4.8 Pharmacotherapy of ADHD Flashcards
What increases someone’s chance for having ADHD?
Higher rate if a first-degree relative like a parent has ADHD
Is the etiology of ADHD multifactoral?
Yes (environmental, genetics, physiological)
How many children w ADHD will get diagnosed in adulthood?
1/3 of children
There is an increased risk of what if ADHD is left untreated?
Increased risk of substance use and antisocial personality disorder
What is the diagnostic criteria of ADHD?
- For each sx domain, must have at least 6 sxs present
- For older adolescents and adults (17 and older), at least 5 sxs are required for either of two specifiers
- Several inattentive or hyperactive sxs must be present prior to age 12
- Several inattentive or hyperactive impulse sxs are present in 2 or more settings
What are the sxs of the inattention domain?
- Fails to give close attention to details, makes careless mistakes
- Difficulty sustaining attention in tasks or play activities
- Doesn’t seem to listen when spoken to directly
- Doesn’t follow through on instructions, fails to finish hw, chores, duties in workplace
- Difficulty organizing tasks and activities
- Avoids, dislikes, reluctant to engage in tasks that require sustained mental effort
- Loses things necessary for tasks
- Easily distracted by extraneous stimuli
- Forgetful in daily activities
What are the sxs of the hyperactivity and impulsivity domain?
- Fidgets w or taps hands/feet, squirms in seat
- Leaves seat in situations when remaining seated is expected
- Runs about or climbs in inappropriate situations
- Unable to play or engage in leisure activities quietly
- Hyperactivity
- Talks excessively
- Blurts out answer before question is completed
- Difficulty waiting their turn
- Interrupts or intrudes on others
How fast are dose response effects seen w stimulants?
Short period of time
What are stimulant dosing considerations for pediatric pts?
Calculating a dose in pediatric pts based on mg/kg not found to be helpful as variations in dosing not found to be due to height or weight
What stimulant dosage formulation is preferred for pts weighing <16 kg?
IR preferred due to limited low-dose availability of long-acting stimulants
When should stimulant be given for ADHD?
Avoid giving dose too late in the day, may give an after-school dose
What requires longer-acting formulations?
Late afternoon sxs
Can a pt use two different stimulants?
No
Can a pt use two different dosage forms of the same stimulant?
Yes
What is special consideration for mydayis (mixed amphetamine salts)?
Max dose 25 mg/day (adults) or 12.5 mg (age 13-17) if CrCl <30-15 ml/min
What are special considerations for daytrana (methylphenidate)?
- Apply patch to outside of hip 2 hrs prior to needed effects, remove after 9 hrs (alternate hip daily)
- Reserved for those who respond to methylphenidate and would benefit from patch
What are special considerations for vyvanse (lisdexamfetamine)?
- Prodrug covalently linked to 1-lysine; converted to dextroamphetamine via 1st pass/hepatic metabolism
- All dosage forms MUST be swallowed whole
- Not useful in no response to dextromethorphan
What are special considerations for jornay AM (methylphenidate hydrochloride)?
- Take dose in evening between 6:30 and 9:30pm
- Must start w titration for dosing, do not switch mg per mg if pt already on IR methylphenidate
What are AEs of stimulants?
- Appetite loss
- Abdominal pain
- Headaches
- Sleep disturbances
- Decreased growth
- Hallucinations or other psychotic scs (rare)
- Increased BP (1-4 mmHg)
- Increased HR (1-2 bpm)
- Sudden cardiac death (rare)
- Priapism
- Peripheral vasculopathy (Reynaud’s)
What is the management of reduced appetite/ weight loss of stimulants?
High calorie meal when stimulant effects are low (breakfast, dinner)
What is the management of stomach ache of stimulants?
Give on full stomach, lower dose if possible
What is the management of insomnia of stimulants?
Dose earlier in day, lower last dose of day or give earlier, consider sedating med at bedtime
What is the management of rebound sxs of stimulants?
Longer acting stimulant trial, atomoxetine, antidepressant
What is the management of irritability, jitteriness of stimulants?
Assess for co-morbid conditions, reduce dose, consider mood stabilizer, or atypical antipsychotic
