international journal of athletic therapy & training may 2011 41

Attention deficit/hyperactivity disorder (ADHD) is a highly prevalent condition. In 2006, the Center for Disease Control and Prevention1 estimated that 4.5 million chil-dren between five and 17 years of age had been diagnosed with ADHD in the United States, which represents 3%–7% of school-aged children. Diagnosis of the condition increased by an average of 3% per year

from 1997 to 2006.1 Boys (9.5%) are more likely to be diagnosed with ADHD than are girls (5.9%).1 Char-acteristics of ADHD include inability to sus-tain attention, inap-propriate activity level, and impulsivity.2 Inat-tention may include difficulty sustaining attention to a task or

instructions, making careless mistakes, or being easily distracted. Inappropriate activity level may manifest as fidgeting, being con-stantly on the move, or talking excessively. Impulsivity may include interrupting others, prematurely answering questions, or inability to wait for one’s turn.2

The most frequent treatments for ADHD are administration of stimulants and psy-chosocial intervention.3 When the individual diagnosed with ADHD is an elite athlete who is subject to drug testing, the choice

Joe J. Piccininni, EdD, CAT(C), Report Editor

Adverse Medication Response of an Elite Athlete With ADHD

CASE REVIEW

Colleen N. Gulick • University of Maryland

of medications is limited. The United States Anti-Doping Agency (USADA)4 and World Anti-Doping Agency (WADA)5 publish a list of banned substances for which positive test results can risk an athlete’s eligibility for a minimum of one year. All S6-classified stimulants (specified and non-specified) are prohibited (Table 1).4,5 Other ADHD medications have not proven to be as effective for management of ADHD as those in the S6 classification.3 This case report presents the course of treatment and adverse effects experienced by an elite ath-lete who was diagnosed with and treated for ADHD.

Case ReportThe patient was a 19-year-old Caucasian female NCAA Division I athlete and UCI cyclist (Union Cyclist International is the governing body for international competi-tive cycling). The athlete had recently been tested and diagnosed with ADHD by her primary care physician. The patient com-pleted an Adult Self-Report Scale (ASRS) symptom checklist. The athlete’s Part A score was18, and her Part B score was also 18, which was highly suggestive of ADHD. The parent completed a Conners Parent Rating Scale6 to assess the frequency of behaviors observed by the parent, the results of which corresponded to the athlete’s self-reported symptoms.

© 2011 Human Kinetics - ATT 16(3), pp. 41–44

The physical demands of athletic activity may produce unforeseen negative side effects when coupled with certain drug classes.

The sympathetic demands of exercise may conflict with the drug’s influence on neuro-logic function.

Key PointsKey Points

42 may 2011 international journal of athletic therapy & training

Physical Examination

Due to escalating issues with academic performance, the athlete and parent consulted the primary care phy-sician (PCP). Issues included inability to attend, high degree of distractibility, and on-going fidgeting and restlessness in multiple environments. Examination of vital signs yielded non-remarkable results for an

elite athlete. The athlete had no known allergies, and the only issue in her past medical history was anemia. Daily iron supplements of two 15-mg liquid doses of Floradix (Flora, Inc., Lynden, WA) had successfully managed the anemia. She had no history of surgery, nor was she taking any prescribed medications. Physi-cal examination produced normal findings, and labora-tory tests yielded normal results. One remarkable find-ing was constant movement of the lower extremities throughout the duration of the examination.

Diagnosis

There is no simple test for the diagnosis of ADHD. The diagnosis can only be made by a trained clinician after a thorough evaluation. In order to accurately detect the presence of ADHD, other possible causes for the symp-toms should be ruled out (Table 2).7,8,9 Comprehensive interviewing of the patient and key individuals in the patient’s life (e.g., parent, teacher, spouse) is necessary to obtain information about the patient’s behaviors. In this case, the primary care physician performed a thorough examination and interview of the athlete. The results of the ASRS and Conners’ Scale were also considered, which supported the diagnosis of an inat-tentive type of ADHD.

Treatment

Because of USADA and WADA restrictions, the primary care physician prescribed Strattera®, which is a non-stimulant medication. Strattera®, or atomoxetine, is a selective norepinephrine reuptake inhibitor, which is rapidly absorbed from the gastrointestinal tract after oral administration (averaging one to two hours to reach maximal plasma concentrations).10 The most common adverse effects are dry mouth (21.2%), insomnia (20.8%), nausea (12.3%), decreased appetite (11.5%), constipation (10.8%), dizziness (6.3%), and sweating (5.2%). Data from clinical trials have also identified modest increase in heart rate (11 beats per minute in standing and 5 beats per minute in a supine position)11 and elevation of systolic blood pressure (2.3 mm Hg).12

The athlete was initially placed on an 18 mg dose for three days, 40 mg dose for three days, and then a stable daily dose of 60 mg. Initial adverse effects of the medication were nausea, extreme fatigue, and decreased appetite. The athlete was participating in two or three workouts per day for both cycling and field hockey. The mode of conditioning was extremely high-intensity interval training (i.e., approximately

Table 1. S6 Classification of Stimulants 4,5

Specified* NonspecifiedAdrenalineCathineEphedrineEtamivanEtilefrineFenbutrazateFencamfaminHeptaminolIsomethepteneLevmetamphetamineMeclofenoxateMethylephedrineMethylphenidateNikethamideNorfenefrineOctopamineOxilofrineParahydroxyamphetaminePemolinePentetrazolPhenpromethaminePropylhexedrinePseudoephedrineSelegilineSibutramineStrychnineTuaminoheptane

AdrafinilAmfepramoneAmiohenazoleAmohetamineAmphetaminilBenfluorexBenzphetamineBenzylpiperazineBrimantanClobenzorexCocaineCropropamideCrotetamideDimethylamphetamineEtilamphetamineFamprofazoneFencamineFenetyllineFenfluramineFenproporexFurfenorexMefenorexMephentermineMesocarbMethamphetamineMethylenedioxyamphet-amineMethylenedioxymetham-phetamineMethylhexaneamineModafinilNorfenfluraminePhendimetrazinePhenmetrazinePhentermine4-phenylpiracetamPrenylamineProlintane

*Specified stimulants are substances that are more susceptible to a credible nondoping explanation for use.

international journal of athletic therapy & training may 2011 43

85-90% of V. O2 maximum). In addition, the athlete

completed two weight training sessions per week. After several days at 60 mg of Strattera® administration, she experienced bouts of cutis ansirina (i.e., goose bumps) and chills with diaphoresis, despite her presence in an environment having an ambient temperature exceeding 90°F. The athletic trainer and the physi-cian initially thought that the symptoms were related to dehydration. Careful attention was directed to adequate hydration before and during workouts, but the symptoms did not resolve. Subsequently, blood glucose level was assessed at various times during the workout sessions. Blood glucose level was found

to be as low as 92 mg/dL and as high as 245 mg/dL, but no clear association between the symptoms and blood glucose level was identified. Compared to previous drug-free exercise performance, an increase in heart rate of 20 to 30 beats per minute for a given level of exercise intensity (i.e., Watts) was mea-sured by a heart rate monitor. Her symptoms were far more pronounced during morning workouts than during afternoon or evening workouts. By the second week on the 60 mg dose of Strattera®, the athlete had vomited four times during workout sessions that were previously completed at the same intensity level without difficulty.

Table 2. Signs and Symptoms of ADHD

Negative Impact Positive Impact

inattention

Difficulty paying attention to details

Makes careless mistakes

Easily distracted by irrelevant stimuli and/or trivial noises

Seems to not listen even when spoken to directly

Difficulty finishing tasks that require concentration

Frequent shifts from one uncompleted activity to another

Procrastination

Has problems organizing tasks

Frequently misplaces needed items

Forgetful during daily activities

impulsivity

Impatience

Difficulty with self-control

Difficulty awaiting one’s turn

Interrupts others

Difficulty keeping emotions in check, i.e. angry outbursts

hyperactivity

Fidgeting, squirming

Restlessness

Difficulty playing quietly or engaging in quiet leisure activities

Always “on the go“ (as if driven by a motor)

Talking excessively*signs and symptoms are usually present across all situations: home, school, & play.7,8,9

creativity

With multiple thoughts at once, one can become an excellent problem solver or very creative artist.

Due to being easily distracted, one may notice what others don’t see.

flexibility

As a result of considering a lot of options at once, one does not become set on one alternative & are open to different ideas.

Enthusiasm & spontaneity

Is rarely boring

Has a lot of different interests

Has a lively personality

Energy & drive

Is motivated to work or play hard and strive to succeed

It may be difficult to distract one from a task that interests him/her, particularly tasks that are interactive or hands-on.

44 may 2011 international journal of athletic therapy & training

After almost four weeks on Strattera®, the athlete was unable to tolerate its side effects. After consulta-tion with the physician and athletic trainer, the athlete decided to stop taking the medication. Approximately 26 hours after the cessation of Strattera® administra-tion, the athlete completed a 25-mile bicycle race with minimal cutis ansirina, chills, or diaphoresis. The next day (approximately 49 hours after the last dose), the athlete completed a 20-mile bicycle race with no adverse effects. USADA officials and the primary care physician agreed that Strattera® was not tolerated by the athlete and that another drug class would be more appropriate.

SummaryThe physiologic changes produced by atomoxetine (Strattera®) can be problematic to the performance of an elite athlete. The sympathetic demands of exercise may conflict with the drug’s influence on neurologic function. For example, the “fight or flight” response that occurs with the onset of exercise increases heart rate, elevates blood glucose level, and increases blood flow to muscles. Strattera® inhibits the uptake of the stress hormone norepinephrine, which can affect the function of smooth, skeletal, and cardiac muscle. During athletic activities, norepinephrine reuptake inhibition has been found to significantly decrease performance at both moderate and high ambient temperatures.12 A review of the literature did not identify any research reports that were specific to the use of Strattera® in athletes. Other than elevated heart rate, the medication side effects experienced by this athlete was not reported in the literature. The extreme physical demands imposed by the activities of an elite athlete may cause adverse effects when combined with some types of medication. The medi-cation side effects reported in this case review could represent an individualized response, but other elite athletes may be susceptible to a similar response to the medication.

Acknowledgment

As a result of the experiences of this athlete, the athletic trainer filed an adverse drug response report with the FDA. Confirmation of receipt of the report has been obtained.

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national health interview survey. 2006 National Center for Health Statistics. Vital Health Statistics. 2007;10(234).

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5. http://www.wada-ama.org/rtecontent/document/2010_Prohibited_List_FINAL_EN_Web.pdf; accessed August 5, 2010.

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9. Symptoms of ADHD and ADD. WebMD - Better Information. Better Health. Amal Chakraburtty, Ed. WebMD, 2010. Web. 28 Nov. 2010. http://www.webmd.com/add-adhd/guide/adhd-symptoms.

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12. Michelson D, Adler L, Spencer T, et al. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry. 2003;53(2):112-120.

Colleen N. Gulick is an undergraduate bioengineering major and athlete at University of Maryland. She is a member of the honors program and field hockey team as well as a three-time junior national cycling champion.