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Healthy Skepticism International News

October 2008

Unpublished letter to Pediatrics

By Jon Jureidini

In May 2008 Circulation published an American Heart Association (AHA) ‘scientific’ statement entitled
‘Cardiovascular monitoring of children and adolescents with heart disease receiving stimulant drugs’
by Vetter VL, Elia J, Erickson C, Berger S, Blum N, Uzark K, Webb CL; American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee; American Heart Association Council on Cardiovascular Nursing.

The Vetter et al statement recommended electrocardiograms be performed routinely on children before they start medications for attention-deficit/hyperactivity disorder (ADHD).

In August 2008, Pediatrics published an American Academy of Pediatrics ‘policy’ statement entitled:
‘Cardiovascular Monitoring and Stimulant Drugs for Attention-Deficit/Hyperactivity Disorder’
by James M. Perrin, MD, Richard A. Friedman, MD, Timothy K. Knilans, MD, the Black Box Working Group, and the Section on Cardiology and Cardiac Surgery [of the American Academy of Pediatrics].

This Perrin et al policy statement was critical of the Vetter et al scientific statement on the grounds that the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics ‘have concluded that sudden cardiac death (SCD) in persons taking medications for ADHD is a very rare event, occurring at rates no higher than those in the general population of children and adolescents’ and ‘stimulant medications have been shown for decades to be effective for treatment of the disorder’.

In response to the Perrin et al policy statement, I submitted the following brief letter to the editor of Pediatrics.

Re: Policy statement on cardiovascular monitoring and stimulant drugs for ADHD (Pediatrics 122(2):451-3)
When considering our clinical response to inconclusive evidence of a rare but potentially fatal effect of a drug, we should take into account the effectiveness of that drug and the frequency of its use. There is no quarrel with the conclusion that the evidence for significant levels of cardiovascular mortality from stimulant drugs is weak. But your policy statement misleadingly claims that ‘stimulant medications have been shown for decades to be effective for the treatment of [ADHD]’. Systemic reviews have repeatedly shown that the evidence for the effectiveness of stimulants in ADHD is mostly based on short-term studies of poor methodological quality,[1] and the recent review by the UK National Institute for Health and Clinical Excellence recommends against the use of stimulants for mild to moderate ADHD.[2] Of more concern are claims in your policy about ‘the substantial risks of not treating ADHD’. Dangerous outcomes associated with ADHD are listed, without acknowledgement that there is no evidence that treating ADHD (with stimulants or otherwise) changes these dangerous outcomes. In fact, there is evidence to the contrary, showing that treatment has no positive effect on academic outcomes or delinquency.[3-5] Even weak evidence of potential harm must be taken seriously when a drug without demonstrated long-term benefit is being prescribed so broadly.

1. King S, Griffin S, Hodges Z, Weatherly H, Asseburg C, Richardson G, et al. A systematic review and economic model of the effectiveness and cost-effectiveness of methylphenidate, dexamfetamine and atomoxetine for the treatment of attention deficit hyperactivity disorder in children and adolescents. Health Technol Assess 2006;10(23).

2. National Institute for Health and Clinical Excellence. Attention deficit hyperactivity disorder (ADHD) - full guideline (pre-publication) Accessed August 2008.

3. The MTA Cooperative Group. A 14-Month Randomised Clinical Trial of Treatment Strategies for Attention-Deficit/ Hyperactivity Disorder Archives of General Psychiatry. 1999;56:1073- 1086.

4. Molina et al. Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. J Am Acad Child Adolesc Psychiatry. 2007 Aug;46(8):1028-40.

5. Jensen et al. 3-year follow-up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry. 2007 Aug;46(8):989-1002.

I received the following reply:

Dear Dr. Jureidini:
Enclosed is a copy of Dr. Perrin’s reply to your Letter-to-the-Editor. I am sorry that we will not be publishing this exchange of correspondence. We receive many items that are worthwhile contributions but must be declined due to lack of space. Thank you for thinking of Pediatrics.
Jerold F. Lucey, MD

Dr. Perrin’s reply read:

While we appreciate the concerns raised by the author(s), the main purpose of the joint statement was to note the lack of evidence supporting the use of electrocardiograms prior to starting medications for ADHD. The value of diagnosis and treatment of ADHD is a topic that the group revising the AAP guidelines for care of ADHD in primary care practice will address. That revision will address the evidence base for treatment.

It seems they missed the point that although its main purpose may have been to dispute evidence about the usefulness of ECGs, the policy statement nevertheless made misleading claims about the usefulness of stimulants.




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Far too large a section of the treatment of disease is to-day controlled by the big manufacturing pharmacists, who have enslaved us in a plausible pseudo-science...
The blind faith which some men have in medicines illustrates too often the greatest of all human capacities - the capacity for self deception...
Some one will say, Is this all your science has to tell us? Is this the outcome of decades of good clinical work, of patient study of the disease, of anxious trial in such good faith of so many drugs? Give us back the childlike trust of the fathers in antimony and in the lancet rather than this cold nihilism. Not at all! Let us accept the truth, however unpleasant it may be, and with the death rate staring us in the face, let us not be deceived with vain fancies...
we need a stern, iconoclastic spirit which leads, not to nihilism, but to an active skepticism - not the passive skepticism, born of despair, but the active skepticism born of a knowledge that recognizes its limitations and knows full well that only in this attitude of mind can true progress be made.
- William Osler 1909