ADHD Flashcards
Essential feature of ADHD is a persistent pattern of _______- impulsivity that interferes with functioning and development
inattention and/or hyperactivity
ADHD is
1. often changing once in adulthood
2. more often diagnosed in adulthood
3. a chronic, lifelong condition
4. a neurodevelopmental disorder
5. 3+4
6. all of the above
5
____% of those diagnosed in childhood continue to have significant sx in adult life
50
what is the prevalence hap between M and F in ADHD
M higher, but gap is shrinking
F tend to have inattentive ADHD which is harder to catch
which of the following is false
1. 70% school aged children with ADHD have at least 2 other psychiatric condition
2. those with ADHD are more likely to have an intellectual disability
3. tends to come with anxiety and depression in adulthood
4. stimulants in adulthood are protective against substance use disorder
1- 1 other psyc condtiion
describe inattentive ADHD
wandering of task, lacking persistence, difficulty sustaining focus, and disorganization not due to defiance or lack of comprehension
describe hyperactive/ impulsivity in adhd
excess motor activity when it is not appropriate (excessive fidgeting, tapping, talkativeness)/ hasty actions that occur in the moment without forethought + have high potential to harm that individual- desire for immediate rewards or inability to delay gratification
list the 3 types of ADHD
inattentive
hyperactive
combined
what are the 6 diagnostic criteria of ADHD
Meets 6 or more of sx criteria (if >17yrs old only req 5)
Present for last 6 mths
Sx interfere with functioning or development
Several sx present prior to 12yrs old
Sx present in 2 or more settings (home/ school)
Sx not explained by another mental disorder, and do not occur exclusively during the course of another psychotic disorder
how many points does one need from either the A1 or A2 category to get an inattentive or hyperactive ADHD diagnosis if they’re under 17? what if they’re older than 17?
6/9 on A1 or 6/9 on A2
5/9 if >17yrs old
what is typically the natural hx of ADHD
Hyperactivity predominant → inattention predominant → inattention and impulsivity predominant
describe mild ADHD
few, if any sx in excess of those required to make a dx are present +sx result in no more than minor impairment in social/ occupational function
describe moderate ADHD
ADHD that is not mild or severe, but in between
describe severe ADHD
many sx in excess fo those required for dx, or several that are severe, or the sx result in significant impairment in social/ occupational functioning
list the 3 categories of RF for ADHD
genetics
environment
temperament
what are 2 temperament descriptors for ADHD
reduced behavioral inhibition, novelty seeking
what are some environmental RF for ADHD
v low birth weight (but most do not develop ADHD), childhood trauma, neurological infections, EtOH/ substances during pregnancy, toxins (ex- lead)
describe genetic risks for ADHD
heritable, elevated risk for 1st degree relatives who have ADHD, no causal genes identified
describe the 2 points for pathophys of ADHD
altered brain anatomy
NT dysregulation
describe the NT dysregulation of ADHD
low tonic pool of DA and NE = not enough negative feedback to presynaptic neuron = neuron doesn’t know what to do if burst
when a burst happens = no negative feedback = DA/NE overwhelms the postsynaptic receptors = impaired attention and hyperactivity
how do stimulants help with NT dysregulation in ADHD
Stimulants reduce reuptake of DA/NE = higher baseline pool = ↑ negative feedback
when a burst happens = better able to control it as the burst amount and stimulus DA/NE amount are more similar, negative feedback not as overwhelmed
describe the altered brain anatomy in ADHD
impaired connectivity between frontal decision making parts of the brain and middle processing parts
what are the causal genes for ADHD
there are none
what are some nonpharm options for ADHD
psychoeducation
psychosocial interventions to promote success in different settings/ interactions
manualized interventions
exercise, sleep hygiene, diet
which of the following is false
1. ADHD meds should be dosed by weight in children
2. caution with MP in 1st trimseter due to risk of cardiac malformations
3. MP is CI in those with FHx/ personal Hx of glaucoma
4. there is no max age for stimulants
1- not weight dosed
list the 4 issues that should be treated before ADHD
psychosis, severe mood disorders ,SUD, suicidality/ violence
name the 2 stimulants used in ADHD
amphetamines, methylphenidate
what is a nonstimulant used for ADHD
atomoxetine
alpha 2a receptor agonists for ADHD
guaifenesin, clonidine
1st line tx for ADHD is
long acting stimulants- methylphenidate or amphetamine based
pros of LA stimulants
↑adherence (comp SA), privacy, compliance, sx coverage, ↓diversion potential, rebound
cons of LA stimulants
cost, often not covered
if a pt has trialed vyvanse and failed, what should be next line?
another LA stimulant- either an amphetamine or methylphenidate
trial at least 2
2nd line tx for ADHD
Short/ intermediate acting stimulants (amphetamine or methylphenidate based)
atomoxetine and guanfacine XR
pros for atomoxetine and guanfacine XR
low abuse potential, alternate SE profile compared to stimulants
cons for atomoxetine and guanfacine XR
less robust evidence, delayed onset at 6-8wks
what agents may be combined with a long acting stimulant for augmentation in suboptimal responders
atomoxetine and guanfacine XR
when should 3rd line agents be used in ADHD
CI to 1st + 2nd line
not indicated in uncomplicated ADHD- would have specialist at this point
what are the 4 3rd line agents for ADHD
Clonidine (a2- adrenergic agonist)
Bupropion (NDRI)
Imipramine (TCA)
Modafinil (unclear MOA- CNS stimulant, DA activity)
which agent is incorrectly matched with it’s SE
1. atomoxetine = increased BP
2. methylphenidate = decreased appetite
3. rebound LA agents = rebound
4. guanfacine = increased HR
4 - guanfacine = decreased HR/ BP
how to treat ADHD rebound
Dividing daily doses into 2 tablets taken at different times to ensure they wear off over a longer period (ex- 9am + 12pm dose)
Supplement with a low dose of SA stimulant to overlap end of LA
which of the following is a pro for drug holidays in ADHD- choose the one with the best evidence
1. avoid being shorter than peers
2. avoids exposure to SEs
3. allows for reassessment of therapy
4. 2+3
5. all of the above
4
not much evidence for growth delay
how to manage insomnia with ADHD
AM dosing preferred, avoid late afternoon/evening doses if possible
Strict sleep schedule and sleep hygiene
non pharm/ pharm measures for sleep if necessary
how to manage rebound hyperactivity with ADHD
May be due to wearing off of therapy
Consider using LA product if not already/ supplemental IR dose
how to manage psychosis/ anxiety with ADHD meds
Not an absolute CI to stimulant therapy
Collaborate, consider adjunct AP, AD, or stabilizing tx
Titrate slowly
how to manage reduced appetite/ growth with ADHD meds
Dose with meals rather than before or supplement meals with boost/ ensure
Schedule means to accommodate hunger
Drug holidays if necessary
how to manage CV risk with ADHD meds
Monographs and most professional societies rec baseline ECG + cardiac eval if any hx of sx CVD- if no hx, not necessary
amphetamines 3 MOA
↑ release of DA and NE from presynaptic neuron, ↓ presynaptic reuptake (competitive inhib), ↑ cerebral cortex and subcortical stimulation
methylphenidate 2 MOA
↑ cerebral cortex stimulation + subcortical stimulation (ACC and precuneus), ↓ presynaptic reuptake of DA and NE (requires effective endogenous catecholamine release)
2 intermediate acting amphetamines are
dextroamphetamine (dexedrine spansules), mixed amphetamine salts (Adderall XR)
lisdexamphetamine onset and peak
<60min/ 3-5hrs
what is the longest acting crushable tablet
vyvanse
which ADHD med is a prodrug
Lisdexamfetamine (vyvanse)
amphetamines are mostly metabolized by
2D6
dexedrine spansules contain a mix of
50/50 of IR/CR sprinkles. Open and sprinkle if needed
onset/ peak of biphentin
30-60min/ 2hrs
Foquest onset/ peak
onset 60min
peak 2, 10hrs
duration of foquest
16hrs
what is the longest acting stimulant
foquest
which of the following can not be crushed/ sprinkled (choose all that apply)
1. Adderall XR
2. ritalin SR
3. biphentin
4. dexedrine spansules
1, 2
how is methylphenidate mtabolized
deesterificatio n
are methylphenidate ER-C and Concerta interchangeable?
no- T max v different, pt will feel effects at different time
biphentin is
metylphenidate CR capsule
concerta is
methylphenidate CR tablet
atomoxetine class
nonstimulants
atomoxetine onset and max effect
2-4wks
max effect in 6-8wks
atomoxetine half life
5hrs as a parent drug, 6-8hrs for metabolites
which can not be used in children <6yrs
1. atomoxetine
2. guaifenesin
1
atomoxetine caution with
SSRIs/ NDRIs that are 2D6 inhibitors like fluoxetine, paroxetine, buproprion
atomoxetime SEs
Insomnia, weight loss/ ↓ appetite, anxiety, incr BP/tachy, somnolence
guaifenesin class
Alpha 2a receptor agonists
guifenesin onset
4-8wks
which has no evidence in adults
1. atomoxetine
2. guaifenesin
2
what is the only agent indicated for adj treatment with stimulants
guaifenesin
you should not take guaifenesin with
grapefruit or fatty meals
guaifenesin metabolism by
CYP 3A4
guaifenesin SEs
Drowsiness, HA, hypotension/ bradycardia, upper abdominal pain, somnolence
modafinil 2 MOAs
↓DA reuptake into presynaptic terminal = ↑ DA activity
Inhibits GABA NT via many effects of 5HT + receptors (GABA system often inhibits = ↓ inhibition = stimulating CNS)
stimulant doses should be titrated _____, and nonstimulants ____
stimulants qwk
nonstimulnts q2wks
Can observe improvements with stimulants in _______ and nonstimulants
stimulants: days to weeks
nonstimulants: wks-mths
what is a CI for stimulants
FHx/ Hx glaucoma
