Pakistan and ADHD

I was trying to research ADHD in Pakistan today and came across this article from J Pak Med Assoc. 2003 Sep;53(9):441-3

Qureshi A, Thaver D.Aga Khan University Hospital, Karachi.

Ok so ADHD exists in Pakistan. Now what is the treatment for it. Primarily would be the use of analeptics. If one class of analeptics is not effective the medication can be switched to the other class and ~90% children respond. One class being the Methylphenidate products like Ritalin and the long acting methylphenidate products and methylated compounds of methylphenidate. The other class is the amphetamine salts like dextroamphetamine and the mixture of the two enantiomers of the dextroamphetamine (Adderall, Vyvanse, Dexedrine). In Pakistan only the MPH compounds are available.

I found Ritalin at an online pharmacy. 10 mg tablets. The price is Rs 4.7 for 10mg. It is certainly not steep. A 40kg child would be taking roughly 1mg/kg/dose as the high end would end up spending ~Rs 18. If this dose is taken two to three times a day the cost increases up to 18x3=54. If this is not given on days off from school, the child will take it ~20 days. So Rs 1080 for an entire month.

Now the question is what is the other option besides Ritalin. Nothing. I have not been able to find Amphetamine salts. Second line medications like Alpha 2 agonists (Guanfacine and Clonidine) which are also used as blood pressure medications are also not available.

Bupropion is available. This also a second to third line agent. 75 mg tablet costs Rs 10. It is usually needed in doses of 150mg-300mg and everyday medication will make it a cost of anywhere from Rs 600-Rs 1200 per month.

Atomoxetine is not available. That would also be a second to third line agent. Especially useful in children who cannot withstand analeptics.

Then there is the tricyclics, which are available but that would be third line agents and not the best medications for a hyperactive child. Side effect profile unfavorable.