ADD/ADHD

Question 1

ADD/ADHD

Answer 1

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

Question 2

Criteria for persistent pattern of inattention

Answer 2

> /= 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

Question 3

Criteria for persistent pattern of hyperactivity/impulsivity

Answer 3

> /= 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

Question 4

ADD/ADHD environmental triggers

Answer 4

Lead exposure
Low birth weight (< 1.5 kg)
Severe social deprivation as infant
Smoking during pregnancy

Question 5

ADD/ADHD food triggers

Answer 5

Chocolate
Eggs
Peanuts

Question 6

ADD/ADHD artificial dyes

Answer 6

Blue #1
Red #3
Yellow #5

Question 7

ADD/ADHD pathophysiology

Answer 7

Decreased cerebral volume

Dysregulation of neurotransmitters

Question 8

Decreased cerebral volume

Answer 8

Caudate nucleus
Cerbellar vermis
Prefrontal cortex (controls appropriate behaviors and inhibitions)

Question 9

Dysregulation of neurotransmitters

Answer 9

DA (executive function, serial learning, sustaining attention, verbal fluency)
NE (mediating energy/fatigue, moderation of behavior based on social cues, motivation, sustaining attention)

Question 10

Diet modifications for ADD/ADHD

Answer 10

Elimination diets (hyperactivity)
Increased essential fatty acids (inattention)
Vitamins and herbs

Question 11

Essential fatty acids

Answer 11

EPA
DHA
Linolenic acid

Question 12

Vitamins and herbs

Answer 12

Attention related (gingko bilboa, ginseng)
Hyperactivity related (lemon balm, valerian root, zinc)

Question 13

Simulants MOA

Answer 13

Increased NE and DA thru reuptake inhibitors

Question 14

Stimulants ADR

Answer 14

Appetite reduction
Dizziness
HA
Insomnia
Irritability
Nausea
Stomach pains
Weight loss

Question 15

Stimulant administration considerations

Answer 15

< 16 kg: short acting
Sx only at school: short acting
Longer acting: Onset w/in 1 hour
High fatty meals: reduce absorption

Question 16

Amphetamine based stimulants MOA

Answer 16

Increased release of DA through exchange mechanism by binding to DA transporter proteins inhibiting reuptake

Question 17

Amphetamine metabolism

Answer 17

2D6

Question 18

Amphetamine advantages

Answer 18

Predictable kinetics

Question 19

Amphetamine disadvantages

Answer 19

Greater abuse potential
Greater growth suppression
Higher rates of worsening tics

Question 20

Short acting amphet

Answer 20

Dexedrine

Dextrostat

Question 21

Intermediate acting amphet

Answer 21

Adderall

Dexedrine spanules*

Question 22

Long acting amphet

Answer 22

Adderall XR*

Vyvanse*

Question 23

Methylphenidate MOA

Answer 23

Occupies DA and NE transporters inhibiting reuptake

Question 24

Methylphenidate metabolism

Answer 24

de-esterification

Question 25

Methylphenidate advantages

Answer 25

Decreased appetite suppression
Less likely to worsen tics
Lessens risk of insomnia

Question 26

Methylphenidate disadvantages

Answer 26

Erratic kinetics

Greater differences between brand and generic products

Question 27

short acting methyl

Answer 27

Focalin
Methylin
Ritalin

Question 28

Intermediate acting methyl

Answer 28

Metadate ER
Methylin ER
Methylphenidate SR
Ritalin SR

Question 29

Long acting methyl

Answer 29

Concerta (will see capsule in poop)
Daytrana
Focalin XR*
Metadate CD*
Ritalin LA*

Question 30

ADD/ADHD non-stimulants

Answer 30

Alpha-2 agonists
Atomoxetine
Bupropion
TCAs

Question 31

Alpha-2 agonist metabolism

Answer 31

3A4

Question 32

Alpha-2 agonist elimination

Answer 32

50/50

Hepatic/renal

Question 33

Alpha-2 agonist ADR

Answer 33

Fatigue
HA
Somnolence

Question 34

Alpha-2 agonists

Answer 34

Clonidine

Guanfacine

Question 35

Clonidine IR dosing

Answer 35

q6-12h
0.05 mg/d
Titrated weekly by 0.05 mg/d
Target 0.1-0.4 mg/d

Question 36

Clonidine ER dosing

Answer 36

q12h
0.1 mg/d
Titrated weekly by 0.1 mg/d
Target 0.2-0.4 mg/d

Question 37

Clonidine administration considerations

Answer 37

Food does not impact absorption
Patch duration of therapy
Children = 5 days
Adolescents = 7 days

Question 38

Guanfacine dosing

Answer 38

1 mg/d
Titrated weekly by 1 mg/d
Target 2-4 mg/d

Question 39

Guanfacine administration considerations

Answer 39

ER: avoid high fatty meals
IR: can be crushed

Question 40

Atomoxetine approval

Answer 40

ADHD

Question 41

Atomoxetine time to effect

Answer 41

6 weeks

Question 42

Atomoxetine MOA

Answer 42

Selectively inhibits reuptake of NE

Question 43

Atomoxetine dosing

Answer 43

Initiation: 0.5 mg/kg/d
Titration: 1-2 mg/kg/d; start 1-2 weeks after initiation

Question 44

Atomoxetine metabolism

Answer 44

2D6

Highly protein bound

Question 45

Atomoxetine ADR

Answer 45

Dizziness
Fatigue
Somnolence

Question 46

Atomoxetine administration considerations

Answer 46

Capsule form only

May dissolve in 60 ml of juice

Question 47

Atomoxetine place in therapy

Answer 47

After failing stimulants

Question 48

Buproprion and ADHD

Answer 48

Off-label use

Question 49

Bupropion time to effect

Answer 49

6 weeks

Question 50

Bupropion MOA

Answer 50

Inhibits reuptake of NE and DA

Question 51

Bupropion dosing

Answer 51

Initiation: 1.5 mg/kg/d
Titration: 
-3 mg/kg/d
-6 mg/kg/d or 300 mg max
Over 7 days

Question 52

Bupropion ADR

Answer 52

Insomnia
Irritability
Nausea

Question 53

Bupropion CI

Answer 53

Seizure pts and eating disorders

Question 54

Bupropion place in therapy

Answer 54

After failure of 1st and 2nd line options

Depression

Question 55

TCA time to effect

Answer 55

4 weeks

Question 56

TCA MOA

Answer 56

Inhibits reuptake of NE and serotonin

Question 57

TCA ADR

Answer 57

Constipation
Dizziness
Sedation
Weight gain

Question 58

TCA place in therapy

Answer 58

3rd line