ADHD Flashcards
Patho
-dec total brain volume in prefrontal cortex, caudate nucleus, anterior cingulate gyrus, cerebellum
-reduced activity in prefrontal and anterior cingulate cortex (reversed w/ stimulants)
-lack of connectivity b/t the prefrontal cortex and precuneus causes lapses in attention and impulse control
-dec activation of the ventral striatum when anticipating reward
-default mode network over-activity (methylphenidate suppresses)
Diagnosis
-must be before 12 yo
-significant impairment must be seen in >/= 2 setting (home, work, etc)
-evidence that symptoms interfere w/ or reduce the quality of social, academic or occupation functioning
-symptoms are not due to another psych disorder
-6 or more inattention sx or hyperactivity (impulsivity)
- >17 yo need at least 5 symptoms
Dietary information
-Iron/zinc supplementation (no enough alone)
-Omega 3: may benefit some people, low SE, results not consistent
-additive free diets (useful in small numbers of children)
-sugar/artificial sweetener avoidance (proper balanced diet)
Treatment (predominant ADHD)
-Methylphenidate or Amphetamine
-inadequate response: atomoxetine, viloxazine, guanfacine, clonidine, bupropion
-then combo therapy or TCA
-if patient has active sub abuse skip methylphenidate and amphetamine
Treatment (predominant comorbidity)
-Bipolar always manage first bc inc risk of mania
-Tourettes: dopamine antagonist or alpha 2 agonist; then add stimulant or whatever wasn’t tried
-BPD: atypical APS, Li, or AED; then add stimulant, then add alternative mood stabilizer
-anxiety or depression: AD; then add stimulant; then alternative AD
Stimulants
-Amphetamine more potent than MPH
-IR: lower cost, less insomnia, fewer growth related ADE, dose a lot during the day bc they have a shorter t1/2
ER: good for medication adherence, some pt require another dose in afternoon to make it through the end of the day
-AE: psychiatric, growth, cardiac, reduced appetite/weight, stomachache, insomnia, HA, rebound sx, irritability
-DDI: other psychostimulants, MAOIs, TCA, antacids, alcohol can cause dose dumping
MPH ER chew
-good for children
-can be halved
MPH CD
-30% IR and 70% ER beads
-can open and put on applesauce
MPH LA
-50% IR and 50% ER beads
-can open and put on applesauce
-between for more severe morning sx compared to CD/MLR bc higher IR component so onset quicker
MPH XR suspension
-requires vigorous shaking for at least 10 sec
-reconstituted by pharmacist (good for 4 months)
MPH OROS
-special delivery system
-swallow whole do not crush/chew
MPH MLR
better for rebound afternoon sx due to larger ER ratio
MPH transdermal patch
-dose not equivalent to oral
-drug active for 3 more hrs after removal
-apply 2 hrs prior to desired onset
-may be worn up to 9 hrs
-tics occur more with patch
-BBW: chemical leukoderma and/or severe allergic contact sensitization
Dex-MPH IR
-no greater benefit over MPH
-1/2 dose of MPH
-lower abuse potential
Dex-MPH XR
-50% IR and 50% ER beads
-afternoon sx control not as good as OROS
Jornay PM (MPH ER)
-1st layer: 10 hrs to dissolve; <5% MPH released
-2nd layer: dissolve throughout the day; 14 hrs to drug peak
-no more than 5% of total drug absorbed in first 10 hours
-administer b/t 6:30-9:30 pm
-starts working when patient wakes up
-if miss dose, skip and resume at next bedtime
-take consistently w or w/o food
Mixed AMP-IR salts and Amphetamine sulfate-IR
approved in children at least 3 yo
Mixed AMP-XR salts
-50% IR and 50% ER
-may be opened and sprinkled on applesauce
AMP sulfate XR soln
dose conversion not 1:1 must retitrate
Lisdexamfetamine
designed for less abuse potential
Dyanavel XR (AMP soln)
-approved for at least 6 yo
-not 1:1 dose conversion
-SE: nose bleed, allergic rhinitis
AMP XR-ODT/ER suspension (Adzenys)
-approved for at least 6 yo
-not 1:1
-food delays time to peak
-5 mg (adderall) = 3.1 mg (adzenys)
Mydayis (mixed AMP salts XR)
- > /= 13 yo
-Has XR, intermediate release, and IR (no potential for trough)
AMP
-preferred stimulant in adults
-preferred for < 5 yo
-afternoon dose should not be given < 6 hrs before bedtime
-CI: CVD
Norepinephrine reuptake inhibitors
-Atomoxetine, Viloxazine XR
-stimulants have greater efficacy than atomoxetine
-takes 6-8 weeks for full benefit
-behavior may worsen initially (atomoxetine)
-AE: not rec in heart problems, liver toxicity (BBW), BBW for new onset suicidality)
-DDI: APS, TCA, Paxil and Prozac inc atomox conc
-Viloxazine has a lot of DDI
Alpha-adrenergic receptor agonists
-Clonidine XR, Guanfacine XR
-enhances working memory and executive functioning
-not as effective as stimulants for mono-therapy
-AE: sedation/dizziness, hypotension, constipation, heart block
-clonidine commonly added adjunct to stimulants
-XR should not be taken with high fat meal
-added on for AE management (insomnia)
Bupropion
-not FDA approved
-found beneficial in adults with ADHD and depression
-AE: less appetite suppression and wt loss compared to stimulants, seizures
-should not be used to alc disorder or eating disorder
TCA
-Imipramine, Dessipramine, Nortriptyline
-AE: sedation, constipation, heart block, weight gain, overdose toxicity, rapid heart beat
Li, VPA, CBZ
-effective for: aggression, explosive behavior, impulsivity
-childhood onset bipolar disorder or combined ADHD-bipolar disorder
APS
-chlorpromazine and haloperidol (hyperactivity, impulsivity, neg effects in learning, cog function and can cause EPS)
-SGA: risperidone, olanzapine, quetiapine, ziprasidone, abilify (severe aggression, risk of metabolic syndrome)
