777 final ADHD Flashcards

Question

ADHD: Psychotherapy

Answer 1

Psychoeducation Focused behavioral therapy Set clear limits with clear expectations Establish/maintain predictable, calm environment with decreased stimuli Establish eye contact before giving instructions Ask to repeat what was heard Limit distractions for homework and encourage one assignment at a time Develop effective coping skills Family therapy School interventions and accomadations

Answer 2

What disorder is prioritized? ADHD treatment often seen as secondary Keep an index of suspicion for ADHD in the presence of mood, anxiety, substance abuse ADHD treatments as augmenting agents to first line tx of mood, anxiety and substance Treat nicotine dependence

Answer 3

Increase release of DA and NE Stimulants and by some noradrenergic agents Adults with anxiety, depression, substance abuse Augment antidepressant or anxiolytic therapies NET inhibitor (NRI’S) a2A –adrenergic agonist (Guanfacine, Clonidine)

Answer 4

Mechanism of action Blocks reuptake of DA and NE Enhances DA and NE in the DLPFC: increased attention, concentration, executive function and wakefulness Enhances DA in basal ganglia: may improve hyperactivity Enhances DA and NE in medial prefrontal cortex: may improve depression, fatigue sleepiness ``` Side effects Insomnia, headache, exacerbation of tics, nervousness, irritability, anorexia, weight loss, palpitations, increased B/P High abuse potential Dosing IR: 2.5 – 10mg BID ER: 10 – 20mg/day ``` Drug interactions May inhibit metabolism of SSRI’s, anticonvulsants, tricyclic antidepressants, coumarin Serious adverse effects may occur if combined with clonidine Not advised for use with MAOI’s Precaution Hypertension, hyperthyroidism, drug abuse

Answer 5

``` Elderly: lower doses Children: not approved under 6 Monitor weight and height Pregnancy: Category C Breast feeding: not recommended ```

Answer 6

IR formulations: 2-4 hour duration of action Ritalin, Methylin, generic methylphenidate Chewable tablets Oral solutions Dosing initial 5mg QAM 5mg at lunch increase 5-10mg each week max dose 60mg SR formulations Older ER: Ritalin SR, Methylin SR, Metadate ER: duration of action 4-6 hours, dosing 20-30mg/day in divided doses Newer ER: Concerta up to 12 hours initial dosing 18mg to 72mg, Ritalin, LA Metadate CD up to 8 hours 20-60mg/day Transdermal formulation initial dosing 10mg/9 hours increase by 5mg max dose 30mg Apply patch 2 hours before needed effect, wear for 9 hours May be possible to dose only during the school week Drug holidays Avoid dosing late in the day

Answer 7

Blocks transporters for DA and NE Competitive inhibitor and pseudosubstrate for NET and DAT d and l-isomer d- isomer more potent for DAT binding d and l-isomers equally potent for NET binding

Answer 8

SR stimulants optimize rate, amount, and length of time that a stimulant occupies NET and DAT Goal: occupy enough of the NET in the PFC At a slow enough pace and long enough duration to enhance tonic NE signaling via a2A receptors Increase tonic DA signaling via D1 receptors Occupy little enough of the DAT in nucleus accumbens not to increase phasic signaling

Answer 9

``` Dexedrine, Dexedrine Spanules, Dextro Stat Mechanism of action Increases NE and DA by blocking reuptake and facilitating release Enhances DA and NE in DLPFC Enhances DA in basal ganglia Enhances DA and NE in medial PFC Pharmacokinetics half-life 10-12 hours High abuse potential May be able to give drug holidays ``` Monitor B/P Children monitor height and weight Drug Interactions MAOI’s slow absorption of amphetamines Can raise corticosteroid levels May antagonize hypotensive effects of veratrum alkaloids and other antihypertensives May increase analgesic effects of meperidine

Answer 10

``` Elderly: caution, lower dose Children Not approved for under 3 Acute effects on growth hormone Ages 3-5 (ADHD) initial 2.5mg Pregnancy Category C Breast-feeding: not recommended ```

Answer 11

Adderall and Adderall XR Pharmacokinetics Mixture of d-amphetamine and l-amphetamine salts in a ratio of 3:1 Adult ½ life of d-amphetamine = 10 hours and l-amphetamine = 13 hours Children ½ life of d-amphetamine = 9 hours and l-amphetamine = 11 hours

Answer 12

Mechanism of Action Prodrug of dextroamphetamine Increases NE and DA actions by blocking reuptake and facilitating their release Enhances DA and NE in DLPFC Enhances DA in basal ganglia Enhances DA and NE in medial PFC Pharmacokinetics: duration of action 10-12 hours Dosing Initial 30mg QAM increase 10-20mg/week up to 70mg

Answer 13

``` Elderly lower doses Children and Adolescents Safety and efficacy not established under 6 Acute effects on growth hormone Pregnancy Category C Breast Feeding Not recommended ```

Answer 14

Atmoxetine Buproprion Desimprimine Nortriptylene

Answer 15

Mechanism of Action Boosts NE/NA and my increase DA in PFC Block NE pumps Increases noradrenergic neurotransmission Side Effects Sedation, fatigue, increased heart rate, increased B/P, sexual dysfunction Dosing Children: over 70kg or less initial 0.5mg/kg/day after 7 days increase to 1.2mg/kg/day up to 100mg/day Adults: 40mg/day after 7 days increase to 80mg/day up to 100mg/day Pharmacokinetics Metabolized by CYP450 2D6 ½ life 5 hours Drug Interactions Plasma concentrations of Atomoxetine may be increased by drugs that inhibit CYP 450 2D6 (paroxetine, fluoxetine) Do not use with MAOI’s (21 days after discontinuation)

Answer 16

``` Elderly Lower dose Reduction of suicidality with antidepressants in adults over 65 Children and Adolescents Approved to treat ADHD in 6 and over Do not use with serious cardiac problems Monitor for suicidal ideation Pregnancy Category C Breast-Feeding Not recommended ```

Answer 17

Alpha 2-A receptors primary mediators of NE in PFC 2 direct acting agonists for a2 receptors Guanfacine Guanfacine ER Clonidine

Answer 18

Clonidine more side effects, less selective agonist on a2 receptors Guanfacine 15-20X more selective for a2 receptors, 10X weaker than Clonidine at inducing sedation and lowering B/P 25X more potent in enhancing PFC function Can be used adjunctively with stimulants to treat patients with oppositional symptoms ADHD caused by low NE in PFC without additional impairments in DA neurotransmission good candidates for Guanfacine ER monotherapy (no way to ID these patients other than a trial of meds)

Answer 19

More selective for a2A receptors Guanfacine ER once a day dosing Guanfacine ER approved for ADHD ages 6-17 Treatment of Tic disorders Mechanisms of Action Central action on postsynaptic alpha 2A receptors in PFC 10-15X more selective for alpha 2A than alpha 2B or 2C Side Effects Hypotension B/P lowered 30-60 minutes after first dose; greatest reduction after 2-4 hours Sedation Rebound HTN with abrupt termination Dosing: IR and ER IR: 1mg/HS after 3-4 weeks increase to 2mg ER: 1mg/HS; increase 1mg/week; max dose 4mg/day

Answer 20

Pharmacokinetics Metabolized by CYP450 3A4 Drug Interactions CYP450 3A inhibitors (nefazodone, fluoxetine, fluvoxamine and ketoconazole) may decrease clearance thereby increasing guanfacine levels CYP450 3A inducers may increase guanfacine clearance Do not administer ER with high fat meals

Answer 21

``` Elderly Elimination ½ life may be longer More sensitive to sedative effects Children and Adolescents Safety and efficacy not established in children under 6 Pregnancy Category C Breast-Feeding No recommended ```

Answer 22

Mechanisms of Action Nonselective agonist at a2 receptors with actions on a2A, a2B and a2C receptors Interacts at imidazoline receptors which may be the cause of sedating and hypotensive actions Side Effects Sedation Hypotension B/P lowered 30-60 minutes after first dose; greatest reduction after 2-4 hours Dosing Initial 0.1mg/bedtime, can increase by 0.1mg/week in divided doses with increased dose at HS max dose 0.4mg/day Taper

Answer 23

Pharmacokinetics ½ life 12-16 hours Metabolized by the liver Excreted renally Drug Interactions Increased CNS depressive and sedative effects when combined with other CNS depressants Severe discontinuation rxn when combined with beta blockers

Answer 24

Elderly Lower doses More sensitive to sedative effects Caution with beta blockers Children and Adolescents Safety and efficacy not established under 6 May be more sensitive to hypertensive effects of withdrawal More likely to experience CNS depression with OD, may have signs of toxicity at 0.1mg Pregnancy Category C Breast-Feeding No adverse effects have been reported in nursing infants

Answer 25

H3 antagonists Boosting acetylcholine function in PFC a-nicotinic receptor agonists a4B2-nicotinic receptor