3 - ADHD Flashcards
What are the 3 hallmark symptoms?
- hyperactivity
- impulsivity
- inattention
When do symptoms present?
usually before age 12, can persist into adulthood
*late-onset ADHD can also occur
For the diagnosis of ADHD, what do the symptoms need to cause and where do they need to be present and for how long?
- need to cause interference with normal development
- present in 2 or more settings (home, school, sports, etc.)
- present for > 6 months
Medications are as effective as therapy, so why bother with therapy?
- Therapy provides coping methods for both child and parent/caregiver
- Gives the child tools to practise and use in the future when they potentially come off of ADHD medication
What are non-pharms?
- Therapy!! (very important)
- exercise
- sleep
- dietary restrictions (reduce sugars, dyes, preservatives) - this is not based on evidence but observation
What are the two MAIN classes of drugs for ADHD?
Stimulants:
- dextroamphetamine (Dexedrine)
- methylphenidate (Concerta, Ritalin)
- mixed salts amphetamine (Adderall)
- lisdexamfetamine (Vyvanse)
Non-stimulants:
- atomoxetine
- guanfacine
- clonidine
What is first line for ADHD?
stimulants
What are some contraindications to stimulant use?
- CV disease
- MAOi use
- History of drug abuse
How long should a trial of stimulants be?
3-4 week trial is reasonable
improvement in symptoms observed in the first week
reasonable to continue for 6-12 months
If no response at 3-4 weeks, then what?
switch stimulants
Can stimulants affect weight and height?
- Yes - long term stimulants may decrease height and weight
- Get a baseline measurement and then need to monitor growth every 3-6 months (dose-dependent s/e)
Are drug holidays a good idea?
Yes - good way to reassess need - do this for a few weeks in the summer.
If diversion of stimulants is suspected, what do you do?
Switch to a non-stimulant:
- Atomoxetine (Straterra)
- Guanfacine (Intuniv)
**lower abuse potential
Out of the stimulants, what is first line?
long-acting agents should be first line
- amphetamine, methylphenidate, lisdexamfetamine
- once daily dosing, less abuse potential
What is atomoxetine and who is it used for?
- NE reuptake inhibitior
- used for those > 6 yo with ADHD
- not a stimulant, not a controlled substance
How long do you need to treat for with atomoxetine to assess efficacy?
- 6-12 weeks
- may take 3-4 weeks too see benefit
Contraindications to atomoxetine?
- CV problems
- narrow angle glaucoma
- MAOi use
List the alpha 2 agonists used for ADHD
- clonidine
- guanfacine
What ADHD symptoms do alpha 2 agonists help with?
- less benefit for inattention
- help with aggression, hyperactivity, impulsivity
Compare clonidine and guanfacine
Guanfacine has more selective neuronal activity and longer DOA, resulting in less sedation and less hypotension
Antidepressants role in ADHD?
2nd or 3rd line or adjunctive tx
What antidepressants can be used in AHDD?
- Buproprion (NDRI) - moderately effective for ADHD
- Venlafaxine (some evidence for it)
- TCAs (short term) - less effective than stimulants
Out of the antipsychotics, which one can be used for ADHD?
low doses of risperidone (does not help with inattention)
What stimulants are safe in pregnancy?
amphetamine and dextroamphetamine
*one study with 1.8 million pregnancies showed they were not associated with increase risk of congenital malformations or cardiac malformations
Caution which stimulant in pregnancy, especially 1st trimester?
methylphenidate (Concerta, Ritalin)
*may be associated with elevated risk of cardiac malformations
What are other options for ADHD in pregnancy?
TCAs, venlafaxine, bupropion
- appear to be safe
- but less effective for ADHD
For breastfeeding, is methylphenidate safe?
- transfer of methylphenidate into breast milk appears to be low, but effects on neurological development have not been studied
- monitor baby for agitation and poor weight gain
For breastfeeding, are amphetamines safe?
- they are transferred into breast milk
- but use appears to be safe, although neurological impact on the infant is also unknown
- monitor for insomnia, agitation, irritability and poor weight gain in the infant
Is atomoxetine safe in breastfeeding?
no studies done
Are alpha 2 agonists safe in breast-feeding? (clonidine and guanfacine)
- they may decrease milk production
- may cause side effects (ex. hypotension) in the infant so other options are preferred
Can risperidone be used in breastfeeding?
limited information about this, use other agents instead
Can you use TCA, bupropion or venlafaxine in breastfeeding?
yes, monitor baby for sedation, weight gain and irritability
Which one can be mixed in water?
Vyvanse
Which ones can be opened and sprinkled into soft foods?
Adderall XR
Dexedrine spansules
Vyvanse and Biphentin capsules
stimulants can exacerbate ___ in some individuals
tics
____ alone or in combination with stimulants is also effective in improving both ADHD and tic symptoms in patients with both conditions
clonidine
