ADHD Flashcards
what is ADHD?
Developmental condition of inattention and distractibility, with or without accompanying hyperactivity
what is the 3 basic forms of ADHD?
Predominantly inattentive Predominantly hyperactive/impulsive Combined
when is ADHD first diagnosed?
Normally diagnosed between 3-7 yrs, although in some cases
it may not be until much later
what are some inattentive symptoms in ADHD?
•short attention span •easily distracted •making careless mistakes •appearing forgetful •losing things •unable to stick at mundane tasks •unable to follow instructions •being unable to concentrate •constantly changing activity •difficulty organising tasks
what are some primary hyperactivity symptoms of ADHD?
•being unable to sit still, especially in calm or quiet surroundings •constantly fidgeting •being unable to settle to tasks •excessive physical movement •excessive talking
what are some impulsiveness symptoms of ADHD?
•being unable to wait for a turn •acting without thinking •interrupting conversations •breaking any set rules •little or no sense of danger
what are some related disorders that can occur alongside ADHD?
Anxiety Disorder ODD Conduct Disorder Depression Sleep disorders tourettes epilepsy learning difficulties
is ADHD carried into adult life?
–Approximately 15% retained the full ADHD diagnosis.
–Approximately 65% were in ‘partial remission’ (with
persistence of some symptoms and continuing
functional impairment, such as psychological, social,
or educational difficulties).
what are the aims of treatment of ADHD?
Reduce functional impairment
•Reduce severity of symptoms
•Improve quality of life
what is done in primary care?
- Explore the presenting problems and extent of impact
* Referral: Formal diagnosis and treatment of ADHD by specialist
when may you initially manage ADHD in primary care?
•May initially manage in primary care if not severe
–Assessment of social and educational impact
–Watchful waiting up to 10 weeks
–Parent group-based ADHD-focused support
how should ADHD be managed in pre-school children?
Drug Tx not recommended
Parent-training/education programme
Specialist advice where ineffective
how should ADHD be managed in school-aged and young people?
Drugs are not first-line.
Parent-training/education programme +/- CBT and
social skills training
Reserve drugs for when persistent significant
impairment after environmental modifications
implemented/ reviewed. Methylphenidate 1st line,
how should ADHD be managed in adults?
Environmental modifications
Drug treatment
(methlyphenidate/ lisdexamfetamine) offered if
ADHD symptoms still cause significant impairment
Non-pharmacological treatment can be considered
alongside
what influences the choice of therapy?
Guidance
•Interactions (drug or disease)
•Licensing (age)
•Individual response
•Convenience
•Adherence
•Reducing stigma e.g. medication at school or workplace
•Storing at administering of CDs at school
•Abuse potential
•Formulation: Risk of stimulant misuse and diversion with IR preparations
•PK profiles – IR may be suitable if more flexible dosing regimens needed , or during initial titration to determine correct dosing
levels. Combination of MR and IR where appropriate
what is 1//2/3 rd line for ADHD?
1st Methylphenidate
2nd Lisdexamfetamine (can use 1st in adults)
3rd Dexamfetamine
what ADHD medication can be abused?
stimulants
eg dexamphetamine
what is methylphenidate?
- Controlled drug, schedule 2
* Increases intrasynaptic concentration of dopamine and noradrenaline in frontal cortex
what are the common side effects from methylphenidate?
–Insomnia, nervousness, headache, decreased appetite,
abdominal pain
–Other gastrointestinal symptoms,
–Cardiovascular effects such as tachycardia, palpitations
and minor increases in blood pressure.
–Growth can be affected, at least in the short term, so
height and weight are monitored regularly and plotted
on growth charts
what are the effecrs of methylphenidate enhanced by?
alcohol
what may methylphenidate affect your ability to do?
drive
how should you initiate methylphenidate?
Start at low dose and titrate against symptoms and side-effects over 4-6 weeks until dose optimisation achieved
why is it important to prescribe methylphenidate by brand?
Prescribe by brand as different MR preparations may not be equivalent
can you stop methylphenidate aburptly?
no
how should you monitor methylphenidate upon initiation and hereafter?
Monitor on initiation of therapy, following dose adjustments and at least every 6 months thereafter: - Pulse, BP - psychiatric symptoms - appetite, weight and height
what driving advice is there for amphetamines?
•Don’t drive if feel dizzy or drowsy, unable to concentrate or if blurred/ double vision
•Helpful to keep copy of prescription in the car as it is an offence to drive with more than a specified amount of
amfetamines in body
–roadside saliva tests/ may need to provide blood sample
what if your driving is not impaired with amphetamines?
Provided driving is not impaired, people found to have more than the specified amount of these drugs in their
body but are taking the drug on the advice of a GP,
pharmacist, or in accordance with the patient information
leaflet will be able to raise a ‘statutory defence’ to avoid prosceution
what is dexamfetamine?
A sympathomimetic amine with a central stimulant and anorectic activity
how does dexamfetamine work?
In addition to blocking the reuptake of dopamine and
noradrenaline via the dopamine transporter (DAT) it also releases dopamine and noradrenaline into the extraneuronalspace by blocking the intraneuronal vesicular monoamine transporter (VMAT).
why is dexamfetamine not first line?
Greater potential for diversion and misuse than the other medications therefore not first-line
how does the half life of dexamfetamine affect the dosage in children?
The elimination half-life of dexamfetamine in children is 6.8 hours, therefore, once or twice daily dosing is sufficient (Brown et al., 1979).
what is lisdexamfetamine?
•Prodrug of dexamfetamine
what is atomoxetine?
elective noradrenaline reuptake inhibitor
•Licensed for ADHD in children aged 6 years and over, adolescents and adults
how does atomocetine differ from stimulants?
by having less effect on subcortical brain regions associated with motivation and reward.
when is atomcetine a good option?
Good option for patients where abuse may be a problem. Alsoatomoxetine does not appear to promote the development of new tics or exacerbation of comorbid anxiety vs. methylphenidate.
what is the common side effects of atomoxetine?
Abdominal pain, decreased appetite, nausea and vomiting, early morning awakening, irritability and mood swings.
•Increased HR and BP (see next slide)
•Prolongs QT interval (avoid concomitant use with other drugs that prolong QT).
what are the symptoms of hepatic disorders in atomoxetine?
–Abdominal pain, unexplained nausea, malaise, darkening of urine, jaundice
who us atimoxetine C/I in?
severe cardiovascular or cerebrovascular disorders
what monitoring should be done for ADHD drugs?
Prior to initiation of drug therapy and every 3-6 months thereafter: •Pulse and after dose changes •BP and after dose changes •Weight (3m if <10yrs) (BMI in adults) •Height in children and young people on growth chart •Sleep disturbances •Erectile dysfunction (atomoxetine) •Cardiovascular assessment
what should you do if weight loss is an issue with ADHD drugs?
–Taking medication with or after food
–Additional snacks early morning or late eve when the stimulant effects of drug have worn off
–Seeking dietary advice
–Increasing consumption of high calorie foods with
good nutritional value
–Changing medication
what are the key interactions with methylphenidate?
anticoagulants carbamazipine MAOIs phenytoin SSRIs TCAs alcohol
what are the key interactions with amphetamines?
moclobemide MAOIs rasagline atimoxetine TCAs SSRIs HIV protease inhibitors
what are the key interactions iwth atomoxetine?
MAOIs
drugs that prolong the QT interval
terbinafine
