the management of attention deficit hyperactivity disorder(ADHD)is well established，but poorly researched［1］.The question is whether there is indeed a justifiable basis for the practice.In the opinion piece by Professors Du and Wang［2］，they argue that on the balance of available evidence it is not justified.Herein lies the issue—the evidence.In reality significant numbers of parents both report side effects［3］and stop medication intermittently［1］，and many sufferers stop treatment prematurely［4］（generally due to adverse effects).The rationale behind‘drug holidays’appears to include concerns regarding prolonged exposure to stimulant medication and the possibility that such exposure may reduce drug efficacy or result in serious side-effects such as reduction in growth.The potential information a drug holiday could provide about the need for further treatment is another commonly voiced rationale［1］.In such a situation one needs to be well informed about the relative risks and benefits.In the only randomised control study to date［5］，which involved a 28-day trial of weekend drug holidays(i.e.，5 days on active stimulant followed by 2 days on placebo versus continuous use of stimulants)，the drug-holiday group showed no worsening of symptoms，a nonsignificant reduction in appetite problems and a marginally significant decrease in insomnia.This study is cited to support the use of drug holidays but the short duration of the drug-holiday，the short length of the study，and the ambiguous results make it difficult to arrive at a definitive conclusion.In contrast，a study of the impact of drug holidays on growth［6］found no significant differences between children who received continuous treatment and those who interspersed treatment with drug holidays.In addition，various studies that assessed burns in children with ADHD(cited in the review by Graham and colleagues［1］)found a relationship between burns and not taking medication on the day of the injury.Taken together these selected studies suggest that drug holidays do not significantly reduce adverse events and may actually contribute to such events.Moreover，the limited evidence available does not make it possible to comment as to whether such cessation of medication leads to clinical deterioration or not.It does appear that symptoms will generally worsen during the period of drug cessation［1］，notwithstanding the findings of the study by Martins and colleagues［5］.In the absence of compelling evidence to support drug holidays，it would appear that such practice should be viewed with caution.Currently the clinician can switch medications or reduce doses if there are concerns about adverse events or inadequate response.Such approaches would appear to be better supported by the existing evidence than drug holidays.

1. Graham J，Banashewski T，Buitelaar J，Coghill D，Danckaerts M，Dittmann RW，et al.European guidelines on managing adverse effects of medication for ADHD.Eur Child Adolescent Psychiatry，2011，20：17-37.

2. Du YS，Wang LJ.Are drug holidays in the treatment of Attention Deficit/Hyperactivity Disorder(ADHD)justified？Shanghai Arch Psychiatry，2011，23(5)：312-314.

3. Tobaiqy M，Stewart D，Helms PJ，Williams J，Crum J，Steer C，et al.Parental reporting of adverse drug reactions associated with attention-deficit hyperactivity disorder(ADHD)medications in children attending specialist paediatric clinics in the UK. Drug Saf，2011，34(3)：2211-219.

4. Didoni A，Sequi M，Panei P，Bonati M，on behalf of the"Lombardy ADHD Registry Group".One-year prospective followup of pharmacological treatment in children with attentiondeficit/hyperactivity disorder.Eur J Clin Pharmacol，2011，67 (10)：1061-1067.

5. Martins S，Tramontina S，Polanczyk G，Eizirik M，Swanson JM，Rhode LA.Weekend holidays during methylphenidate use in ADHD children：a randomised clinical trial.J Child Adolesc Psychopharmacol，2004，14(2)：195-206.

6. Spencer TJ，Faraone SV，Biederman J，Lerner M，Cooper KM，Zimmerman B，Concerta Study Group.Does prolonged therapy with a long-acting stimulant suppress growth in children with ADHD.J Am Acad Child Adolesc Psychiatry，2006，45 (5)：527-537.

Division of Psychiatry，Faculty of Health Sciences，University of the Witwatersrand，Johannesburg，South Africa.

E-mail：christopher.szabo@wits.ac.za