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Background: Attention Deficit Hyperactivity Disorder (ADHD) is a very common clinical presentation at the child and adolescent psychiatric clinics. Often stimulant medications are prescribed to treat ADHD. One of the most common side effects of stimulant medications is appetite suppression. Frequently, patients present not only with ADHD diagnosis but present with other diagnoses as well. Pertaining to the specific disorders, they are prescribed differed medications while they are on stimulant medications. It is imperative to assess appetite suppressant effect of the other medications as well as medical and psychiatric conditions. Two cases are presented here for further discussion: Case 1: Patient X was a 14-year-old mixed-race male who presented to the child and adolescent psychiatry clinic for a follow-up appointment. He carried a diagnosis of ADHD and was prescribed Methylphenidate extended-release 54 mg in the morning. According to the mother as well as the patient, his ADHD symptoms were well controlled with his stimulant medication. He had been doing well at school, at home, and was maintaining good grades. He was having an adverse effect from the medication including appetite suppression and lack of weight gain. The patient’s mother reported that he had not been eating much at breakfast and at lunch. Upon further inquiry, it was found out that patient was taking his medication on an empty stomach in the morning, at least one hour before his breakfast. At that visit, he was instructed to take his medication after a full/big breakfast every morning. During the next follow-up appointment, his appetite improved and the patient was able to eat better at breakfast and at lunch, and he also gained a couple of pounds. Case 2: Patient Z was a 15-year-old Caucasian male who was given the diagnosis of ADHD, Generalized Anxiety Disorder, and Tic Disorder. He has prescribed Methylphenidate extended-release 18 mg in the morning and Zoloft 50 mg in the morning. During one of his follow-up appointments at a child psychiatry clinic, the mother was concerned about his poor appetite and the lack of weight gain. According to the mother, the patient was not eating well and not gaining weight. At that visit his weight was 103 pounds, height was 5 feet 6 inches. His BMI was 16.6. The patient was considered underweight. During that visit, it was noted that the patient was also taking Topiramate 100 mg in the morning for Tic Disorder. Topiramate was prescribed by his neurologist. The mother reported that his tics were under control for many months with Topiramate. As poor appetite and lack of weight gain were significant issues at that visit, it was recommended that the mother discuss these concerns with the neurologist to see whether or not Topiramate can be reduced or tapered off. Especially, since the patient’s tics were under control for months as he grew older. During a subsequent follow-up appointment, the mother reported that the patient’s Topiramate was gradually tapered off by the neurologist and the patient continued to stay tic free. At the same time, his appetite got better and he started to gain weight. Discussion: The following measures can be considered when patients present with decreased appetite while on stimulant medications and being treated for ADHD: 1. Thorough medical and psychiatric history should be assessed. There are many medical and psychiatric conditions that can cause decreased appetite, for example, hypothyroidism, depression, anxiety, and anorexia nervosa. 2. Detailed substance abuse history should be obtained, especially a history of misuse/abuse of stimulant medication, methamphetamine, and cocaine. 3. Appropriate treatment recommendation should be considered pertaining to the relevant medical/ psychiatric diagnosis and/or substance use disorder. 4. Meticulous history of prescription medications should be gathered, which also can suppress appetite other than stimulant medications, e.g. Topiramate, Wellbutrin, and Amantadine. 5. Careful history should be obtained to better understand how the patient is taking medications, with meals or on an empty stomach. The parents/caregivers should be advised to dispense medications with or after full meals. 6. Supper time can be delayed a little bit to give time for stimulant medications to wear off, to help improve the appetite at supper time. 7. Parents/caregivers may consider offering the patient a small snack at night prior to bedtime. 8. If the above steps do not work, the risk/benefit ratio should be assessed carefully based on the individual patient’s clinical presentation and situation. If indicated, a different stimulant medication, preferable from the methylphenidate group, can be recommended. If appetite suppression and the lack of weight gain are significant, non-stimulant medications for ADHD can be considered.
