ADHD

Question 1

Stimulant drugs for ADHD should be trialed for ___ and continued for ____ if responding.

Answer 1

Stimulant drugs for ADHD should be trialed for 3-4wks, and continued for 6-12mths if responding, with follow ups every 3 mths.

Question 2

long acting stimulants are first line because

Answer 2

they last 8-14h which decreases abuse and rebound sx and also improves adherence

Question 3

intermediate acting stimulants should be used

Answer 3

as adjuncts and dosed no later than 4pm as they last up to 8 hours

Question 4

what are contraindications to stimulants?

Answer 4

hypersensitivity, symptomatic CVD (including moderate to severe HTN), uncontrolled hyperthyroidism, history of drug abuse or MAOI use

Question 5

What is Modafinil’s place in therapy?

Answer 5

It’s a less effective CNS stimulant that isn’t approved or used for ADHD

Question 6

What safety parameters should be monitored in patients starting stimulants?

Answer 6

increased HR & BP - monitor week 1 then q3m
GI upset decreased appetite - monitor weight Q2W F6M then Q6M
neuro (anxiety, dizziness, irritability, insomnia, headache) - monitor week 1 then monthly F3M then Q6M

Question 7

What are signs of stimulant overdose?

Answer 7

glassy eyes, insomnia, hyperactivity

Question 8

What are rare side effects of stimulants?

Answer 8

leukopenia, insomnia, hyperactivity

Question 9

What should be recommended for patients with a history of psychosis?

Answer 9

Try non stimulant options like atomoxetine or guanfacine first since stimulants can increase the risk of psychosis

Question 10

what is the onset of stimulants?

Answer 10

1 week

Question 11

what are second and third line options?

Answer 11

2nd: atomoxetine (NRI), guanfacine (a2 adrenergic)
3rd: clonidine, antidepressants (bupropion, venlafaxine, TCAs)

Question 12

when should stimulant meds be reassessed?

Answer 12

usually once a year during the summer months, a drug holiday is trialed to reassess need for tx.

Question 13

can stimulants be abruptly discontinued?

Answer 13

abrupt discontinuation may cause withdrawal symptoms in some, so consider tapering over weeks in patients who have been on tx for over 3 months

Question 14

What are the 4 intermediate acting stimulants?

Answer 14

Dexedrine (dextroamphetamine) IR (don’t crush) BID, SR (can sprinkle) QAM
Ritalin (methylphenidate) IR TID, SR BID (may combine w IR)

Question 15

What are the 5 long acting stimulants?

Answer 15

Vyvanse (lisdexamfetamine) 
Adderal XR (mixed salts amphetamine ER)
Biphentin (methylphenidate CR)
Foquest (methylphenidate CR)
Concerta (methylphenidate bilayer CR)
All except Concerta can be sprinkled on food & Vyvanse can be mixed in water

Question 16

Pregnancy considerations?

Answer 16

avoid atomoxetine and caution using methylphenidate in 1st trimester - TCA, bupropion and venlafaxine are safe

Question 17

Breastfeeding consideration?

Answer 17

Clonidine and guanfacine may decrease milk production