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Therapeutics P3 Fall > ADHD > Flashcards

ADHD Flashcards

1
Q

ADHD Patho

A

Reduced activity in prefrontal and anterior cingulate cortex -> stimulants

Default mode network over-activity -> methylphenidate

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2
Q

ADHD symptoms

A

Inattention
Hyperactivity
Impulsivity

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3
Q

ADHD diagnosis

A
  • sx onset before 12
  • significant impairment in at least 2 settings with documented symptoms
  • sx reduce quality of social, academic, or occupation functioning
  • sx are not due to another psychiatric/substance use disorder
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4
Q

DSM 5 inattention/hyperactivity (impulsivity)

A

children and adolescents (<17)
- 6 or more symptoms for at least 6 months

adolescents and adults (17 and up)
- at least 5 symptoms required

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5
Q

ADHD presentation (infancy)

A
  • irritability, fidgeting, crying
  • difficulty feeding
  • short periods of sleep/frequently interrupted sleep
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6
Q

ADHD presentation preschool (3-5)

A
  • excessive motor activity
  • intense temper tantrums
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7
Q

ADHD presentation school age (6-11)

A
  • difficulty academically
  • combined inattentive and hyperactive/impulsive
  • comorbid oppositional defiant disorder, conduct disorder, aggression (greater risk for SUD in adolescence)
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8
Q

ADHD presentation adolescents (12-18)

A
  • inattention and impulsivity > hyperactive
  • significant functional impairment
  • higher rates of delinquency, drug and alcohol use
  • speeding/MVA > in ADHD vs non-ADHD
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9
Q

ADHD presentation adults (>18)

A
  • inattention
  • cognitive deficits
  • impatient
  • greater risk of unemployment, unstable relationships, psychiatric hospitalization, incarceration
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10
Q

Non-pharm (preschool/school age)

A
  • parent/family education on ADHD
  • training on behavioral modification
  • behavioral classroom management (BCM)
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11
Q

Non-pharm (adolescent)

A
  • break up assignments into manageable segments
  • structured schedule
  • behavioral peer inventions (BPI)
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12
Q

Non-pharm Adolescent/Adult

A
  • ADHD specific CBT
  • Metacognitive therapy (2hr/wk x 12 weeks)
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13
Q

Use of Iron and Zinc Supplementation

A

enhances therapeutic benefit of stimulants
(only in youth with known deficiencies)

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14
Q

First line therapy for ADHD

A
  • Methylphenidate or Dexmethylphenidate
  • Dextroamphetamine or Mixed Amphetamine Salts
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15
Q

Second line ADHD treatment

A

Atomoxetine
Viloxazine
Guanfacine ER
Clonidine ER
Bupropion

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16
Q

ADHD third line treatment

A
  • combo therapy
  • TCA
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17
Q

Predominant Tourette’s + ADHD treatment

A

1st:
- dopamine antagonist
- alpha-2 agonist (guanfacine / clonidine)

(Some response)
- add stimulant, atomoxetine, or alpha-2 agonist

(Inadequate response)
- alternative dopamine antagonist or alpha-2 agonist

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18
Q

Predominant bipolar (and/or severe aggression) + ADHD treatment

A

TREAT BIPOLAR FIRST

1st: atypical antipsychotic, lithium, or anticonvulsant

(Some Response)
- add stimulant

(Inadequate response)
- alternative or additional mood stabilizer

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19
Q

Predominant depression/anxiety + ADHD treatment

A

1st: antidepressant

(Some response)
- add stimulant

(Inadequate response)
- alternative antidepressant

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20
Q

Stimulant MOA

A

Methylphenidate and Amphetamines

  • block dopamine and NE reuptake
  • amphetamines increase catecholamine release
  • inhibit monoamine oxidase
  • different stimulants work through different pathways -> lack of response to one class does not mean lack of response to another
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21
Q

Which is more potent: Methylphenidate or Amphetamines?

A

Amphetamines

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22
Q

Stimulants:
IR Formulation Pearls

A
  • Dose BID-TID (short T1/2)
  • Drug onset: 15-30 min
  • Duration: 2-6 hrs

Advantages:
- lower cost
- less insomnia
- fewer growth related ADE

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23
Q

Stimulants:
Long acting/ ER formulation pearls

A
  • once daily dosing
  • 8-12 hrs sx control

Advantages
- medication adherence

24
Q

Stimulants: ADE

A

Psychiatric
- psychosis/mania
- aggression
- severe anxiety/ anxiety attacks

Cardiac
- increased HR and BP
- increased risk for ED visits
- serious but generally negligible in patients without preexisting CVD conditions

Growth:
- 1cm/yr decrease over 1-3 yrs
- 3kg weight deficit in 1st year
- steadies out over time

25
Stimulant DDIs
Caffeine, Modafanil, nicotine -> additive ADE MAOI -> do not use within 14 days TCA -> TCA concentrations inc w/ MPH Antacids, PPI, H2RA -> increase absorption of MPH IR + decrease absorption MPH DR Antacids -> dec excretion of AMP PPI -> inc absorption of AMP Acidic agents (fruit juice) -> dec absorption of AMP CYP2D6 inhibitors -> inc exposure to AMP salts Alcohol -> stimulant dumping
26
Stimulant ADE Management: reduced appetite / weight loss
high calorie meals when stimulant effect is low (breakfast/bedtime) cyproheptadine at bedtime
27
Stimulant ADE Management: stomachache
- take on full stomach - lower dose
28
Stimulant ADE Management: Insomnia
- give dose earlier in day - lower the last dose of the day - add sedating medication at bedtime (guanfacine, clonidine, melatonin, or cycloheptadiene)
29
Stimulant ADE Management: Headache
- divide dose - take with food - give an analgesic
30
Stimulant ADE Management: Rebound Sx
long acting stimulant trial Atomoxetine Antidepressant
31
Stimulant ADE Management: irritability/ jitters
assess for comorbid condition reduce dose consider mood stabilizer or atypical antipsychotic
32
Stimulant ADE Management: dysphoria / euphoria
- reduce dose - reassess diagnosis - consider alternative therapy
33
Stimulant ADE Management: Zombie-like state
- reduce dose - change stimulant medication
34
Stimulant ADE Management: Tics
- reduce dose - consider alternate med
35
Stimulant ADE Management: HTN or pulse fluctuation
- Reduce dose - Change medication
36
Stimulant ADE Management: Hallucinations
- DC stimulant - reassess diagnosis - mood stabilizer and / or antipsychotic
37
MPH Formulation Onset : Duration
IR -> 20-60min : 3-6 hrs ER -> 60-80min : 3-8 hrs ER Chewable -> 60-120min : 10-12hrs CD -> 20-60min : 6-8 hrs LA -> 10-60min : 6-8 hrs XR suspension -> 45min : 12hrs OROS -> 30-60min : 10-12hrs MLR -> 20-60min : 12hrs MLR-02 -> 30-60min : 13hrs XR-ODT -> 60min : 12hrs PM -> >/=10hrs : 24-36hrs Transdermal patch -> 60-120min : 11-12hrs
38
Dex-MPH formulation onset : duration
IR -> 30min : 3-6 hrs XR -> 30 min : 9-12hrs Dex-MPH / Ser-Dex-MPH -> 2hrs : 10-12hrs
39
Cotempla XR-ODT (MPH) pearls
do not push tablet through foil, peel back blister pack dissolve on tongue; no liquid needed
40
Jornay PM (MPH ER) pearls
Delexis drug delivery system -> multiple layer beads - 1st layer: 10 hrs (< 5% MPH) - 2nd layer: dissolves throughout the day: 14hrs to peak evening dosing not recommended to convert mg to mg from other MPH products
41
MPH Pearls
preferred product in children/adolescents time to peak concentration delayed by high fat meals tics occur more often with transdermal patch BBW for skin reaction with transdermal patch - chemical leukoderma and/or severe allergic contact sensitization caution in pats w/ glaucoma, tics, psychosis, and concurrent MAOI use safe with epilepsy Priapism reported after prolonged exposure, dose increases, or drug withdrawal
42
Dyanavel XR (amphetamine ER solution)
- approved >/= 6 yrs - dose conversion not 1:1 (re-titrate when switching) - ADE: epistaxis (nose bleeds), upper abdominal pain, allergic rhinitis
43
Amphetamine XR-ODT / ER suspension (Adzenys)
- approved >/= 6 years - dose conversion not 1:1 - can be taken w/wo food - DO NOT CHEW ODT
44
Mydayis (mixed single entity amphetamine salts ER)
- >/= 13yo - onset: 1-2hrs - duration: 16 hrs - cannot convert mg to mg with other amphetamines - triple time release beads within capsule to reduce med wearing off
45
AMP pearls
- inc release of DA and NE into synapse - enhance release of NE in periphery - high fat meals delay time to peak - preferred stimulant in adults - IR doses should not be given < 6hrs before bed - IR formulation preferred <5 yo - CI with Hx of cardiovascular disease
46
NE reuptake inhibitors: Agents
Atomoxetine (Strattera) Viloxazine ER (Qulbree)
47
NE reuptake inhibitors time to onset / peak
1-2 weeks to onset 4-8 weeks to peak (with atomoxetine behavior may worsen initially)
48
NE reuptake inhibitors ADE
- Upset stomach - psychiatric effects - CV effects (QTc prolongation) - greater risk fatigue, sedation, and dizziness - liver toxicity (atomoxetine) - renal dose adjustment (viloxazine) - BBW: new-onset suicidality
49
NE reuptake inhibitors DDI
do not use with other QTc prolonging meds (antipsychotics, TCAs) Atomoxetine - concentration inc with paroxetine & fluoxetine Viloxazine - antidepressants - antipsychotics - benzos - buprenorphine, hydrocodone, methadone, oxycodone
50
A- adrenergic agonists agents
Clonidine ER (Kapvay) Guanfacine ER (Intuniv)
51
Alpha adrenergic agonists pearls
- inc blood flow to pre-frontal cortex -> enhances working memory and executive function - not as effective as stimulants for monotherapy - ADE: sedation/dizziness, hypotension, constipation, heart block - Clonidine commonly added as adjunct to stimulants - ER should not be taken with high fat meal
52
Other treatment: Bupropion
Bupropion 50-300 mg/day - weak DA and NE reuptake inhibitor - found beneficial in adolescents with ADHD and depression - ADE: appetite suppression/weight loss (less than stimulants) seizures
53
Other treatment: TCAs
Imipramine 50-150mg/day Desipramine 300mg/day Nortriptyline 300 mg/day - up to 4 weeks to see max effects - ADE: sedation/dizziness, constipation, heart block, weight gain, overdose toxicity, rapid heart beat
54
Other treatment: Lithium/Anticonvulsants
Li Valproate Carbamazepine - Effective for: aggression, explosive behavior, impulsivity - childhood onset bipolar disorder or combined ADHD-bipolar disorder
55
Other treatments: Antipsychotics
Chlorpromazine & Haloperidol - hyperactivity - impulsivity - negative effects on learning, cognitive function, and can cause extrapyramidal ADE Second Gen: Risperidone, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole - severe aggression (comorbid conduct or BPD) - risk of metabolic syndrome

Therapeutics P3 Fall (21 decks)

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