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NAPLEX Review > ADHD > Flashcards

ADHD Flashcards

1
Q

What does ADHD stand for?

A

Attention deficit hyperactivity disorder

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2
Q

What is ADHD characterized by?

A

ADHD is characterized by symptoms of inattention, hyperactivity and impulsivity. Patients often have difficulty focusing, are easily distracted, have trouble staying still and are frequently unable to control impulsive behavior

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3
Q

What plays a role in ADHD?

A

Defects in the dopamine pathways that regulated reward anticipation and emotional self-regulation can play a role in ADHD

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4
Q

What is the primary treatment for ADHD?

A

The primary treatment for ADHD is stimulant medications (e.g. methylphenidate and amphetamine) because they raise dopamine and norepinephrine levels

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5
Q

What is the first line treatment and second line treatment for pre-school aged children (age 4-5 years)?

A

First-line treatment for pre-school aged children (age 4-5 years) is parent training in behavior management and/or behavioral classroom interventions

*Methylphenidate can be considered if moderate-severe symptoms persist despite behavioral interventions

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6
Q

What is considered first line in patients > 6 years old?

A

ADHD medications are considered first line ion patients > 6 years old and should be used with behavioral interventions when available

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7
Q

What is the definition of inattention?

A

> 6 symptoms of inattention for children up to age 16, or >5 symptoms for ages 17 and older; symptoms must have been present for at least 6 months and are inappropriate for the developmental level

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8
Q

What are symptoms of inattention?

A

Fails to pay attention, has trouble holding attention, does 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 and is forgetful

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9
Q

What is the definition of hyperactivity and impulsivity?

A

> 6 symptoms of hyperactivity-impulsivity for children up to age 16, or >5 symptoms for ages 17 and older; symptoms must have been present for at least 6 months and are in inappropriate for the developmental level

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10
Q

What are symptoms of hyperactivity and impulsivity?

A

Often fidgets or squirms, leaves seat unexpectedly, runs about when not 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 and interrupts or intrudes on others

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11
Q

What conditions must be met to have the diagnosis of ADHD?

A
  • 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 or relatives, babysitters)
  • Symptoms interfere with functioning and are not caused by another disorder
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12
Q

What are the advantages of fish oil?

A

Fish oil are increasingly used for various psychiatric conditions and have been shown to modestly improve cognitive function and behavior in children with ADHD

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13
Q

What is the purpose of using melatonin with stimulants?

A

Melatonin is used to help with sleep onset in individuals taking stimulants

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14
Q

What are first line medications for ADHD?

A

Stimulants are the first-line medications for ADHD

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15
Q

What are the different formulations offered that are patient friendly?

A

Capsule, chewable tablet, orally-disintegrating, patch, suspension

  • Some capsule contents can be sprinkled on a small amount of applesauce
  • Vyvanse capsule contents can be mixed in water, orange juice or yogurt
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16
Q

What formulations are preferred for children?

A

Long-acting formulations are preferred for children, who would otherwise need a dose during the day at school, to help maintain more steady symptom control

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17
Q

What is considered a second line treatment medication for ADHD?

A

Atomoxetine (Strattera), a non-stimulant medication, can be tried when stimulants do not work well enough (after trials of 2-3 medications)

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18
Q

When can Strattera be considered first-line?

A

Strattera can be used first line when prescribers are concerned about the possibility of abuse by the patient or family

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19
Q

What are other alternative medications that can be used for the treatment of ADHD?

A

Guanfacine ER (Intuniv) and clonidine ER (Kapvay) are non-stimulant medications that can be used alone or in combination with stimulants

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20
Q

What must be dispensed with stimulants?

A

All stimulants are C-II medications and must be dispensed with a MedGuide

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21
Q

What is the boxed warning for all stimulant medications?

A

Stimulant medications have a high potential for abuse and dependence, so risk for abuse should be assessed prior to dispensing

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22
Q

What are some symptoms of abuse?

A

Dilated pupils, increased heart rate and blood pressure, sweating, tremor, anxiety

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23
Q

What can occur when stimulants are abused long-term?

A

When abused long-term, tolerance and psychological dependence can occur, with varying degrees of abnormal behavior (including psychotic episodes when injected)

*when withdrawing treatment from someone abusing a stimulant , severe depression can occur

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24
Q

What are some contraindications of stimulants?

A
  • Do not use within 14 days of a MAO inhibitor due to the risk of hypertensive crisis when used together
  • Due to risk of cardiovascular events, some stimulants are contraindicated with comorbid heart failure, recent myocardial infarction, arrhythmias, or moderate-severe hypertension
  • Most stimulants are contraindicated in patients with marked anxiety, tension, agitation, glaucoma, hyperthyroidism, or a history of Tourette’s syndrome or other tic disorders
25
Q

What are some warnings associated with stimulants?

A
  • Increased levels of dopamine and norepinephrine can increase heart rate and blood pressure and can cause serious cardiovascular events in children and adults with or without preexisting cardiac disease
  • Other vascular problems (e.g. priapism, Raynaud’s disease) can occur and may require dose reduction or discontinuation
  • New onset-psychosis or mani or an exacerbation of preexisting psychosis can occur
  • Some stimulants can lower the seizure threshold
  • A loss of appetite is common and can contribute to a decrease in child’s growth trajectory
  • The risk of serotonin syndrome is increased when stimulants are used in combination with other serotonergic drugs
  • Visual disturbances can occur
26
Q

What is the MOA of stimulants?

A

Stimulants block the reuptake of norepinephrine and dopamine

27
Q

How are stimulants dosed?

A

Most stimulants are dosed every morning (IR products and some others can be given in divided doses), with doses titrated up every seven days, as needed, to reduce adverse effects

*Stimulants do not need to be tapered off when used as directed

28
Q

What are some examples of stimulants?

A

Methylphenidate (Ritalin, Concerta, Quillivant, Daytrana), Dexmethylphenidate (Focalin), Amphetamine, Dextroamphetamine and Combinations (Adderall), Lisdexamfetamine (Vyvanse), Methamphetamine

29
Q

What are some warnings associated with Daytrana?

A

Loss of skin pigmentation at application site and areas distance from the application site (can resemble vitiligo); allergic contact dermatitis with local reactions

30
Q

What is a warning associated with Concerta?

A

Do not use with GI narrowing conditions (e.g. motility issues, small bowel disease)

31
Q

What are some side effects of methylphenidate?

A

Insomnia, decreased appetite/weight loss, headache, irritability, nausea/vomiting, blurry vision, dry mouth

32
Q

What are some monitoring parameters of Methylphenidate?

A

Consider ECG prior to treatment; monitor BP and HR, cardiac symptoms, CNS effects, abuse potential and height and weight (children)

33
Q

What is an important note about Concerta OROS delivery?

A

The outer coat dissolves fast to give immediate action, and the rest is released slowly; can see a ghost tablet in stool; harder to crush which decreases abuse potential

34
Q

What is an important note about Jornay PM?

A

Outer coating delays initial drug release 10 hours to allow for evening dosing; inner coating controls the slow release of the drug during the day

35
Q

What is an important note about Daytrana?

A

Apply 2 hours before desired effect (or as soon as the child awakens so it starts to deliver prior to school); remove after 9 hours; alternate hips daily

36
Q

What is an important note about the Methylphenidate chewable tablets?

A

Contain phenylalanine (avoid with PKU)

37
Q

What are some notes of dexmethylphenidate?

A
  • Active isome of methylphenidate, to convert from methylphenidate to dexmethylphenidate use one-half on the total daily dose of methylphenidate
  • Serdexmethylphenidate: prodrug to dexmethylphenidate, provides extended duration of action following faster-acting dexmethylphenidate
38
Q

What is the boxed warnings of amphetamine?

A

Misuse can cause sudden death and serious CV events

39
Q

What is a warning associated with Adzenys ER?

A

Risk of intestinal necrosis when used with sodium polystyrene sulfonate or sorbitol

40
Q

What are some notes associated with amphetamine?

A
  • IR products approved for children > 3 years of age (except Evekeo ODT)
  • AAP guidelines do not recommended dextroamphetamine in children < 5 years of age
  • ER formulations cannot be substituted for other amphetamine products on a mg-per-mg basis, following dosing schedule provided by manufacturer
  • Conversion from Adderall XR to Adzenys ER or XR-ODT; use 3.1 mg for each 5 mg dose of Adderall XR
  • Dyanavel XR, Adzenys ER: shake suspension prior to use
  • Do not take with acidic foods such as juice or vitamin C (decreased absorption)
41
Q

What are some notes associated with Vyvanse?

A

Low abuse potential; prodrug composed of l-lysine (amino acid) bonded to dextroamphetamine; it is hydrolyzed in the blood to active dextroamphetamine; if injected or snorter, the fast effect (rush) is muted

42
Q

What are some examples of non-stimulants?

A

Atomoxetine (Strattera), Clonidine ER (Kapvay), Clonidine IR (Catapres), Guanfacine ER (Intuniv)

43
Q

What is the therapeutic class of Atomoxetine?

A

Selective norepinephrine reuptake inhibitor

44
Q

What is a boxed warning associated with Atomoxetine?

A

Risk of suicidal ideation; monitor for suicidal thinking or behavior, worsening mood, or unusual behavior

45
Q

What are contraindications of Atomoxetine?

A

MAO inhibitor use within the past 14 days, glaucoma, pheochromocytoma, severe cardiovascular disorders

46
Q

What are some warnings associated with Atomoxetine?

A
  • Aggressive behavior, treatment-emergent psychotic or manic symptoms, orthostasis and syncope, allergic reactions, priapism, urine hesitancy and retention
  • Rare but severe hepatotoxicity (most often within 120 days of starting treatment)
  • Serious cardiovascular events; assess at baseline and as needed during treatment and avoid use if known cardiac disease
  • Projected height and weight can be reduced in children
47
Q

What are some side effects of Atomoxetine?

A

Decreased appetite, insomnia, somnolence, dry mouth, hypertension, tachycardia, headache, nausea, abdominal pain, erectile dysfunction, decreased libido

48
Q

What are some monitoring parameters of Atomoxetine?

A

BP, HR, ECG, mood, height and weight (children)

49
Q

What is a counseling point about Atomoxetine?

A

Do not open the capsule (ocular irritant)

50
Q

What therapeutic class is Clonidine and Gunafacine?

A

Central Alpha-2A Adrenergic Receptor Antagonists

51
Q

What are some warnings associated with the central alpha-2A adrenergic receptor agonists?

A
  • Dose-dependent cardiovascular effects (bradycardia, hypotension, orthostasis, syncope), sedation and drowsiness
  • Do not discontinue abruptly (can cause rebound hypertension)
  • Guanfacine: skin rash (rare, discontinue if occurs); dose adjustments required with CYP3A4 inducers and inhibitors
52
Q

What are some side effects of the central alpha-2A adrenergic receptor agonists?

A

Dry moth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension, headache, nausea, abdominal pain

53
Q

What are some monitoring parameters of central alpha-2A adrenergic receptor agonists?

A

BP, HR

54
Q

What are some notes about central alpha-2A adrenergic receptor agonists?

A
  • Must be tapered off to decrease the risk of rebound hypertension: decrease dose (<0.1 mg/day for clonidine and <1 mg/day for guanfacine) every 3-7 days
  • Do not substitute IR clonidine or guanfacine for ER formulations
55
Q

What is a major drug interaction of Atomoxetine?

A

Atomoxetine is a CYP2D6 substrate; CYP2D6 inducers or inhibitors can necessitate a change in atomoxetine dose

56
Q

What are some major drug interactions of clonidine and guanfacine?

A
  • Watch for additive sedation when used in combination with other CNS depressants
  • Use caution with other drugs that decrease blood pressure and heart rate (e.g. beta blockers, non-DHP CCBs)
  • Guanfacine: double the dose if used with strong CYP3A4 inducers and decrease the dose by 50% if used with strong CYP3A4 inhibitors
57
Q

What are some key counseling points of stimulants?

A
  • MedGuide required
  • Can cause increased heart rate and blood pressure, serious cardiovascular events, insomnia, psychosis, priapism
  • Decreased appetite: eat a larger breakfast to prevent weight loss; check height and weight regularly in children
  • Ghost tablet in stool (Concerta)
  • Some formulations contain phenlyalanine, so do not use if you have phenylketonuria
58
Q

What are some key counseling points of Atomoxetine?

A
  • MedGuide required

- Can cause liver damage, suicidal ideation, somnolence

NAPLEX Review (45 decks)

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