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May 2023 > 221018 PA Attention Deficit Hyperactivity Disorder > Flashcards

221018 PA Attention Deficit Hyperactivity Disorder Flashcards

1
Q

ADHD
3 hallmark symptoms

A

Impulsiveness
Hyperactivity
Inattention

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2
Q

ADHD
The principal subtype

A

Combined Inattention and Hyperactive (70-80%)

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3
Q

ADHD
Diagnosis

A

6 6 (-) 2
at least 6 symptoms (5 if age from 17)
at least 6 months
negative impact on social and academic/occupational activities
Two or more setting

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4
Q

ADHD
Inattention symptoms

A
  1. Fail: attention to details, careless mistakes in school work
  2. Difficulty in task/play activities
  3. Not seem to listen when spoken directly
  4. Not follow the instruction/ no finish school work
  5. Difficulty organizing tasks and activities
  6. Avoid, dislike, reluctantly engages in tasks requiring mental effort
  7. Lose things at school
  8. Distracted by extraneous stimuli
  9. Forgetful in daily activities
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5
Q

ADHD
Hyperactive-Impulsive symptoms

A
  1. Fidget with hands/feet in seat
  2. Leave seat in class
  3. Run/climbs excessively in situation where inappropriate
  4. Difficulty: play in leisure activities quietly
  5. Acts as if “driven by a motor”
  6. Talk excessively
  7. Blurts out before questions completed
  8. Difficulty: awaiting turn
  9. Interrupt or intrudes on others
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6
Q

ADHD
Goal of therapy

A

Adverse reaction decrease
Decrease core symptoms, Improve academic and behavioural performance
Herself - Improve social functioning and self esteem
Develop QoL

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7
Q

ADHD
Non-pharm 1st line

A

4-6 age

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8
Q

ADHD
1st medication for above 6 yrs
Lâu dài: Vườn - Ao - Chuồng Bền Forever

A

long-acting stimulants: 8-14 hours
Concerta (OROS methylphenidate) 12h
Adderall XR (mixed salts amphetamine) 10-12h
Vyvanse (lisdexamfetamine) 13-14h
—-
Biphentin 10-12h
Foquest 16h

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9
Q

ADHD
Long-acting benefits

A

Trial 3-4 weeks before re-assessment
1. Single daily => adherence + avoid administering med at school
2. Increase efficacy compare non-stimulant
3. Decrease abuse + rebound

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10
Q

ADHD
2nd line
Ngắn Trung DRag (kéo lê)

A
  1. short/intermediate acting: 3-8 hours
    Ritalin IR/SR (Methylphenidate) 8h
    Dexedrine (Dextroamphetamine) 4-8h
  2. Atomoxetine (Strattera) upto 24h
  3. Guanfacine (Inutive XR) upto 24h
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11
Q

ADHD
Failure of methylphenidate, do next?

A

Trial of amphetamines
and vice versa
before 2nd line

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12
Q

ADHD
Onset of action
Stimulant and non-stimulant

A

Stimulant 1-3 wks
Non-stimulant: 4-8 wks, up to 12 wks (=> 1-3 months)

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13
Q

Stimulants MAMa
Block reuptake of dopamine and norepinephrine

A

Methylphenidate
Amphetamines
Mixed amphetamines

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14
Q

ADHD
Stimulant: avoid and caution, affect on children

A

Avoid: psychiatric comorbidities
Caution: CV comorbidities
Affect on childern: Growth (minimal + insignificant), decrease Weight and height

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15
Q

ADHD
Norepinephrine reuptake inh

A

Atomoxetine
Onset: 2-4 wks
Max benefit: 6-8 wks
Titrate q14d

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16
Q

ADHD
Compare Atomoxetine with stimulants

A

Less effective
Less grow depression, sleep disturbance

High: Sedation => monitor suicidal ideation

Increase QT, severe hepatotoxicity
Metabolized by CYP2D6

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17
Q

ADHD
Selective alpha 2a receptor agonist

A

Guanfacine
Similar to clonidine
MOA: reduce norephedrine release, increase blood to brain
Max benefit: 4 wks
Titrate q14d => Stop abruptly: rebound (increase HR+BP)
Mono or adjunct to stimulants
Less effective than stimulants

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18
Q

ADHD
3rd for “comorbid”

A

Depression: bupropion, venlafaxine, TCAs (desipramine), SSRI (1st), + stimulants => monitor: serotonin Sx
TICS (Tourette syndromes: nervous, lặp lại hành động, càu nhàu…), hyper-impulsivity: clonidine
modafinil

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19
Q

ADHD
Decrease dose to manage SE
myrxtx: stop and reevaluate

A
  1. Irritability, aggression, mani: decrease dose or d/c + reassess
  2. TICS/abnormal movement: decrease dose or atomoxetine/clonidine: instead
  3. Increase HR/BP: decrease dose or change stimulant formulation. Atomoxetine instead
  4. Hallucination: ONLY d/c stimulant + reassess.
20
Q

ADHD
Decreased growth SE

A

Drug holiday during summer
Atomoxetine: instead

21
Q

ADHD
Headache, stomachache

A

Headache: divided dose with food. Use analgesic
Stomache: full stomach

22
Q

ADHD
Insomnia

A

Earlier in the day
Change formulation to intermediate

23
Q

ADHD
Anorexia

A

Given with high calorie meal (morning and HS)

24
Q

ADHD
Extended “drug holidays” from stimulants

A

Not recommended:
children moderate to severe ADHD (doing well on stimulants)

25
Q

ADHD
4 weeks of school year

A

avoid stop or start medication within this time

26
Q

ADHD
Vyvanse least likely SE

A

Weigh gain

27
Q

ADHD
Best option for combined ADHD
a. Ritalin IR
b. Adderall XR
c. Concerta
d. Atomoxetine

A

b. Adderall XR

28
Q

amphetamine based D.A.V
ám Cục Dược

A

Dexedrine (dextroamphetamine immediate-release tablets 3–5 h, sustained-release, 6–8 h)
Adderall XR (mixed salts amphetamine extended-release capsules 10-12h, 50% IR, 50% DR)
Vyvanse (lisdexamfetamine 13–14 h)

29
Q

Methylphenidate-based Agents
Mấy Thím thích R&B Fan Club

A

Ritalin (immediate-release tablets 3-4h, methylphenidate sustained-release tablets 3-8h)
Biphentin (methylphenidate controlled-release capsules 10-12h, 40% IR, 60% gradual effect))
Foquest (methylphenidate controlled-release capsules 16h 20% IR, 80% delayed controlled)
Concerta (methylphenidate bilayer controlled-release tablets 12h, 22% IR, 78% LA)

30
Q

Alpha2-adrenergic Agonists - Avoid concurrent use with TCAs
Ủng hộ GÁC A2

A

Clonidine
Guanfacine (Intuniv) - caution: + CYP3A4 inh (clarithromycin, ketoconazole) => increase [guanfacine]
CYP3A4 inducer (CBZ, phenobarbital, phenytoin, rifampin, dexamethasone) => decrease [guanfacine]

31
Q

Norepinephrine Reuptake Inhibitors
No Auto chiến lược (Strategy) hạn chế reuptake

A

Atomoxetine, Strattera
Weight based dosing for <70kg & > 70kg

32
Q

Pregnancy

A

Non-pharm
amphetamine + Dextroemphetamine
Safe but less effective: TCAs, bupropion, venlafaxine
Caution: methylphenidate, atomoxetine, clonidine/1st trimester, lisdexamfetamine, guanfacine (no report)
Avoid: risperidone

33
Q

Breastfeeding

A

Non-pharm
Monitor breastfed infant when use 1st ( methyphenidate, amphetamine), 3rd (TCAs, bupropion, venlafaxine)
No report: 2nd (atomoxetine)
Decrease milk production: Clonidine, guanfacine

34
Q

Stimulants
AE common, continue trial
Ăn kém, ngủ kém

A

Anorexia
Weight loss
Abdominal pain

Insomnia
Irritability
Dizziness
Headache

35
Q

Stimulants DI

A

Avoid MAOi (phenelzine, tranylcypromine, moclobemide) => hypertensive increase
Theophylline
SSRIs, SNRIs: serotonin syndrome
methyphenidate: wafarine, CBZ, phenytoin, phenobarbital…

36
Q

iMCQ Before initiating stimulant therapy in a patient with ADHD, which of the following does need to be done during an investigation.

A

b. Height and weight
c. Heart rate
d. Blood pressure

37
Q

iMCQ How these nonpharmacologic options are compared to stimulants

A

Non-pharms are less effective at reducing the core symptoms of ADHD.

38
Q

iMCQ Bupropion: The psychostimulants used in the treatment of ADHD?

A

Bupropion is NOT a psychostimulant but rather an antidepressant

39
Q

iMCQ Which of the following should NOT be crushed or chewed?

A

I. Adderall XR
II. Vyvanse
III. Dexedrine Spansules
IV. Concerta

40
Q

iMCQ What percentage of patients with ADHD will respond to psychostimulant treatment?

A

70-75%

41
Q

iMCQ If there is no response to a psychostimulant after two sufficient trials of approx. 3-4 weeks, then?

A

atomoxetine can be added to current treatment.

42
Q

Extended drug holidays, e.g., several months over the summer holidays, in children with moderate to severe ADHD symptoms who are doing well on the medication.

A

generally not recommended

43
Q

Abrupt discontinuation of stimulants in some individuals, especially if they have been treated for prolonged periods (> 3months) and/or at maximum doses

A

may cause withdrawal symptoms
tapering over several weeks

44
Q

Avoid risk of hypertensive crisis if abruptly discontinued alpha2-adrenergic agonists

A

must be tapered by less than or equal to 1 mg every 3–7 days

45
Q

What is associated with less withdrawal than other agents?

A

Atomoxetine

46
Q

Bipolar disorder + ADHD

A

Treat Bipolar Disorder first.
Treatment of ADHD can be offered when Bipolar Disorder is stabilized.
Refer to specialist.

47
Q

Major Depression + ADHD

A

Treat the most impairing disorder first. Moderate to severe depression should be treated first and suicide must be assessed in all cases. Dysthymia and mild depression may benefit from ADHD treatment first.
Stimulants can be combined with the majority of antidepressants when monitored. Also consider CBT.
In adults, Bupropion and Desipramine may reduce ADHD symptoms, but with an effect size significantly lower than psychostimulants.

May 2023 (9 decks)

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