CASE REVIEW Joe J. Piccininni, EdD, CAT(C), Report Editor Adverse Medication Response of an Elite Athlete With ADHD

Colleen N. Gulick • University of Maryland

Attention deficit/hyperactivity disorder of medications is limited. The United States (ADHD) is a highly prevalent condition. In Anti-Doping Agency (USADA)4 and World 2006, the Center for Disease Control and Anti-Doping Agency (WADA)5 publish Prevention1 estimated that 4.5 million chil- a list of banned substances for which dren between five and 17 years of age had positive test results can risk an athlete’s been diagnosed with ADHD in the United eligibility for a minimum of one year. All States, which represents 3%–7% of school- S6-classified stimulants (specified and aged children. Diagnosis of the condition non-specified) are prohibited (Table 1).4,5 increased by an average of 3% per year Other ADHD medications have not proven from 1997 to 2006.1 to be as effective for management of ADHD 3 Key Points Boys (9.5%) are more as those in the S6 classification. This case Key Points likely to be diagnosed report presents the course of treatment and The physical demands of athletic activity with ADHD than are adverse effects experienced by an elite ath- may produce unforeseen negative side girls (5.9%).1 Char- lete who was diagnosed with and treated for effects when coupled with certain drug acteristics of ADHD ADHD. classes. include inability to sus- tain attention, inap- Case Report The sympathetic demands of exercise may propriate activity level, conflict with the drug’s influence on neuro- and impulsivity.2 Inat- The patient was a 19-year-old Caucasian logic function. tention may include female NCAA Division I athlete and UCI difficulty sustaining cyclist (Union Cyclist International is the attention to a task or governing body for international competi- instructions, making careless mistakes, or tive cycling). The athlete had recently been being easily distracted. Inappropriate activity tested and diagnosed with ADHD by her level may manifest as fidgeting, being con- primary care physician. The patient com- stantly on the move, or talking excessively. pleted an Adult Self-Report Scale (ASRS) Impulsivity may include interrupting others, symptom checklist. The athlete’s Part A score prematurely answering questions, or inability was18, and her Part B score was also 18, to wait for one’s turn.2 which was highly suggestive of ADHD. The The most frequent treatments for ADHD parent completed a Conners Parent Rating are administration of stimulants and psy- Scale6 to assess the frequency of behaviors chosocial intervention.3 When the individual observed by the parent, the results of which diagnosed with ADHD is an elite athlete corresponded to the athlete’s self-reported who is subject to drug testing, the choice symptoms. © 2011 Human Kinetics - ATT 16(3), pp. 41–44 international journal of Athletic Therapy & training may 2011  41 elite athlete. The athlete had no known allergies, and Table 1. S6 Classification the only issue in her past medical history was anemia. of Stimulants 4,5 Daily iron supplements of two 15-mg liquid doses of Specified* Nonspecified Floradix (Flora, Inc., Lynden, WA) had successfully Adrenaline Adrafinil managed the anemia. She had no history of surgery, Cathine Amfepramone nor was she taking any prescribed medications. Physi- Ephedrine Amiohenazole cal examination produced normal findings, and labora- Etamivan Amohetamine tory tests yielded normal results. One remarkable find- Etilefrine Amphetaminil ing was constant movement of the lower extremities Fenbutrazate Benfluorex throughout the duration of the examination. Fencamfamin Benzphetamine Heptaminol Benzylpiperazine Diagnosis Isometheptene Brimantan Levmetamphetamine Clobenzorex There is no simple test for the diagnosis of ADHD. The Meclofenoxate Cocaine diagnosis can only be made by a trained clinician after Methylephedrine Cropropamide a thorough evaluation. In order to accurately detect the Methylphenidate Crotetamide presence of ADHD, other possible causes for the symp- Nikethamide Dimethylamphetamine toms should be ruled out (Table 2).7,8,9 Comprehensive Norfenefrine Etilamphetamine interviewing of the patient and key individuals in the Octopamine Famprofazone patient’s life (e.g., parent, teacher, spouse) is necessary Oxilofrine Fencamine to obtain information about the patient’s behaviors. Parahydroxyamphetamine Fenetylline In this case, the primary care physician performed a Pemoline Fenfluramine thorough examination and interview of the athlete. Pentetrazol Fenproporex The results of the ASRS and Conners’ Scale were also Phenpromethamine Furfenorex Propylhexedrine Mefenorex considered, which supported the diagnosis of an inat- Pseudoephedrine Mephentermine tentive type of ADHD. Selegiline Mesocarb Sibutramine Methamphetamine Treatment Strychnine Methylenedioxyamphet- Because of USADA and WADA restrictions, the primary Tuaminoheptane amine care physician prescribed Strattera®, which is a non- Methylenedioxymetham- stimulant medication. Strattera®, or atomoxetine, is a phetamine selective norepinephrine reuptake inhibitor, which is Methylhexaneamine Modafinil rapidly absorbed from the gastrointestinal tract after Norfenfluramine oral administration (averaging one to two hours to reach Phendimetrazine maximal plasma concentrations).10 The most common Phenmetrazine adverse effects are dry mouth (21.2%), insomnia Phentermine (20.8%), nausea (12.3%), decreased appetite (11.5%), 4-phenylpiracetam constipation (10.8%), dizziness (6.3%), and sweating Prenylamine (5.2%). Data from clinical trials have also identified Prolintane modest increase in heart rate (11 beats per minute in *Specified stimulants are substances that are more susceptible to a credible standing and 5 beats per minute in a supine position)11 nondoping explanation for use. and elevation of systolic blood pressure (2.3 mm Hg).12 Physical Examination The athlete was initially placed on an 18 mg dose for three days, 40 mg dose for three days, and then Due to escalating issues with academic performance, a stable daily dose of 60 mg. Initial adverse effects the athlete and parent consulted the primary care phy- of the medication were nausea, extreme fatigue, and sician (PCP). Issues included inability to attend, high decreased appetite. The athlete was participating in degree of distractibility, and on-going fidgeting and two or three workouts per day for both cycling and restlessness in multiple environments. Examination field hockey. The mode of conditioning was extremely of vital signs yielded non-remarkable results for an high-intensity interval training (i.e., approximately

42  may 2011 international journal of Athletic Therapy & training