Dr. Bob's Psychopharmacology Tips

Pemoline for ADD

Date: Tue, 9 May 1995 08:24:49 -0700 (PDT)
From: Stephen Sulzbacher <sis@u.washington.edu>
Subject: Pemoline for ADD

I would appreciate hearing people's experiences with pemoline (Cylert) as a treatment for ADD in adolescents. Is it as good as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine)? I believe one significant advantage of Cylert is that it is long-acting, eliminating the need for a midday dose of medicine (often complicated for adolescents).

--Eleanor Counselman, Ed.D.

I have recommended pemoline in cases where a child has failed to show objective evidence of response to methylphenidate or dextroamphetamine and the parents still insisted on a medication. In those cases, I sang the praises of this new compound which only required q.d. administration. With proper "placebo coaching" we achieved remarkable success in several cases.

Date: Tue, 9 May 1995 06:32:48 -0600 (CST)
From: Peter Matthews <matthwsp@duke.usask.ca>
Subject: Pemoline for ADD

I have used Cylert in the past as a replacement for Ritalin at adolescence. The same objections there are for Ritalin and its different formulations apply to Cylert and Dexedrine. They may all be wanted by street drug users. This puts the child, the school and sometimes the home at serious risk in our area. I have tended to move to desipramine when faced with this dilemma and it works reasonably well in adolescence.

One problem that the adolescent faces that younger children do not is the effect of the various sex hormones. These seem to have a distinct impact on the medications employed. In addition there is the risk-taking and exploratory behaviour typical of the age. Adolescents seem to turn into nocturnal creatures for a while and this interacts with the stimulants' tendency to delay sleep onset. So there are complex considerations in selecting an appropriate medication.

I think Cylert is less effective than the shorter acting stimulants, takes longer to build its effects and carries the same side effects with the added risk of liver problems.

From: CharanL@aol.com (Michael Levin, MD)
Date: Wed, 10 May 1995 02:10:14 -0400
Subject: Pemoline for ADD

I've never seen any good long-term response to Cylert, nor have I heard of one, except, of course, hearsay anecdotal cases. Cylert is about one sixth of the potency of Ritalin but lasts much longer. It has a tendency for accumulation and after a very short (from few days to few weeks) "honeymoon" period almost all patients start experiencing side effects (sleep and appetite problems, irritability, depression). From personal anecdotal experience: when I was conducting double-blind placebo-controlled studies which included Cylert, I almost always knew which week my patient had Cylert by distressed calls a few days after the switch was made.

Cylert is always listed next to Ritalin and Dexedrine but it is much less practical. It is usually favored by practitioners who would rather not deal with triplicate prescription forms and controlled substances (in many states Cylert can be called in to a pharmacy and refilled on the phone).

From: "Robert A. Katz, M.D." <trp.fish@ix.netcom.com>
Date: Wed, 10 May 1995 07:49:07 -0400
Subject: Pemoline for ADD

My experience with Cylert is not the same as with Ivan's report of an 80% failure rate. I use Cylert mainly for children who have problems not only associated with academics and behavioral dyscontrol while in school but with children who present with these problems along with out of control behavior at home that clearly has a destructive impact upon family functioning.

Date: Thu, 11 May 1995 06:55:22 -0600 (CST)
From: Peter Matthews <matthwsp@duke.usask.ca>
Subject: Pemoline for ADD

I suppose it simply shows that there are different experiences. I was only talking yesterday to a family in which there were two very rambunctious boys and Ritalin was hard to manage because of the short half life. I have used Cylert and obtained day long control with no significant sleep or appetite problems.

I do agree that there seems to be a lower chance that Cylert will succeed and I have drifted away from using it very often. Perhaps there is an experience factor that lets me choose those instances where Ritalin is likely to be successful now.

Date: Mon, 17 Jul 1995 13:55:00 -0600
From: dr-bob@uchicago.edu (Robert Hsiung)
Subject: Pemoline for ADD

There have been a number of opinions that pemoline doesn't work so well for ADD.

I mentioned this to a pemoline rep, and she gave me a reprint: Relative Efficacy of Long-Acting Stimulants on Children with ADHD, Pediatrics, 1990, 86: 226-237.

"Several direct comparisons of pemoline with methylphenidate or dextroamphetamine have shown it to be similar in its efficacy (2 refs). ... However, it remains widely believed that pemoline is less effective..."

They had 22 boys in their double-blind, placebo-controlled study. Each child received, in random order, placebo bid, methylphenidate 10 bid, Ritalin-SR 20 qd, dextroamphetamine 10 qd, and pemoline 56.25 qd, for 3-6 days each.

The bottom line: of the 15 for whom they recommended continued treatment, for 6 it was dextroamphetamine, for 4 each pemoline and Ritalin-SR, and for 1 methylphenidate.

Date: Fri, 12 Jan 1996 21:18:12 EST
From: HRudMD@aol.com (Howard Rudominer, M.D.)
Subject: Choice of second-line meds for ADHD

I myself have not been happy with pemoline, because of the close monitoring necessary as well as it never really working as well as methylphenidate or dextroamphetamine.

Date: Tue, 16 Apr 1996 04:23:15 -0500
From: bret@Vnet.net (Bret Burquest)
Subject: Pemoline for ADD

In adolescents I almost always start with bupropion (Wellbutrin) for ADD/ADHD. If this is not helpful and the family/child is not in crisis, I will try pemoline (Cylert) and find it helpful sometimes even in those who took methylphenidate (Ritalin) with some improvement years before. My practice probably has more substance abuse than most; most teens I see are users.

From: HRudMD@aol.com (Howard Rudominer, M.D.)
Date: Sat, 4 Jan 1997 22:15:07 -0500
Subject: Pemoline for ADD

Abbott Labs just announced that they were changing their labelling on Cylert to include a boxed warning describing liver failure and to indicate that Cylert should not ordinarily be considered for first line drug therapy for ADHD.

Date: Fri, 30 May 1997 00:07:23 -0700
From: "Jonathan A. Slater, M.D." <jas14@columbia.edu>
Subject: Pemoline for ADD

I generally don't use it as a first line ADHD drug, i.e., I would probably use Ritalin, Dexedrine, Adderall, then tricyclics, bupropion, guanfacine. I do still have a couple of kids on Cylert who do exceptionally well on it and poorly on everything else.

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