66. ADHD Flashcards
ADHD is the most common neurodevelopmental disorder in ____, occurring almost twice as often in boys compared to girls
children
ADHD is characterized by symptoms of __
inattention, hyperactivity, and impulsivity
The primary treatment for ADHD is ___ medications because they raise ___ levels
stimulant meds (e.g. methylphenidate, amphetamine)
raise dopamine and NE levels
ADHD medications are considered first line in pts ≥ ___ yo and should be used with behavioral interventions when available
≥6yo
DSM-5 Dx criteria for ADHD
Inattention:
≥ 6 symptoms of inattention for children up to age 16 (≥5 symptoms for ages 17 or older)
Symptoms must have been present for at least 6 months and are inappropriate for the developmental level
Symptoms:
Fails to pay attention, has trouble holding attention, dose not pay attention when someone is talking, does not follow through on instructions, fails to finish schoolwork, has difficulty organizing tasks, avoids or dislikes tasks which require mental effort, loses things, is easily distracted, is forgetful
Hyperactive + Impulsivity:
≥6 symptoms of hyperactive-impulsivity for children up to age 16 (≥5 symptoms for ages 7 and older)
Symptoms must have been present for at least 6 months and are inappropriate for the developmental level
Symptoms:
Often fidgets or squirms, leaves seat unexpectedly, runs about when no appropriate, unable to play quietly, is “on the go” as if “driven by a motor”, talks excessively, blurts out answers, has trouble waiting his/her turn, interrupts or intrudes on others
Following conditions must be met:
- several inattentive or hyperactive-impulsive symptoms were present before age 12
- symptoms must have been present in 2 or more settings (e.g. at home, school, work, with friends, relatives, or babysitters)
- symptoms interfere with functioning and are not caused by another disorder
Natural products used for ADHD
Fish oil
Melatonin used to help with sleep onset in individuals taking stimulants
Why are long-acting formulations of stimulants preferred for children?
To maintain more steady symptom control and avoid need for dose during day at school
___, a non-stimulant med, can be tried when stimulants do not work well enough (After trials of 2-3 meds) for ADHD. Can be used first line when prescribers are concerns about possibility of abuse by pt or family.
Atomoxetine (Strattera)
____ and ___ are non-stimulant meds that can be used alone or in combo with stimulants for ADHD
Guanfacine ER (Intuniv) and clonidine ER (Kapvay)
Patient-friendly formulations for stimulants used in ADHD
Capsule
- some can be sprinkled on a small amount of applesauce (e.g. Adderall XR, Ritalin LA)
- Vyvanse capsules can be mixed in water, OJ, or yogurt
Chewable tab (e.g. Vyvanse)
ODT
Patch (e.g. Dayrana)
Suspension
Examples of first-line stimulants used for ADHD
Taken in AM
Methylphenidate (e.g. Concerta, Daytrana, Ritalin)
Lisdexamfetamine (Vyvanse)
Dextroamphetamine/Amphetamine (Adderall, Adderall XR)
Examples of meds used to help sleep at night in ADHD pts
clonidine IR (Catapres)
Diphenhydramine (OTC, 25-50mg)
Melatonin (OTC, 2-5mg)
All stimulants are ___ scheduled meds and must be dispensed with MedGuide
C-II
Do not use stimulants within ___ of MAOi d/t risk of ____ when used together
14 days
hypertensive crisis
Warnings with stimulant use
Increase HR and BP (d/t increased levels of DA and NE), can cause serious CV events in children and adults
Other vascular problems (e.g. ppriapism, Raynaud’s disease)
New-onset psychosis or mania, or an exacerbation of preexisting psychosis (e.g. mixed/manic episode in bipolar disorder)
Lower seizure threshold
Loss of appetite - can decrease child’s growth trajectory
Serotonin syndrome risk
Stimulants MOA
block reuptake of NE and DA
How often are stimulant doses titrated?
every 7 days as needed
Do simulants need to be tapered off?
No (when used as directed (i.e. not abused))
Methylphenidate formulations and doses
IR tablet: Ritalin - start 5mg BID, 30 min before breakfast and lunch (Max 60mg/day)
ER tablet: Concerta - start 18-36mg QAM (max 72mg/day), OROS delivery
ER capsule: Ritalin LA, Jornay PM - Jornay PM taken at night
Transdermal patch: Dayrana - QAM
Dexmethylphenidate (Focalin, Focalin XR) is the active isomer of ___
methylphenidate
To convert from methylphenidate to dexmethylphenidate use 1/2 of TDD of methylphenidate
Side effects of methylphenidate
Insomnia, decreased appetite/weight loss, HA, irritability, N/V, blurry vision, dry mouth
Monitoring for methylphenidate
Consider ECG prior to treatment; monitor BP and HR, cardiac symptoms, CNS effects, abuse potential and height/weight in children
Concerta formulation notes
OROS delivery, outer coat dissolve fast for immediate action, rest released slowly
can see ghost tab in stool
harder to crush = decrease abuse potential
Why is Jornay PM taken at night?
Outer coating delays initial drug release 10hrs to allow evening dosing, the rest releases slowly during day
Daytrana (methylphenidate patch) application notes
Apply 2 hrs before desired effect
Remove after 9 hrs
Alternate hips daily
Boxed warnings for Adderall (Dextroamphetamine/amphetamine)
Misuse can cause sudden death and serious CV events
Vyvanse (lisdexamfetamine) is the prodrug of ____
dextroamphetamine
What is unique about Vyvanse and abuse potential?
Low abuse potential; prodrug, if injected or snorted, fast effect (rush) is muted
Which SNRI can be used as second-line for ADHD?
Atomoxetine (Strattera)
Boxed warnings for atomoxetine (Strattera)
Suicidal ideation
Contraindication for atomoxetine (Strattera)
MAOi use within 14 days, glaucoma, phenochromocytoma, severe CV disorders
Side effects with atomoxetine (Strattera)
decreased appetite, insomnia, somnolence, dry mouth, HTN, tachycardia, HA, nausea, abd pain, ED/decreased libido
atomoxetine (Strattera) capsules should NOT be opened. Why?
Ocular irritant
Clonidine ER (Kapvay), Guanfacine ER (Intuniv) MOA
central alpha-2A adrenergic receptor agonists
When is clonidine ER (Kapvay) taken?
QHS
Warnings with Clonidine ER (Kapvay), Guanfacine ER (Intuniv)
dose-dependent CV effects (bradycardia, hypotension, orthostasis, syncope), sedation and drowsiness
Do NOT d/c abruptly (can cause rebound HTN)
guanfacine: skin rash (rare, d/c if occurs)
Side effects with Clonidine ER (Kapvay), Guanfacine ER (Intuniv)
Dry mouth, somnolence, fatigue, dizziness, constipation, decraese HR, hypotension, HA, nausea, abd pain
Which stimulant medications used in ADHD come as chewable tablets?
Vyvanse, QuilliChew ER, and methylphenidate IR
