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445- Pain and Mental Health > ADHD > Flashcards

ADHD Flashcards

1
Q

Essential feature of ADHD is a persistent pattern of _______- impulsivity that interferes with functioning and development

A

inattention and/or hyperactivity

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2
Q

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

A

5

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3
Q

____% of those diagnosed in childhood continue to have significant sx in adult life

A

50

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4
Q

what is the prevalence hap between M and F in ADHD

A

M higher, but gap is shrinking
F tend to have inattentive ADHD which is harder to catch

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5
Q

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

A

1- 1 other psyc condtiion

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6
Q

describe inattentive ADHD

A

wandering of task, lacking persistence, difficulty sustaining focus, and disorganization not due to defiance or lack of comprehension

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7
Q

describe hyperactive/ impulsivity in adhd

A

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

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8
Q

list the 3 types of ADHD

A

inattentive
hyperactive
combined

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9
Q

what are the 6 diagnostic criteria of ADHD

A

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

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10
Q

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?

A

6/9 on A1 or 6/9 on A2
5/9 if >17yrs old

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11
Q

what is typically the natural hx of ADHD

A

Hyperactivity predominant → inattention predominant → inattention and impulsivity predominant

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12
Q

describe mild ADHD

A

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

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13
Q

describe moderate ADHD

A

ADHD that is not mild or severe, but in between

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14
Q

describe severe ADHD

A

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

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15
Q

list the 3 categories of RF for ADHD

A

genetics
environment
temperament

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16
Q

what are 2 temperament descriptors for ADHD

A

reduced behavioral inhibition, novelty seeking

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17
Q

what are some environmental RF for ADHD

A

v low birth weight (but most do not develop ADHD), childhood trauma, neurological infections, EtOH/ substances during pregnancy, toxins (ex- lead)

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18
Q

describe genetic risks for ADHD

A

heritable, elevated risk for 1st degree relatives who have ADHD, no causal genes identified

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19
Q

describe the 2 points for pathophys of ADHD

A

altered brain anatomy
NT dysregulation

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20
Q

describe the NT dysregulation of ADHD

A

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

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21
Q

how do stimulants help with NT dysregulation in ADHD

A

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

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22
Q

describe the altered brain anatomy in ADHD

A

impaired connectivity between frontal decision making parts of the brain and middle processing parts

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23
Q

what are the causal genes for ADHD

A

there are none

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24
Q

what are some nonpharm options for ADHD

A

psychoeducation
psychosocial interventions to promote success in different settings/ interactions
manualized interventions
exercise, sleep hygiene, diet

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25
Q

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

A

1- not weight dosed

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26
Q

list the 4 issues that should be treated before ADHD

A

psychosis, severe mood disorders ,SUD, suicidality/ violence

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27
Q

name the 2 stimulants used in ADHD

A

amphetamines, methylphenidate

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28
Q

what is a nonstimulant used for ADHD

A

atomoxetine

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29
Q

alpha 2a receptor agonists for ADHD

A

guaifenesin, clonidine

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30
Q

1st line tx for ADHD is

A

long acting stimulants- methylphenidate or amphetamine based

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31
Q

pros of LA stimulants

A

↑adherence (comp SA), privacy, compliance, sx coverage, ↓diversion potential, rebound

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32
Q

cons of LA stimulants

A

cost, often not covered

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33
Q

if a pt has trialed vyvanse and failed, what should be next line?

A

another LA stimulant- either an amphetamine or methylphenidate

trial at least 2

34
Q

2nd line tx for ADHD

A

Short/ intermediate acting stimulants (amphetamine or methylphenidate based)

atomoxetine and guanfacine XR

35
Q

pros for atomoxetine and guanfacine XR

A

low abuse potential, alternate SE profile compared to stimulants

36
Q

cons for atomoxetine and guanfacine XR

A

less robust evidence, delayed onset at 6-8wks

37
Q

what agents may be combined with a long acting stimulant for augmentation in suboptimal responders

A

atomoxetine and guanfacine XR

38
Q

when should 3rd line agents be used in ADHD

A

CI to 1st + 2nd line
not indicated in uncomplicated ADHD- would have specialist at this point

39
Q

what are the 4 3rd line agents for ADHD

A

Clonidine (a2- adrenergic agonist)
Bupropion (NDRI)
Imipramine (TCA)
Modafinil (unclear MOA- CNS stimulant, DA activity)

40
Q

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

A

4 - guanfacine = decreased HR/ BP

41
Q

how to treat ADHD rebound

A

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

42
Q

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

A

4
not much evidence for growth delay

43
Q

how to manage insomnia with ADHD

A

AM dosing preferred, avoid late afternoon/evening doses if possible
Strict sleep schedule and sleep hygiene
non pharm/ pharm measures for sleep if necessary

44
Q

how to manage rebound hyperactivity with ADHD

A

May be due to wearing off of therapy
Consider using LA product if not already/ supplemental IR dose

45
Q

how to manage psychosis/ anxiety with ADHD meds

A

Not an absolute CI to stimulant therapy
Collaborate, consider adjunct AP, AD, or stabilizing tx
Titrate slowly

46
Q

how to manage reduced appetite/ growth with ADHD meds

A

Dose with meals rather than before or supplement meals with boost/ ensure
Schedule means to accommodate hunger
Drug holidays if necessary

47
Q

how to manage CV risk with ADHD meds

A

Monographs and most professional societies rec baseline ECG + cardiac eval if any hx of sx CVD- if no hx, not necessary

48
Q

amphetamines 3 MOA

A

↑ release of DA and NE from presynaptic neuron, ↓ presynaptic reuptake (competitive inhib), ↑ cerebral cortex and subcortical stimulation

49
Q

methylphenidate 2 MOA

A

↑ cerebral cortex stimulation + subcortical stimulation (ACC and precuneus), ↓ presynaptic reuptake of DA and NE (requires effective endogenous catecholamine release)

50
Q

2 intermediate acting amphetamines are

A

dextroamphetamine (dexedrine spansules), mixed amphetamine salts (Adderall XR)

51
Q

lisdexamphetamine onset and peak

A

<60min/ 3-5hrs

52
Q

what is the longest acting crushable tablet

A

vyvanse

53
Q

which ADHD med is a prodrug

A

Lisdexamfetamine (vyvanse)

54
Q

amphetamines are mostly metabolized by

A

2D6

55
Q

dexedrine spansules contain a mix of

A

50/50 of IR/CR sprinkles. Open and sprinkle if needed

56
Q

onset/ peak of biphentin

A

30-60min/ 2hrs

57
Q

Foquest onset/ peak

A

onset 60min
peak 2, 10hrs

58
Q

duration of foquest

A

16hrs

59
Q

what is the longest acting stimulant

A

foquest

60
Q

which of the following can not be crushed/ sprinkled (choose all that apply)
1. Adderall XR
2. ritalin SR
3. biphentin
4. dexedrine spansules

A

1, 2

61
Q

how is methylphenidate mtabolized

A

deesterificatio n

62
Q

are methylphenidate ER-C and Concerta interchangeable?

A

no- T max v different, pt will feel effects at different time

63
Q

biphentin is

A

metylphenidate CR capsule

64
Q

concerta is

A

methylphenidate CR tablet

65
Q

atomoxetine class

A

nonstimulants

66
Q

atomoxetine onset and max effect

A

2-4wks
max effect in 6-8wks

67
Q

atomoxetine half life

A

5hrs as a parent drug, 6-8hrs for metabolites

68
Q

which can not be used in children <6yrs
1. atomoxetine
2. guaifenesin

A

1

69
Q

atomoxetine caution with

A

SSRIs/ NDRIs that are 2D6 inhibitors like fluoxetine, paroxetine, buproprion

70
Q

atomoxetime SEs

A

Insomnia, weight loss/ ↓ appetite, anxiety, incr BP/tachy, somnolence

71
Q

guaifenesin class

A

Alpha 2a receptor agonists

72
Q

guifenesin onset

A

4-8wks

73
Q

which has no evidence in adults
1. atomoxetine
2. guaifenesin

A

2

74
Q

what is the only agent indicated for adj treatment with stimulants

A

guaifenesin

75
Q

you should not take guaifenesin with

A

grapefruit or fatty meals

76
Q

guaifenesin metabolism by

A

CYP 3A4

77
Q

guaifenesin SEs

A

Drowsiness, HA, hypotension/ bradycardia, upper abdominal pain, somnolence

78
Q

modafinil 2 MOAs

A

↓DA reuptake into presynaptic terminal = ↑ DA activity
Inhibits GABA NT via many effects of 5HT + receptors (GABA system often inhibits = ↓ inhibition = stimulating CNS)

79
Q

stimulant doses should be titrated _____, and nonstimulants ____

A

stimulants qwk
nonstimulnts q2wks

80
Q

Can observe improvements with stimulants in _______ and nonstimulants

A

stimulants: days to weeks
nonstimulants: wks-mths

81
Q

what is a CI for stimulants

A

FHx/ Hx glaucoma

445- Pain and Mental Health (21 decks)

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