ADHD and gender: are risks and sequela of ADHD the same for boys and girls?

BACKGROUND: Research comparing treatment-referred boys and girls with attention-deficit/hyperactivity disorder (ADHD) has yielded equivocal results. Contradictory findings may be associated with differential referral practices or unexplored interactions of gender with ADHD subtypes. METHOD: We examined possible gender differences in ADHD and its subtypes among children aged 4 to 17 in a representative community sample (N = 1896) in Puerto Rico. Caretakers provided information through the Diagnostic Interview Schedule for Children (version IV) and a battery of impairment, family relations, child problems, comorbidity and treatment measures. RESULTS: ADHD was 2.3 times more common in boys than girls, but with one exception there was little evidence that the patterns of associations of ADHD with correlates were different for boys and girls. The exception was school suspension, which was more common among ADHD boys than girls. Additional gender interactions were found when ADHD subtypes were considered. Among those with combined type (n = 50), boys were more likely to be comorbid with mood disorders than girls. For those with the inattentive type (n = 47), girls were more likely to be comorbid with anxiety disorders than boys. CONCLUSIONS: Our findings lend cross-cultural generalizability to recent reports that gender does not interact with correlates for ADHD overall, but that it may play a role in subtypes.

Effect of candesartan and lisinopril alone and in combination on blood pressure and microalbuminuria.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blocking drugs (ARB) block the effect of angiotensin II by different mechanisms. It has been suggested that combined therapy may be more effective at reducing blood pressure (BP) than higher doses of either drug. METHODS: Twenty-three elderly patients with systolic hypertension completed a double-blind crossover study comparing placebo, candesartan (C) 16 mg, C32 mg, lisinopril (L) 20 mg, L40 mg and C16 mg + L20 mg. Treatment periods were one month and ambulatory BP measurements were performed at the end of each period. The effects on albumin excretion in eight patients with microalbuminuria were determined. RESULTS: All treatments lowered BP. The falls in systolic and diastolic BP with C16, C32, L20 and L40 were similar. Plasma renin rose to a similar extent. A plateau effect was reached with C16 and L20. Systolic BP on the combination of C16 + L20 was lower than on each monotherapy (C16, 3.8 mmHg [p=0.002]; C32, 6.4 [0.0003]; L20, 2.9 [0.05]; L40, 3.3 [0.003]). The additional fall in BP with the combination appeared to be due to recruitment of non-responders, rather than to an additive effect in most patients. All treatments reduced microalbuminuria to a similar extent. The combination was well tolerated and there was no deterioration in renal function. CONCLUSION: When patients are on a plateau dose of an ACE inhibitor or an ARB, addition of the other drug class has a small but significant incremental effect on BP in the overall group. However, some patients respond better to one drug class than to the other and this may explain the results. This study lends no support to the use of these two drugs in combination to treat hypertension.

Effect of different antihypertensive drug classes on central aortic pressure.

Central aortic systolic blood pressure (BP) is an important determinant of cardiac workload and cardiac hypertrophy. The relationship of central aortic systolic BP and brachial BP varies depending on the stiffness of blood vessels. It is not certain whether the different drug classes affect the brachial and aortic systolic BP in a similar manner. In a double-blind crossover study, we measured the effects of the four major drug classes compared with placebo on central aortic pressure. Central aortic pressure and various indices were determined using the Sphygmo Cor apparatus. The study was undertaken in patients aged 65 to 85 years with systolic BP >150 mm Hg at study entry. Results are reported for 32 patients who had satisfactory applanation tonometry in all five periods. Calcium channel blockers and diuretics caused a greater fall in brachial artery systolic BP than angiotensin-converting enzyme (ACE) inhibitors or beta-blocking drugs. On placebo, central aorta augmentation pressure and index were 23 mm Hg and 33.3%; on ACE inhibitors the values were 18 mm Hg and 30%; on beta-blockers, 26 mm Hg and 38.5%; on calcium channel blockers, 16 mm Hg and 28%; and on diuretics, 17 mm Hg and 28.8%. The augmentation pressure on beta-blocking drugs was greater than on the other three drug classes (P <.05), and augmentation pressures on ACE inhibitors, calcium channel blockers, and diuretics were less than on placebo (P <.05). The lowest central aortic pressures were achieved with calcium blocking drugs and diuretics. Therapy based on brachial artery recordings may thus overestimate the effect of beta-blocking drugs on central aortic systolic BP and underestimate the effectiveness of ACE inhibitors and calcium blocking drugs. The clinical importance of this discrepancy needs to be evaluated.

The effect of nonsteroidal anti-inflammatory drugs on blood pressure in patients treated with different antihypertensive drugs.

Hypertension and arthritis are both common diseases in the older age group and require pharmacologic treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) alter renal function if given in high enough doses, reducing renal blood flow and the glomerular filtration rate and causing sodium retention. In salt sensitive subjects, this retention of sodium will cause blood pressure to rise. Salt sensitivity is more common in elderly patients, in diabetics, and in people with renal failure. When most antihypertensive drugs are used, people become salt sensitive, as shown by the additive effect of salt restriction or diuretics on blood pressure response. The responses to dihydropyridine and possibly other calcium channel blocking drugs are not affected to any major extent by sodium intake or by diuretics. Studies are described which indicate that indomethacin elevates blood pressure in elderly people treated with enalapril, but not in people whose blood pressure is controlled with amlodipine or felodipine. It is unclear whether the various NSAIDs have different effects on blood pressure. It is proposed that if the same analgesic effect is achieved with the same amount of cyclooxygenase inhibition, the response will be similar. Aspirin, used in a prophylactic dose, does not inhibit to this extent and does not elevate blood pressure. If elderly people require NSAIDs, it would appear that dihydropyridine calcium channel blocking drugs are more effective at lowering and maintaining blood pressure control and should be one of the drugs used. If patients are on other antihypertensive agents, it is important to monitor blood pressure when a NSAID is added to therapy.

Different drug classes have variable effects on blood pressure depending on the time of day.

BACKGROUND: Blood pressure (BP) is controlled by a variety of systems, the activities of which vary throughout the day. As drugs are developed that selectively block these systems, the fall in BP may not be consistent over 24 h. METHODS: A total of 24 patients (aged >65 years) with systolic BP (SBP; >150 mm Hg) that had not been treated entered a substudy of a larger study performed in 74 patients. In a double blind, crossover study with a balanced design, they received placebo, atenolol 50 mg, perindopril 8 mg, felodipine 10 mg, or hydrochlorothiazide 50 mg. The study periods were 2 months. Ambulatory BP monitoring was performed at the end of each period, and was divided into awake periods (9:00 AM to 10:00 PM), sleep periods (12:00 AM to 6:00 AM), and morning periods (6:00 AM to 9:00 AM). Medication was taken at 9:00 AM. RESULTS: The four drug classes lowered 24-h mean SBP (P <.05), but the fall with atenolol was less than with the other drugs. The fall in awake BP with perindopril was less than with felodipine or hydrochlorothiazide. Atenolol caused no significant fall in sleep or morning SBP, and the falls with the other three drugs were significant and were greater than the fall with atenolol. The fall in sleep BP with perindopril was greater than with the other drug classes. The awake-sleep difference in SBP increased with perindopril, stayed the same with felodipine and hydrochlorothiazide, and was reduced by atenolol. CONCLUSIONS: In this study, the response to the different drug classes differed. The response to drugs that work relatively nonspecifically (diuretics, calcium blockers) was relatively consistent over 24 h. The response to beta blockers and to angiotensin converting enzyme inhibitors reflected the activity of control systems. This finding supports the concept of multiple drug therapy that may need to be tailored to the time of day.

A comparison of candesartan, felodipine, and their combination in the treatment of elderly patients with systolic hypertension.

Monotherapy frequently does not cause adequate blood pressure (BP) reduction and goal BP is not achieved. This double-blind, randomized, crossover, placebo-controlled study investigated, using a factorial design, the interaction between a dihydropyridine calcium channel blocking drug (felodipine 5 mg) and an angiotensin type I receptor blocking drug (candesartan 16 mg) on the control of BP as assessed by 24-h ambulatory monitoring. A total of 31 elderly patients with systolic hypertension completed all four arms of the study. Candesartan and felodipine lowered mean 24-h BP to a similar extent (candesartan 12.2 +/- 2.6/7.5 +/- 1.8; felodipine 11.9 +/- 2.2/5.7 +/- 1.4 mm Hg). The combination lowered it by 21.0 +/- 2.1/11.2 +/- 1.2 mm Hg, and this fall was significantly greater than with either of the monotherapies (P < .005) and was fully additive with no interactive term. The responder rate with the combination (90%) was greater than with candesartan (61%) or felodipine (55%). Microalbuminuria or proteinuria was present in 12 of 31 patients at randomization despite previous BP control. Candesartan and the combination both reduced urinary albumin excretion. Albumin excretion was not reduced by felodipine despite BP control similar to that achieved with candesartan. Side effects were infrequent and were fewer on the combination than on placebo or on the monotherapies. The combination of felodipine 5 mg and candesartan 16 mg has additive effects on BP in elderly patients with systolic hypertension. The combination was well tolerated and is suitable for use in patients who do not have an adequate response to monotherapy.