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
What is the management of hallucinations of stimulants?
D/c stimulant, reassess diagnosis
What is the management of sudden cardiac death risk of stimulants?
- Risk no greater in clinical trials than general population - assess risk of cardiac structural abnormality and family hx
- If concern, cardiac ECHO
What are the monitoring parameters of stimulants?
- Appetite
- Behavior
- BP
- Growth rate (height/weight)
- HR
- Sleep
- ECG may be considered based on cardiac risk
Which drugs are alpha 2 agonists?
- Intuniv (guanfacine ER)
- Kapvay (clonidine ER)
What substrate is intuniv (guanfacine ER)?
3A4 substrate
What must be done if pt wanted to d/c alpha 2 agonists?
Must be tapered if d/c to avoid rebound HTN
Which drugs are NE reuptake inhibitors?
- Atomoxetine (strattera)
- Viloxazine (Qelbree)
What substrate is atomoxetine (strattera)?
2D6
What is dosing of atomoxetine (strattera) based on?
Weight based dosing
How must viloxazine (qelbree) be taken?
Swallow capsules whole or put in applesauce
What substrate is viloxazine (qelbree)?
2D6/UGT substrate
What inhibitor is viloxazine (qelbree)?
Strong 1A2 inhibitor
What are AEs of atomoxetine and viloxazine?
- Increased HR and BP
- increase in suicidal thinking (boxed warning)
What are AEs of clonidine and guanfacine?
- Decreased HR and BP, orthostasis
- Somnolence
- Dizziness
- Rebound HTN if abrupt d/c
What are monitoring parameters of non-stimulants?
- Appetite
- Behavior
- BP
- Growth rate (height, weight): atomoxetine
- HR
- LFTs (atomoxetine)
- Sleep
Is bupropion FDA approved for ADHD?
No
What inhibitor is bupropion?
2D6
What is bupropion CI in?
CI in seizure disorders and eating disorders
Is TCA more effective than methylphenidate?
No
What is a big concern w TCAs?
Cardiac concerns - sudden cardiac death in children, lethal in overdose
When would atypical antipsychotics be useful in a pt w ADHD?
May be useful if there is comorbid bipolar disorder, conduct disorder, intermittent explosive disorder
Can atypical antipsychotics be used as monotherapy for ADHD?
No
What are the AAP tx guidelines for preschool age pts?
- 1st line: parent training in behavior management (PTBM)
- 2nd line: PTMB + FDA approved med
What are the AAP tx guidelines for elementary and middle school age?
1st line: FDA approved med + PTBM
What are the AAP tx guidelines for adolescents (age 12-18)?
1st line: FDA approved med, may offer PTBM
What are the APP med recommendations for preschool age pts?
- 1st line: methylphenidate
- Non stimulant meds are not FDA approved for this age group
What are the APP med recommendations for elementary/middle school/adolescent pts?
- 1st line: stimulants
- 2nd line: atomoxetine, guanfacine ER, clonidine ER
What are the APP med adjunctive tx recommendations?
- May be considered if stimulant is not fully effective or limited by SEs
- Only guanfacine ER and clonidine ER have evidence as adjuncts to stims
What does the NICE: ADHD 2018 guidelines for adults recommend?
- Methylphenidate (short or LA) OR lisdexamfetamine [if no response, switch]
- Dextroamphetamine (if unable to tolerate lisdexamfetamine long half life)
- Atomoxetine (if no sx response to above agents)
