4-22 Drugs for ADHD Flashcards
What is the triad of symptoms that characterize ADHD?
Inattentiveness, Hyperactivity, Impulsiveness
In addition to the ‘triad’, what else characterizes ADHD?
Triad: Inattentiveness, Hyperactivity, Impulsiveness
Maladaptive and Pervasive – occurs in more than 2 settings
Academic and Behavioral Problems
Onset Prior to Age 12
Probable Organic Cause - Exact Etiology Unknown
How prevalent is ADHD?
8.25 % of School Age Children
2 % of Adolescents (1:50)
- 8 % of 20 year-olds (1:125)
- 2 % of 30 year olds (1:500)
- 05 % of 40 year olds (1:2000)
What is the DSM criteria for ADHD?
EITHER: 6 or more symptoms of
Inattention and/or
Hyperactivity & Impulsivity
AND
Onset before age 12 years
Impairment in at least 2 Settings - (i.e., at school and at home)
Impairment in social, academic or occupational function
No other pervasive disorder
In addition to the DSM criteria, what else should be specified in an ADHD Dx?
Specify whether:
Combined presentation, i.e., both inattention and hyperactivity-impulsivity criteria are met for the past 6 months.
Predominantly inattentive presentation
Predominantly hyperactive/impulsive presentation
Specify if:
Partial remission
Current severity: mild, moderate, severe
What are the pitfalls in Dx’ing ADHD?
DSM criteria also describes NORMAL kids!
No Physical or Lab Markers
Significant Overlap w/ other diagnoses
Public Awareness, Misinformation
What are some things that ADHD is not?
ADHD is a biologic process
ADHD is not a disorder of morality
What kind of syndrome is ADHD? What things factor into causes?
ADHD is a behavioral syndrome, not merely a result of unreasonable expectations and a fast paced society.
ADHD is a behavior disorder with multiple presentations and multiple possible causes including genetic, brain injury, abnormal brain development, and environmental factors.
ADHD involves biochemical messengers
Dopamine, Norepinephrine, Epinephrine, others (?)
What is an important non-Rx Tx for ADHD?
Education:
Patient
Parent
Teachers and Caregivers
Physician
What do medications for ADHD increase?
compliance
peer acceptance
efficiency
on-task behavior
accuracy
short term memory
problem-solving
parent-child interactions
performance of motor tasks
Name some stimulants that can Tx ADHD.
methylphenidate (Ritalin, Methylin)
dexmethylphenidate (Focalin, Focalin XR)
Dextroamphetamine (Dexedrine)
amphetamine mixed salts (Aderall)
racemic amphetamine sulfate (Evekeo)
lisdexamfetamine (Vyvanse)
What are the different forms of methylphenidate?
Short-acting
(generic, Ritalin, Methylin ChewableTablets, Methylin Oral Solution)
Intermediate-acting
(Metadate ER, Ritalin SR)
Long-Acting
Metadate CD, Ritalin LA, Concerta,
Daytrana (patch), Quillivant XR (long-acting syrup), Aptensio XR
What is different about Vyvanse?
An oral prodrug that is converted to d-amphetamine and l-lysine by enzymatic hydrolysis. Longer duration than that of other amphetamine preparations, similar efficacy.
Cannot be crushed and then injected to get an amphetamine-like high.
What are the actions of stimulants on DA?
Psychostimulant actions:
Methylphenidate- increases DA by blocking reuptake of DA (similar to cocaine)
Amphetamines block DA reuptake and increase release of DA and NE by displacing natural neurotransmitter from storage vesicles (reverse transport)
What are the actions of atomoxetine on NTs, NT levels?
NE reuptake inhibitor
Unknown mechanism increases prefrontal cortex DA
What are the actions of amphetamine on neurons?
Mostly works on presynaptic neurons
- taken up into cell and causes DA release into synapse
- blocks uptake of DA and NE into vesicles
- diffuses into vesicles causing DA release into cytoplasm
- inhibits DA transporter protein
What is the action of methylphenidate? How common is it?
increases DA
Methylphenidate (MPH) is the active ingredient in the majority of stimulant medication in the U.S.
Effective in reducing symptoms of ADHD in both children and adults
Acts by blocking dopamine reuptake
Most preparations are mixtures of d- & l- enantiomers; the pure d-threo –methylphenidate is sold as dexmethylphenidate (Focalin)
What is the action of amphetamines?
increases NE, DA
What is the action of atomoxetine?
increases NE
What is the action of guanfacine or clonidine?
Decrease CNS sympathetic outflow
What is the expected benefit of stimulants?
Improved CONCENTRATION
evidence: better grades, etc.
All other benefits are secondary
What are the problems and some ADRs with stimulants?
Misinformation, Unrealistic Expectations
Controlled Substance
Adverse Effects
Sleep disturbance
Appetite Suppression
Tics
Anemias (rare)
What are the effects of intermediate-acting methylphenidate?
effects on behavior can be seen within 30 min
Duration 3-5 hours
Immediate-acting now often used concurrently with a long-duration product either to provide a boost early in the morning, or to smooth withdrawal in the late afternoon
Oral tablets and chewable tablets available
What are the characteristics of long-acting methylphenidate?
Slower onset, longer duration
Have become the mainstay of treatment
Sustained-release (SR), extended-release (ER, LA), or osmotic release (Concerta)
Up to 10-12 hr duration
Transdermal patch – (Daytrana)
