59. Attention Deficit Hyperactivity Disorder (ADHD)

Question 1

Which of the following medications are centrally-acting alpha agonists? (Select ALL that apply.)

A. Modafinil
B. Armodafinil
C. Clonidine extended-release
D. Guanfacine extended-release
E. Atomoxetine

Answer 1

C, D. Kapvay and Intuniv are centrally-acting alpha agonists. Both agents (as clonidine and guanfacine) are old blood pressure drugs that are having a resurgence as ADHD drugs.

Question 2

A father is picking up a stimulant prescription for his thin, eight year-old son who is beginning therapy for ADHD. The father mentions that his son is a poor eater and he hopes he does not lose weight on this medication. The pharmacist can include the following helpful advice: (Select ALL that apply.)

A. The child’s height and weight should be monitored regularly by the physician.
B. The stimulant can be taken at dinner and bedtime, as this will lessen the loss of appetite.
C. Pack healthy snacks for the child to eat at school.
D. It is important to eat a good, healthy breakfast that includes protein; this will help your child maintain weight and concentrate well in school.
E. If the child has difficulty eating during the day, it is possible to use a “patch” formulation that is applied at night, to help your child eat more during the day. If this would be helpful, please ask your child’s doctor.

Answer 2

A, C, D. Stimulants are never taken before sleep; they cause insomnia.

Question 3

Stimulants used for ADHD are scheduled by the DEA as the following controlled category:

A. C I
B. C II
C. C III
D. C IV
E. C V

Answer 3

B. This is a controlled medication (C II). It has a potential to be abused. The medicine should not be shared and must be stored where it cannot be taken by the wrong person or stolen.

Question 4

A patient gave the pharmacist a prescription for Vyvanse 30 mg daily #30. Vyvanse contains the following compound:

A. Lisdexamfetamine
B. Dexmethylphenidate
C. Methylphenidate transdermal patch
D. Methylphenidate IR-extended release
E. Methylphenidate

Answer 4

A. The generic name of Vyvanse is lisdexamfetamine.

Question 5

Shannon is an eighth grade “C” student who has difficulty focusing in school and is disruptive and angry. The school psychologist referred the family to a psychiatrist who started Shannon on atomoxetine 40 mg daily and told her family to schedule a follow-up appointment. Select the correct statements concerning atomoxetine: (Select ALL that apply.)

A. Atomoxetine requires adjunctive therapy with olanzapine when used in teenagers.
B. Atomoxetine can decrease appetite.
C. Atomoxetine is not controlled.
D. Atomoxetine is a selective norepinephrine reuptake inhibitor, and can cause headache.
E. Atomoxetine requires close monitoring during initiation and dose titrations for worsening of mental behavior.

Answer 5

B, C, D, E. Children and adolescents treated with atomoxetine (Strattera) should be closely monitored for clinical worsening, as well as agitation, irritability, suicidal thinking or behaviors, and unusual changes in behavior, especially during the initial few months of therapy or when the dose is changed.

Question 6

A patient gave the pharmacist a prescription for Daytrana. Which of the following is an appropriate generic substitution forDaytrana?

A. Lisdexamfetamine
B. Dexmethylphenidate
C. Methylphenidate transdermal patch
D. Methylphenidate IR-extended release
E. Methylphenidate

Answer 6

C. The generic name of Daytrana is methylphenidate transdermal patch.

Question 7

A patient was using methylphenidate ext-release for ADHD. It helps somewhat but the psychiatrist felt that an addition ofKapvay might be useful. Which of the following statements concerning Kapvay are correct? (Select ALL that apply.)

A. Kapvay is stimulating and should be taken in the morning.
B. Common side effects are tachycardia and dry mouth.
C. Kapvay can be used alone, or in addition to another ADHD medication.
D. If stopped suddenly, the patient’s blood pressure could shoot up quickly; titrate off if discontinuation is required.
E. Kapvay contains extended-release clonidine.

Answer 7

C, D, E. Clonidine is sedating; this is started QHS but is generally increased to twice daily dosing. Common side effects are bradycardia, sedation and dry mouth.

Question 8

Stimulant medications used for ADHD in children are filled monthly. During each visit (or sometimes less frequently) the following should be monitored: (Select ALL that apply.)

A. Height and weight
B. Blood pressure
C. Heart rate
D. ECG
E. ADHD symptoms, and the child’s mood

Answer 8

A, B, C, E. Some prescribers post-date three months worth of prescriptions, but the patient can get only one-month filled at a time. An ECG may have been checked prior to starting the stimulant medication. In some cases the BP and HR is checked monthly, and the height and weight less frequently.

Question 9

Medication Guides, or MedGuides, contain important safety information. They contain FDA-approved patient education and are considered part of a drug’s labeling. Choose the correct statements concerning MedGuides: (Select ALL that apply.)

A. Instruct the patient to review the MedGuide for important safety information-dispense with each new prescription and with each refill.
B. Instruct the patient to review the MedGuide for important safety information-dispense with each new prescription-refills do not require a MedGuide.
C. Atomoxetine does not require a MedGuide.
D. Stimulants used for ADHD require a MedGuide.
E. Stimulants used for narcolepsy, such as Provigil, require a MedGuide due to the risk of worsening psychiatric symptoms and risk of suicide.

Answer 9

A, D. The stimulants and atomoxetine require a MedGuide, with each new prescription and refill. The MedGuide warning for stimulants involves psychiatric and heart-related problems. The MedGuide warning for atomoxetine concerns suicidal thoughts in children and teenagers, worsening psychiatric problems, liver damage and heart problems. Stimulants used for narcolepsy, such as Provigil, require a MedGuide due to the risk of severe rash.

Question 10

Which of the following ADHD medications releases the medication as immediate-release and extended-release in an OROS delivery system?

A. Adderall
B. Vyvanse
C. Focalin
D. Concerta
E. Daytrana

Answer 10

D. With Concerta, the most popular ADHD medication (also in the generic formulation), the capsule’s outer coat dissolves fast to give immediate action, and the rest is released slowly. With this formulation the child takes one dose in the morning, has medication on-board for homeroom period, and does not require noon-time dosing in the nurse’s office.

Question 11

A patient gave the pharmacist a prescription for Ritalin 2.5 mg BID. Choose the correct name for the generic component inRitalin immediate release.

A. Dextroamphetamine
B. Methylphenidate
C. Lisdexamfetamine
D. Dexmethylphenidate
E. Amphetamine

Answer 11

B. The generic name of Ritalin is methylphenidate.

Question 12

A hospital nurse has variable work shifts at the hospital. She went to a physician complaining of trouble staying awake and was given a prescription for Provigil. Choose the correct statements concerning Provigil: (Select ALL that apply.)

A. The generic name is modafinil.
B. It is a C II agent.
C. Side effects include somnolence.
D. It is also approved for insomnia.
E. Dispense MedGuide due to the risk of severe rash.

Answer 12

A, E. Modafinil (Provigil) is a C IV agent. It is commonly used for narcolepsy. Other indications are obstructive sleep apnea/hypopnea syndrome, and shift work disorder. It promotes wakefulness, not sleep.

Question 13

Stimulant medications used for ADHD include the following warnings: (Select ALL that apply.)

A. Risk of lymphoma or other cancers
B. Risk of heart-related problems
C. Risk of psychiatric problems
D. Risk of abuse/diversion
E. Risk of severe skin rashes

Answer 13

B, C, D. Stimulants carry warnings for risk of heart related problems and new or worsened psychiatric problems. They have potential for dependency and should not be stopped abruptly.

Question 14

Which of the following ADHD medications contains both dextroamphetamine and amphetamine?

A. Adderall
B. Vyvanse
C. Focalin
D. Concerta
E. Daytrana

Answer 14

A. Adderall contains dextroamphetamine and amphetamine (mixed salts). Adderall XR is a popular drug used for ADHD in adults, and occasionally, in children.

Question 15

A pharmacist is dispensing atomoxetine to an adult patient who has a history of alcohol and drug abuse. The pharmacist should be careful to include these counseling statements: (Select ALL that apply.)

A. This drug can be abused; do not share with others and store in a safe place.
B. Use caution when driving or operating machinery while taking this medication.
C. If you develop nausea with a decrease in appetite, malaise (weak, lack of energy) or abdominal pain, you should be seen by a healthcare provider quickly.
D. Be careful to avoid eating fatty foods due to risk of weight gain and elevated blood sugar with this medication.
E. This medication is useful for headaches.

Answer 15

B, C. Atomoxetine can cause liver damage (rarely, but possible). Symptoms of liver damage can include nausea, loss of appetite, vomiting, diarrhea, malaise, and abdominal pain in the upper right part of the stomach (near the liver). Atomoxetine does not cause weight gain. It can decrease appetite (anorexia).

Question 16

Carmen is a 13 year old freshman in high school. Her younger brother takes methylphenidate extended-release 54 mg Q AM for ADHD. Carmen decided to take one of his tablets to help her stay awake in order to prepare for a biology exam. Two hours post-ingestion Carmen complained to her mother that she was feeling “completely wired out” and couldn’t think straight. Her mother got scared and took Carmen to the 24-hour emergency care clinic. Carmen had a blood pressure of 144/88 and a heart rate of 122 beats per minute. She had no obvious psychosis, seizure activity or any other medical condition. The intake nurse noted that the patient was suffering from likely amphetamine toxicity with an elevated BP and HR. What is the best course of action for Carmen at this time?

A. Flumazenil, given to reverse the symptoms of amphetamine toxicity.
B. Naloxone, given to reverse the symptoms of amphetamine toxicity.
C. A sedative such as lorazepam, given by injection, followed by observation.
D. Haloperidol, to control symptoms.
E. Chlorpromazine, to control symptoms.

Answer 16

C. There is no specific antidote for amphetamine toxicity. In milder cases a sedative with observation is used. Antihypertensives may be required; the usual drug of choice in this case would be beta blockers, to reverse the hypertensive effects from amphetamines. If the patient had psychosis she might require an antipsychotic in addition to the benzodiazepine. Seizures can be present with severe overdose and would require treatment. Psychosis and seizures are more likely following injection.

Question 17

A patient was using methylphenidate extended-release for ADHD. It helps somewhat but the psychiatrist felt that an addition of Intuniv might be useful. Which of the following statements concerning Intuniv are correct? (Select ALL that apply.)

A. Intuniv should not be taken with high-fat foods.
B. Common side effects are akathisia and agitation.
C. Intuniv can be used alone, or in addition to another ADHD medication.
D. Intuniv is a CYP 3A4 inducer.
E. Intuniv contains extended-release guanfacine.

Answer 17

A, C, E. This drug is well-tolerated overall, but possible side effects are somnolence, hypotension, bradycardia and headaches. It can also cause nausea and upper GI pain. Intuniv is a CYP 3A4 substrate (not an inducer, or inhibitor); the concentration of the Intuniv can be increased or decreased by other drugs.

Question 18

Choose the correct brand name for the long-acting formulation of clonidine approved for ADHD:

A. Tenex
B. Intuniv
C. Kapvay
D. Strattera
E. Nuvigil

Answer 18

C. The brand name of clonidine extended-release is Kapvay.

Question 19

A patient gave the pharmacist a prescription for Focalin 5 mg BID. Which of the following is an appropriate generic substitution for Focalin?

A. Dexmethylphenidate
B. Methylphenidate transdermal patch
C. Methylphenidate IR-extended release
D. Methylphenidate
E. Lisdexamfetamine

Answer 19

A. The generic name of Focalin is dexmethylphenidate.

Question 20

Which of the following drugs is considered to have a lower risk of abuse since the drug requires conversion to an active stimulant and a quick “high” is averted?

A. Vyvanse
B. Ritalin
C. Ritalin SR
D. Adderall XR
E. Focalin

Answer 20

A. Vyvanse is a pro-drug that is converted via first pass intestinal and hepatic metabolism. Snorting or injection bypasses this step and the quick “high” is not as quick as hoped for by the person injecting. Concerta is difficult to abuse as well since it is hard to chew or crush.

Question 21

The pharmacist is counseling the parent of an 11-year old boy who has received an ADHD diagnosis and will begin therapy with methylphenidate sustained release. The following counseling points should be conveyed to the parent. (Select ALL that apply.)

A. Your child will have increased appetite initially; make sure that he does not overeat (eventually the appetite will decrease).
B. Report at once if the child is seeing or hearing things that are not real, believing things that are not real, or are acting suspicious.
C. This medicine has the potential to be abused; store the medicine where it cannot be taken by the wrong person or stolen.
D. Report at once if the child has chest pain, shortness of breath, or fainting.
E. The medication is likely to be increased when you return to the prescriber (unless the child has good relief from the starting dose); it is normal to require a stronger dose than the starting dose.

Answer 21

B, C, D, E. Stimulants should not be used in patients with heart problems or serious psychiatric conditions. Report at once if the child has chest pain, shortness of breath, or fainting. Report at once if the child is seeing or hearing things that are not real, believing things that are not real, or is suspicious. All stimulants require a MedGuide.

Question 22

An eight year old boy is impolite to his mother and barely responds to her requests to do his schoolwork or clean up messes. However, he is relatively well behaved at school and the teacher does not consider him to possess behavioral problems. The parents reported that the symptoms started about 6 months ago and he has become very difficult to manage. They have requested that the physician prescribe an ADHD drug. They were provided with a prescription forConcerta. Select the correct statement:

A. The use of Concerta does not meet recommended criteria.
B. The use of Concerta is appropriate.
C. Focalin XR would be a better option.
D. The Daytrana patch would be a better option.
E. Adderall XR would be a better option.

Answer 22

A. To be treated for ADHD, the child must have symptoms of inattention and symptoms of hyperactivity/impulsivity. Impairment from the symptoms must be present in 2 or more settings (e.g., at school or work and at home). In this case, since the child is reported to behave well in school, it is more appropriate to guide the mother in ways to help direct her son’s behavior. The symptoms should also have begun at an earlier age.

Question 23

Choose the correct counseling statement for the Daytrana patch:

A. Place on right hip one morning, left hip the following morning; alternate daily
B. Alternate the hip where the patch is placed bi-weekly
C. Alternate the hip where the patch is placed each week
D. Hold the patch on skin for 7 seconds
E. Remove the patch during bathing or showering

Answer 23

A. The patch is applied to the hip area in the morning (avoid waistline on pants as it may cause it to rub off; the patch was designed before the popularity of pants that hang around the hips.) It is applied two hours before the desired effect and replaced each morning. The hips are rotated each day: left hip on odd days, right hip on even days. Instruct the patient to hold the patch on the skin for 30 seconds and smooth down the edges. If applied correctly, the patch should stay on during bathing and swimming.

Question 24

Which of the following statements concerning Intuniv or Kapvay are correct? (Select ALL that apply.)

A. Both clonidine and guanfacine are activating; the child may require diphenhydramine for sleep.
B. Guanfacine is a CYP 3A4 substrate; higher doses will be required if taken with 3A4 inducers and lower doses will be required if taken with 3A4 inhibitors.
C. Both clonidine and guanfacine come as other formulations; do not use concurrently.
D. Both clonidine and guanfacine lower blood pressure (and were originally used as blood pressure drugs); use caution with other drugs that lower blood pressure.
E. Both clonidine and guanfacine are sedating; use caution with other CNS depressants.

Answer 24

B, C, D, E. Somnolence is sedation.

Question 25

The pharmacist is counseling the parent of a child who has received an ADHD diagnosis and will begin therapy with FocalinXR. The following counseling points should be conveyed to the parent:

A. The capsules can be opened and mixed with any cold juice or cereal.
B. The capsule contents can be sprinkled on applesauce (if not warm and used right away-swallow, but do not chew).
C. The capsule contents can be sprinkled on applesauce. The medicine, once mixed in applesauce, cannot be stored longer than 4 hours.
D. The capsules cannot be opened; if your child cannot swallow the capsule, please ask your doctor for a capsule that can be opened or for a patch formulation; this drug comes in other formulations.
E. The capsule contents can be mixed in 4 ounces (1/2 cup) cold water only.

Answer 25

B. Patient instructions for Focalin XR include the following: Swallow capsules whole with water or other liquids. Do not chew, crush, or divide the capsules or the beads in the capsule. If you or your child cannot swallow the capsule, open it and sprinkle the small beads of medicine over a spoonful of applesauce and swallow it right away without chewing.

Question 26

A patient gave the pharmacist a prescription for Strattera. Choose the correct statements concerning Strattera: (Select ALLthat apply.)

A. The generic name is atomoxetine.
B. A two week wash-out period is required between atomoxetine and Nardil.
C. The capsule contents can be sprinkled on a spoonful of applesauce. The medicine, once mixed in applesauce, cannot be stored and should not be chewed.
D. Common side effects include headache, somnolence, xerostomia and decreased appetite.
E. It is a selective norepinephrine reuptake inhibitor.

Answer 26

A, B, D, E. Stimulants are first-line agents for ADHD, however atomoxetine is sometimes used first if abuse potential is suspected. Or, atomoxetine can be tried if a patient has failed trials of different stimulant agents. Do not open the capsule; swallow whole.

Question 27

A mother reports that her child, who started methylphenidate BID approximately two weeks ago, is having trouble sleeping since beginning the medication. Which of the following statements are correct? (Select ALL that apply.)

A. The child can use Kapvay in the morning.
B. If the child is taking the second dose late in the day, instruct the parent that both doses can be taken with breakfast.
C. Taking a long-acting medicine that is dosed once daily in the morning may be helpful since a dose is not taken later in the day.
D. Clonidine, taken QHS, may be helpful.
E. Diphenhydramine, taken QHS, may be helpful.

Answer 27

C, D, E. Once daily formulations (and the older twice daily) often cause night-time sleep problems, and a sleep agent may be required. If an agent is needed for sleep, it is given at bedtime.

Question 28

A pharmacist is dispensing Vyvanse to a patient who is beginning therapy for ADHD. Correct counseling statements include the following. (Select ALL that apply.)

A. The capsule contents can be mixed with a small amount of applesauce if taken right away; do not chew the applesauce.
B. The capsule contents can be opened and mixed in water.
C. Nausea is possible, especially when the medicine is being started or during the initial time when the dose is being increased by the doctor.
D. It is important to eat a healthy breakfast before the medicine kicks in; it can decrease your appetite during the day.
E. This medication has a Medication Guide that describes the most important safety considerations; please take the time to read it.

Answer 28

B, C, D, E. Vyvanse is not mixed with applesauce. Instead, the contents can be mixed with a small amount of water if taken right away. It cannot be left around or the long-acting beads will dissolve. Put some more water in the glass afterwards and drink that, too, to get the full dose.

Question 29

David is a fifth grade student who was recently diagnosed with ADHD and given a prescription for Concerta 54 mg daily. The first day he took the medication, David complained of nausea and abdominal pain. That afternoon, the smell of his teacher made him complain vocally which earned the child detention. Select the correct statement:

A. The starting dose was too low.
B. The starting dose was too high.
C. Concerta is not an appropriate choice in a boy of this age.
D. Methylphenidate would be a more appropriate option.
E. The pharmacist should recommend meclizine, given QAM with the stimulant dose.

Answer 29

B. Stimulant medications commonly cause abdominal pain and nausea. In this case, the starting dose was too high and, consequently, the GI complaints were worsened. An appropriate starting dose of Concerta is 18 mg.

Question 30

Choose the correct brand name for the long-acting formulation of guanfacine approved for ADHD:

A. Tenex
B. Intuniv
C. Kapvay
D. Strattera
E. Nuvigil

Answer 30

B. The brand name of guanfacine extended-release is Intuniv.