ADHD Flashcards
ADHD Patho
Reduced activity in prefrontal and anterior cingulate cortex -> stimulants
Default mode network over-activity -> methylphenidate
ADHD symptoms
Inattention
Hyperactivity
Impulsivity
ADHD diagnosis
- 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
DSM 5 inattention/hyperactivity (impulsivity)
children and adolescents (<17)
- 6 or more symptoms for at least 6 months
adolescents and adults (17 and up)
- at least 5 symptoms required
ADHD presentation (infancy)
- irritability, fidgeting, crying
- difficulty feeding
- short periods of sleep/frequently interrupted sleep
ADHD presentation preschool (3-5)
- excessive motor activity
- intense temper tantrums
ADHD presentation school age (6-11)
- difficulty academically
- combined inattentive and hyperactive/impulsive
- comorbid oppositional defiant disorder, conduct disorder, aggression (greater risk for SUD in adolescence)
ADHD presentation adolescents (12-18)
- inattention and impulsivity > hyperactive
- significant functional impairment
- higher rates of delinquency, drug and alcohol use
- speeding/MVA > in ADHD vs non-ADHD
ADHD presentation adults (>18)
- inattention
- cognitive deficits
- impatient
- greater risk of unemployment, unstable relationships, psychiatric hospitalization, incarceration
Non-pharm (preschool/school age)
- parent/family education on ADHD
- training on behavioral modification
- behavioral classroom management (BCM)
Non-pharm (adolescent)
- break up assignments into manageable segments
- structured schedule
- behavioral peer inventions (BPI)
Non-pharm Adolescent/Adult
- ADHD specific CBT
- Metacognitive therapy (2hr/wk x 12 weeks)
Use of Iron and Zinc Supplementation
enhances therapeutic benefit of stimulants
(only in youth with known deficiencies)
First line therapy for ADHD
- Methylphenidate or Dexmethylphenidate
- Dextroamphetamine or Mixed Amphetamine Salts
Second line ADHD treatment
Atomoxetine
Viloxazine
Guanfacine ER
Clonidine ER
Bupropion
ADHD third line treatment
- combo therapy
- TCA
Predominant Tourette’s + ADHD treatment
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
Predominant bipolar (and/or severe aggression) + ADHD treatment
TREAT BIPOLAR FIRST
1st: atypical antipsychotic, lithium, or anticonvulsant
(Some Response)
- add stimulant
(Inadequate response)
- alternative or additional mood stabilizer
Predominant depression/anxiety + ADHD treatment
1st: antidepressant
(Some response)
- add stimulant
(Inadequate response)
- alternative antidepressant
Stimulant MOA
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
Which is more potent: Methylphenidate or Amphetamines?
Amphetamines
Stimulants:
IR Formulation Pearls
- Dose BID-TID (short T1/2)
- Drug onset: 15-30 min
- Duration: 2-6 hrs
Advantages:
- lower cost
- less insomnia
- fewer growth related ADE
Stimulants:
Long acting/ ER formulation pearls
- once daily dosing
- 8-12 hrs sx control
Advantages
- medication adherence
Stimulants: ADE
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
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
Stimulant ADE Management: reduced appetite / weight loss
high calorie meals when stimulant effect is low (breakfast/bedtime)
cyproheptadine at bedtime
Stimulant ADE Management: stomachache
- take on full stomach
- lower dose
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)
Stimulant ADE Management: Headache
- divide dose
- take with food
- give an analgesic
Stimulant ADE Management: Rebound Sx
long acting stimulant trial
Atomoxetine
Antidepressant
Stimulant ADE Management: irritability/ jitters
assess for comorbid condition
reduce dose
consider mood stabilizer or atypical antipsychotic
Stimulant ADE Management: dysphoria / euphoria
- reduce dose
- reassess diagnosis
- consider alternative therapy
Stimulant ADE Management: Zombie-like state
- reduce dose
- change stimulant medication
Stimulant ADE Management: Tics
- reduce dose
- consider alternate med
Stimulant ADE Management: HTN or pulse fluctuation
- Reduce dose
- Change medication
Stimulant ADE Management: Hallucinations
- DC stimulant
- reassess diagnosis
- mood stabilizer and / or antipsychotic
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
Dex-MPH formulation onset : duration
IR -> 30min : 3-6 hrs
XR -> 30 min : 9-12hrs
Dex-MPH / Ser-Dex-MPH -> 2hrs : 10-12hrs
Cotempla XR-ODT (MPH) pearls
do not push tablet through foil, peel back blister pack
dissolve on tongue; no liquid needed
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
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
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
Amphetamine XR-ODT / ER suspension (Adzenys)
- approved >/= 6 years
- dose conversion not 1:1
- can be taken w/wo food
- DO NOT CHEW ODT
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
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
NE reuptake inhibitors: Agents
Atomoxetine (Strattera)
Viloxazine ER (Qulbree)
NE reuptake inhibitors time to onset / peak
1-2 weeks to onset
4-8 weeks to peak
(with atomoxetine behavior may worsen initially)
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
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
A- adrenergic agonists agents
Clonidine ER (Kapvay)
Guanfacine ER (Intuniv)
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
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
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
Other treatment: Lithium/Anticonvulsants
Li
Valproate
Carbamazepine
- Effective for: aggression, explosive behavior, impulsivity
- childhood onset bipolar disorder or combined ADHD-bipolar disorder
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
