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Clinical 2 (Part B) > 6 - ADHD > Flashcards

6 - ADHD Flashcards

1
Q

What sort of questions do you want to know about someone presenting with ADHD symptoms?

A
  • severity
  • when they are happening
  • personality of patient
  • height and weight bc appetite may be affected
  • sleep patterns
  • symptom history
  • eating patterns
  • economics
  • potential for drug abuse
  • cardiac Hx
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2
Q

What 2 groups of symptoms are involved in diagnosing ADHD?

A
  • Inattentive symptoms

- Hyperactive/Impulsive symptoms

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3
Q

Do kids have to have both inattentive and hyperactive symptoms to be diagnosed with ADHD ?

A

Nope

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4
Q

What is the criteria for inattentiveness symptoms for ADHD?

A

> 6 symptoms of inattention > 6 months

  • does not give close attention to details or makes careless mistakes
  • trouble keeping attention
  • doesn’t listen when spoken to directly
  • often does not follow through on instructions and fails to finish schoolwork or chores
  • trouble organizing
  • often avoids things that take a lot of mental effort
  • often loses things
  • easily distracted
  • forgetful
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5
Q

What is the criteria for hyperactivity/impulsiveness symptoms for ADHD?

A

> 6 symptoms of hyperactivity-impulsivity > 6 months to an extent that is disruptive:

Hyperactive:

  • often fidgets
  • often gets up from seat when remaining in seat is expected
  • often excessively runs about or climbs when and where it is not appropriate
  • often has trouble playing or doing leisure activities quietly
  • is often on the go
  • talks excessively

Impulsive:

  • blurts out answers before questions have been finished
  • trouble waiting for their own turn
  • interrupts or intrudes others
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6
Q

Besides the symptoms of hyperactivity and inattentiveness what other criteria is required for ADHD diagnosis?

A
  • Some symptoms that cause impairment were present before the age of 12
  • Some impairment from the symptoms is present in two or more settings (school/work and at home)
  • There must be clear evidence of significant impairment in social, school or work functioning
  • The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorders. The symptoms are not better accounted for by another mental disorder (mood disorder, anxiety disorder, dissociative disorder, personality disorder)
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7
Q

Describe the diagnosis of ADHD in 1 sentence.

A

Symptoms of inattention or hyperactivity and impulsivity or all 3 must be present during childhood and cause functional impairment in 2 different settings for 6 months to meet diagnostic criteria for ADHD.

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8
Q

What types of ADHD are there?

A
  • Predominantly Inattentive Type (ADD)
  • Predominantly Hyperactive-Impulsive Type
  • Combined Type
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9
Q

Does a response to stimulants confirm the diagnosis of ADHD?

A

Nope - stimulants can positively impact children who do not have ADHD

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10
Q

There is a large degree of ________ associated with the disease

A

heritability

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11
Q

What comorbidities often cloud the diagnosis of ADHD?

A
  • anxiety/mood disorders
  • defiant disorders
  • conduct disorders
  • tic disorders
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12
Q

What are the 4 types of treatment arms in MTA study?

A
  • Med management alone
  • Behavior treatment alone
  • Combined meds & behaviour Tx
  • Routine community care
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13
Q

What were the results of the MTA study?

A

Medication management alone OR combined meds and behaviour treatment are NEARLY EQUALLY EFFECTIVE & SUPERIOR TO behaviour treatment alone or community based treatment

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14
Q

So based on the results of MTA study, should we just give medication?

A

*the data tells you to just use medication but the behavioural therapy has other benefits - it teaches parents and kids coping strategies

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15
Q

What is our primary goal in treating ADHD?

A

making them function well in school and work, want to see increased academic performance and job rates, etc.

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16
Q

What are some medical considerations that influence medication choice?

A
  • Treatment guidelines
  • Urgency of treatment
  • Duration of effect
  • Patient preference
  • Co-morbid symptoms
  • Previous treatment success
  • History of drug abuse (individual or family)
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17
Q

What are some practical considerations that influence medication choice?

A
  • Adherence
  • Stigma
  • Cost/insurance
  • Administration (by parent or teacher)
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18
Q

What are the 2 branches of medications for treatment of ADHD?

A
  • stimulants (most common)

- non-stimulants

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19
Q

Stimulants:

Describe methylphenidate short acting (immediate release)

A
  • short duration of action
  • BID or TID dosing
  • symptoms may return between doses
  • lunch time dose (involves school)
  • stigma
  • questions/compliance
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20
Q

Stimulants:
Describe Ritalin SR

[methylphenidate SR (sustained release)]

A

**THIS PRODUCT SHOULD NOT BE USED

Kinetics:

  • older SR technology - wax matrix
  • rarely used
  • theoretically extends to cover noon
  • 2 pm dose may be required
21
Q

Stimulants:
Describe Biphentin

[methylphenidate SR (sustained release)]

A

Pharmacare - covered part 1

Kinetics:

  • 40% immediate release, 60% gradual release
  • Effectives last 10-12 hours
  • 8 doses - makes easier titration
  • capsules can be opened and sprinkled
  • can directly convert from IR
22
Q

What is the problem with sustained release dosing?

A

Sometimes you’ll give SR in am for school then short acting right after school to get through homework this way it doesn’t affect sleep at bedtime

23
Q

Stimulants:
Describe Concerta

[methylphenidate SR (sustained release)]

A
  • uses OROS (osmotic-controlled release oral delivery system) technology
  • 22% immediate release 78% long acting release
  • effects last 10-12 hours
  • 18, 27, 36, and 54 mg caps
  • titration issues
24
Q

Stimulants:

Describe Dexedrine IR

Amphetamine-based short acting product

A
  • short duration of action
  • BID or TID dosing
  • symptoms may return between doses
  • lunch-time dose - involve school
  • stigma
  • questions/compliance
  • covered by pharmacare
25
Q

Describe the cost and coverage of Dexedrine Spansules

A
  • relative inexpensive (50 cents per capsule)
  • 10mg and 15mg available
  • pharmacare - covered
26
Q

Describe the Kinetics of dexedrine Spansules

A
  • effects last 6-8 hours

- shorter duration than other longer acting products

27
Q

Describe the cost and coverage of Adderall XR (mixed amphetamine salts)

A
  • $2.75/dose

- not covered by pharmacare

28
Q

Describe the kinetics of Adderall XR (mixed amphetamine salts)

A
  • mixed salts - but primarily dextro-amphetamine
  • effects last 10-12 hours
  • 50/50 delivery - immediate and delayed release
  • occasionally have to top up - late afternoon to extend activity
29
Q

Describe Vyvanse (Lisdexamfetamine)

A

Prodrug - therapeutically inactive - cleave L-lysine to give D-amphetamine

30
Q

Describe the dosing of Vyvanse (Lisdexamfetamine)

A
  • Starting dose 20-30mg daily am
  • Titration 7 days by 10mg
  • Max dose 60mg
31
Q

Describe the cost and coverage of Vyvanse (Lisdexamfetamine)

A
  • $4 per day
  • CDR - don’t list
  • covered by pharmacare (part 1 benefit)
32
Q

Describe the kinetics of Vyvanse (Lisdexamfetamine)

A
  • Effects last 13 hours in children
  • Capsule may be opened and diluted in water
  • Delivery not influenced by gastric pH or transit time
  • Reduced abuse potential (evidence ?)
33
Q

List 2 Non-stimulants

A
  • Strattera (Atomoxetine)

- Intuniv XR (Guanfacine)

34
Q

Non-stimulants:

MOA of Straterra (Atomoxetine)

A

selective inhibitor of the presynaptic norepinephrine transporter mechanism

35
Q

Non-stimulants:

Describe the dosing of Straterra (Atomoxetine)

A

3 step titration (capsules whole):

  • 0.5mg/kg x 10 days
  • 0.8mg/kg x 10 days
  • 1.2mg/kg x 10 days
  • 6 to 8 weeks for full effect
  • once daily
  • comorbid (enuresis, tic spectrum disorders, anxiety)
  • no substance abuse or diversion potential

enuresis = bed wetting

36
Q

Non-stimulants:

Describe the cost and coverage of Straterra (Atomoxetine)

A
  • $4 per day
  • CDR - don’t list
  • not covered by pharmacare
37
Q

Non-stimulants:

Describe the kinetics of Straterra (Atomoxetine)

A
  • Bioavailability increases from 64-94% in poor metabolizers
  • 1/2 life increases from 5.2 hours to 21.6 hours
  • 10 fold higher concentrations
  • 7% of caucasians, 2% african americans, <1% asians
38
Q

Non-stimulants:

AE of Straterra (Atomoxetine)

A
  • decreased appetite
  • ab pain
  • somnolence (sleepiness)
  • lower growth
  • CV issues (increased BP and HR)

Other potential concerns include: suicidal ideation, liver failure

39
Q

Non-stimulants:

MOA of Intuniv XR (guanfacine)

A

central alpha 2 adrenergic agonists - increases blood flow to prefrontal cortex - enhances working memory and executive functioning

40
Q 
Non-stimulants:
Intuniv XR (guanfacine) has a \_\_\_\_\_ half life and duration of action than clonidine
A

longer

41
Q

Non-stimulants:

SE of Intuniv XR (guanfacine)

A

less sedation and dizziness than clonidine but still lowers heart rate and blood pressure

42
Q

Non-stimulants:

Place in therapy for Intuniv XR (guanfacine) ?

A

2nd line mono therapy (not as effective as stimulants) or as adjunctive therapy

43
Q

Non-stimulants:

Describe the dosing of Intuniv XR (guanfacine)

A

Starting dose - 1mg daily

  • Increase by 1mg daily (not more quickly than weekly)
  • Maximum daily dose 4mg
44
Q

What safety concerns and SE are parents concerned with?

A

Cardiac:

  • sudden cardiac death not increased in general population
  • need to be concerned with kids with pre-existing cardiac conditions
  • monitor HR and BP

Growth:

  • can affect growth and weight
  • minor ?

Common SE:
-insomnia, anorexia, headache, weight loss, new onset tics, irritability

45
Q

What is included in the Vanderbilt Assessment Follow-up?

A
  • symptoms
  • performance/function
  • side effects
46
Q

Do ADHD drugs increase the risk of suicide?

A

No compelling evidence that it increases the rate of suicide, but something to keep in mind

47
Q

What is a drug holiday and what role dose it have in the treatment of ADHD ?

A
  • Summer holidays, weekends, spring break
  • Because it can affect social life it may not be a good idea
  • Starting and stopping may make them more irritable
  • Take it by a case by case basis to see if it’s best for that patient
48
Q

What short term and long term benefits are expected with the medication?

A

Good evidence short-term for improvement in school and home life.

No evidence long-term

49
Q

How long should patients be treated?

A
  • Different for every patient

- Some kids grow out of it (either their symptoms improve or they’re just better at managing their symptoms)

Clinical 2 (Part B) (30 decks)

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