ADD/ADHD Flashcards
ADD/ADHD
All 5 must be present
Persistent pattern of inattention and/or hyperactivity/impulsivity
Several inattentive or hyperactive/impulsive sx were present prior to 12 years of age
Several inattentive or hyperactive/impulsive sx are present in >/= 2 settings (home, school, work)
Clear evidence that sx interfere with daily functioning (academic, occupational, social)
Sx do NOT occur during course of other psychotic disorders
Criteria for persistent pattern of inattention
> /= 6 sx for at least 6 months
Fails to give close attention to details or makes careless mistakes
Difficulty sustaining attention in tasks or play
Often does not seem to listen when spoken to directly
Often does not follow through on instructions failing to finish work
Difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks requiring sustaining mental effort
Often loses things necessary for tasks or activities
Often easily distracted by extraneous stimuli
Often forgetful in daily activities
Criteria for persistent pattern of hyperactivity/impulsivity
> /= 6 sx for at least 6 months
Often fidgets tapping hands and feet or squirming
Often leaves seat when remaining seated is expected
Often runs or climbs in inappropriate situations
Often unable to play or engage in leisure activities quietly
Often on the go or driven by a motor
Often talks excessibely
Often blurts out answer prior to question completion
Often interrupts or intrudes on others
ADD/ADHD environmental triggers
Lead exposure
Low birth weight (< 1.5 kg)
Severe social deprivation as infant
Smoking during pregnancy
ADD/ADHD food triggers
Chocolate
Eggs
Peanuts
ADD/ADHD artificial dyes
Blue #1
Red #3
Yellow #5
ADD/ADHD pathophysiology
Decreased cerebral volume
Dysregulation of neurotransmitters
Decreased cerebral volume
Caudate nucleus
Cerbellar vermis
Prefrontal cortex (controls appropriate behaviors and inhibitions)
Dysregulation of neurotransmitters
DA (executive function, serial learning, sustaining attention, verbal fluency)
NE (mediating energy/fatigue, moderation of behavior based on social cues, motivation, sustaining attention)
Diet modifications for ADD/ADHD
Elimination diets (hyperactivity)
Increased essential fatty acids (inattention)
Vitamins and herbs
Essential fatty acids
EPA
DHA
Linolenic acid
Vitamins and herbs
Attention related (gingko bilboa, ginseng) Hyperactivity related (lemon balm, valerian root, zinc)
Simulants MOA
Increased NE and DA thru reuptake inhibitors
Stimulants ADR
Appetite reduction Dizziness HA Insomnia Irritability Nausea Stomach pains Weight loss
Stimulant administration considerations
< 16 kg: short acting
Sx only at school: short acting
Longer acting: Onset w/in 1 hour
High fatty meals: reduce absorption
Amphetamine based stimulants MOA
Increased release of DA through exchange mechanism by binding to DA transporter proteins inhibiting reuptake
Amphetamine metabolism
2D6
Amphetamine advantages
Predictable kinetics
Amphetamine disadvantages
Greater abuse potential
Greater growth suppression
Higher rates of worsening tics
Short acting amphet
Dexedrine
Dextrostat
Intermediate acting amphet
Adderall
Dexedrine spanules*
Long acting amphet
Adderall XR*
Vyvanse*
Methylphenidate MOA
Occupies DA and NE transporters inhibiting reuptake
Methylphenidate metabolism
de-esterification
Methylphenidate advantages
Decreased appetite suppression
Less likely to worsen tics
Lessens risk of insomnia
Methylphenidate disadvantages
Erratic kinetics
Greater differences between brand and generic products
short acting methyl
Focalin
Methylin
Ritalin
Intermediate acting methyl
Metadate ER
Methylin ER
Methylphenidate SR
Ritalin SR
Long acting methyl
Concerta (will see capsule in poop) Daytrana Focalin XR* Metadate CD* Ritalin LA*
ADD/ADHD non-stimulants
Alpha-2 agonists
Atomoxetine
Bupropion
TCAs
Alpha-2 agonist metabolism
3A4
Alpha-2 agonist elimination
50/50
Hepatic/renal
Alpha-2 agonist ADR
Fatigue
HA
Somnolence
Alpha-2 agonists
Clonidine
Guanfacine
Clonidine IR dosing
q6-12h
0.05 mg/d
Titrated weekly by 0.05 mg/d
Target 0.1-0.4 mg/d
Clonidine ER dosing
q12h
0.1 mg/d
Titrated weekly by 0.1 mg/d
Target 0.2-0.4 mg/d
Clonidine administration considerations
Food does not impact absorption
Patch duration of therapy
Children = 5 days
Adolescents = 7 days
Guanfacine dosing
1 mg/d
Titrated weekly by 1 mg/d
Target 2-4 mg/d
Guanfacine administration considerations
ER: avoid high fatty meals
IR: can be crushed
Atomoxetine approval
ADHD
Atomoxetine time to effect
6 weeks
Atomoxetine MOA
Selectively inhibits reuptake of NE
Atomoxetine dosing
Initiation: 0.5 mg/kg/d
Titration: 1-2 mg/kg/d; start 1-2 weeks after initiation
Atomoxetine metabolism
2D6
Highly protein bound
Atomoxetine ADR
Dizziness
Fatigue
Somnolence
Atomoxetine administration considerations
Capsule form only
May dissolve in 60 ml of juice
Atomoxetine place in therapy
After failing stimulants
Buproprion and ADHD
Off-label use
Bupropion time to effect
6 weeks
Bupropion MOA
Inhibits reuptake of NE and DA
Bupropion dosing
Initiation: 1.5 mg/kg/d Titration: -3 mg/kg/d -6 mg/kg/d or 300 mg max Over 7 days
Bupropion ADR
Insomnia
Irritability
Nausea
Bupropion CI
Seizure pts and eating disorders
Bupropion place in therapy
After failure of 1st and 2nd line options
Depression
TCA time to effect
4 weeks
TCA MOA
Inhibits reuptake of NE and serotonin
TCA ADR
Constipation
Dizziness
Sedation
Weight gain
TCA place in therapy
3rd line
