OROS-Methylphenidate-Induced Raynaud's Phenomenon: A Dose-Related Side Effect.

Abstract

[Author Affiliation]Ozlem Bayram. Department of Child and Adolescent Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Meram, Konya, Turkey.Sabri Herguner. Department of Child and Adolescent Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Meram, Konya, Turkey.Address correspondence to: Ozlem Bayram, Meram Tip Fakultesi, Cocuk ve Ergen Psikiyatrisi AD, Meram, Konya, Turkey, E-mail: dr.ozlemkarakaya@gmail.comTo The Editor:Attention-deficit/hyperactivity disorder (ADHD) is characterized by developmentally inappropriate symptoms of inattention, hyperactivity, and/or impulsivity, with onset before the age of 12 years (American Psychiatric Association 2013). Stimulants, such as methylphenidate (MPH), are used as the first-line treatment for children with ADHD, and their safety and efficacy are well established. Osmotic controlled-release oral delivery system (OROS)-MPH is a long-acting stimulant designed to release gradually increasing concentrations of MPH over 10-12 hours.Raynaud's phenomenon (RP) is a peripheral vasculopathy characterized by recurrent reversible episodes of vasospasm, which are triggered by cold and emotional stress. Color changes, including pallor, cyanosis, and erythema, are observed, and patients may have complaints of numbness and pain. Vascular, neuronal, and intravascular abnormalities have a role in its pathogenesis (Herrick 2005).Some reports described cases with RP induced by ADHD medications including MPH and dextroamphetamine (Syed and Moore 2008; Yu et al. 2010). In this report, we will describe a 14-year-old girl with ADHD who experienced RP during 27 mg OROS-MPH treatment but not during 18 mg treatment.Case ReportA 14-year-old girl was referred to our outpatient clinic with complaints of inattentiveness, concentration problems, and learning difficulties. She had been receiving low grades in her classes. According to her mother, she had had similar problems since elementary school, but had never had hyperactivity and impulsivity. According to her psychiatric assessment, she was diagnosed with ADHD-inattentive type, and OROS-MPH 27 mg was initiated. At her second visit to our clinic, 4 weeks later, significant improvement was seen in her symptoms of inattention. However, 3 days after she started to take OROS-MPH, she began feeling cold in both her feet and hands. The coldness in her feet and hands was occurring 3 hours after drug intake, and went on for 12 hours. We decided to discontinue OROS-MPH for 2 days, and her complaint improved. When she restarted taking OROS-MPH, her symptoms of coldness reemerged. Then we decided to taper the dose of OROS-MPH to 18 mg. On this dose, she did not experience coldness in her feet and hands, so we decided to continue her treatment in this dosage.During her physical examination, her toes and fingers were cold to the touch but ulceration, necrosis, and skin discoloration were not observed. A rheumatologist found no joint stiffness, rash, arthralgia, fatigue, fever, or nail changes. The patient reported no drug allergies. There was no family history of connective tissue diseases. Laboratory investigations of rheumatic illness, including erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and antinuclear antibodies (ANA), were unremarkable. …