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ADHD Flashcards

1
Q

What increases ADHD risk by 2-3x?

A

Very low birth weight

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2
Q

How do stimulants help with ADHD?

A

Reducing activity in the prefrontal and anterior cingulate cortex

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3
Q

How does methylphenidate help with ADHD?

A

Suppresses default mode network over-activity

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4
Q

ADHD diagnosis

A

MUST have onset of symptoms before age 12
- Significant impairment in at least 2 settings with documented symptoms
- Interfere with daily life
- Not due to other psychiatric disorder

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5
Q

ADHD symptom requirements

A

6 or more symptoms for at least 6 months

For older adolescents/adults, 5 symptoms

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6
Q

In which age range do most diagnoses occur?

A

School age (6-11)

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7
Q

What is first line treatment for predominant ADHD?

A

MPH or dexMPH

DextroAMP or AMP salts

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8
Q

You have inadequate response to MPH or AMP… what do you do next?

A

Try the other

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9
Q

T/F: SNRIs (Atomoxetine, Viloxazine) have similar efficacy to stimulants in ADHD

A

FALSE: they are less efficacious

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10
Q

What is second line treatment for ADHD?

A

Atomoxetine, Viloxazine

Guanfacine ER or IR, Clonidine ER or IR, Bupropion

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11
Q

Where do you start ADHD therapy in active substance abuse?

A

Second line

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12
Q

What is third line treatment for ADHD?

A

Combination treatment or TCA

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13
Q

What is first line ADHD treatment with predominant Tourette’s?

A

Dopamine agonist or alpha-2 agonist

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14
Q

What is second line ADHD treatment with predominant Tourette’s?

A

Add stimulant, atomoxetine, or alpha2

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15
Q

What is third line ADHD treatment with predominant Tourette’s?

A

Alternative DA or alpha2

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16
Q

What is first line ADHD treatment with predominant BPD?

A

Atypical antipsychotic, lithium, anticonvulsant

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17
Q

What is second line ADHD treatment with predominant BPD?

A

Add stimulant (very low dose)

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18
Q

What is third line ADHD treatment with predominant BPD?

A

Alternative or additional mood stabilizer

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19
Q

What is first line ADHD treatment with predominant anxiety or depression?

A

Antidepressant

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20
Q

What is second line ADHD treatment with predominant anxiety or depression?

A

Add stimulant

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21
Q

What is third line ADHD treatment with predominant anxiety or depression?

A

Alternative antidepressant

22
Q

Immediate release formation advantages

A
  • Low cost
  • Less insomnia
  • Fewer growth related ADE
23
Q

Long acting/extended release formation advantages

A

Medication adherence

24
Q

Stimulant ADEs

A
  • Psychiatric effects (very rare)
  • Cardiac issues (barely any change)
  • Growth (not very significant, dose related)
25
Stimulant ADEs
- Additive effects with psychostimulants (modafinil, caffeine, nicotine) - No MAOis <14 days - MPH can increase TCA conc. - GERD drugs increase MPH IR and reduce MPH ER - Antacids increase AMP, PPIs increase AMP absorption - Acidic substances lower AMP - CYP2D6 inhibitors increase AMP (fluoxetine, bupropion) - Alcohol causes dose dumping
26
How do you manage weight loss in ADHD?
Take high calorie meals when stimulant effect is low Cyproheptadine at bedtime
27
How do you manage stomachache in ADHD?
Take on full stomach Lower dose
28
How do you manage insomnia in ADHD?
Give dose earlier in the day Lower last dose Add sedating medication (not melatonin in prepuberty)
29
How do you manage headache in ADHD?
Divide dose, give with food, analgesic
30
How do you manage rebound in ADHD?
Long acting stimulant Atomoxetine, antidepressant
31
How do you manage irritability jitteriness
Comorbid? Reduce dose Consider mood stabilizer or atypical antipsychotic
32
Methylphenidate
Preferred for children/adolescents (not FDA approved until 6 y/o) - Time to peak delayed by high fat meals - Titrate weekly until response - BBW for patch!!! contact allergy and chemical leukoderma - skin changes color - Patch has more tics, only indicated up to 17 y/o - Safe in epilepsy - Priapism possible - DDIs less likely than AMP - Males have higher bioavailability
33
Amphetamine
FDA approved in children 3+ but NOT PREFERRED** - Peak is around 3 hours in IR - ER is mostly 50/50 - Lisdexamphetamine designed for less abuse potential - Preferred in adults - Titrate weekly until response - IR preferred in <5 y/o - Contraindicated in CV disease - DexAMP patch can be used >6 years old into adulthood
34
Patches for MPH and AMP
- 9 hour max wear time - Use 2 hours before effect is needed - MPH only applied to hip, AMP more variability - >50% MPH remains in patch, <10% dexAMP remains in patch
35
What MPH formulation is best for severe morning symptoms?
MPH LA (50IR/50ER)
36
What are most MPH ER products composed of?
30% IR / 70% ER
37
What MPH formulation is best for afternoon rebound symptoms?
MPH MLR (larger ER ratio)
38
T/F: DexMPH is more potent than MPH
TRUE: give 1/2 dose of MPH for same effect
39
What is important about Ser-DexMPH
Prodrug -> less abuse potential but suicide risk
40
How do you take MPH PM?
At bedtime, 10h time to effect Do NOT let patients take in the morning if they forget, it will mess everything up
41
What to use in a >3 y/o for ADHD
Try behavioral interventions first (obvi) IR MPH preferred*** IR AMPs FDA approved
42
What to use in >6 y/o for ADHD
Anything basically (most studied group)
43
What to use in >13 years for ADHD
Mydayis (ER AMP/DexAMP)
44
SNRIs in ADHD
- 1-2 weeks for effect, 6 week trial - Safe in children/teens/adults - QTc prolongation - Fatigue, dizziness - Suicide BBW - Liver toxicity for atomoxetine long term - Renal dosing for viloxazine - Atomoxetine BID to improve tolerability
45
Atomoxetine DDIs
CYP2D6 (paroxetine, fluoxetine)
46
Viloxazine DDIs
CYP1A2, CYP 2D6, CYP3A4 - Antidepressants, antipsychotics, benzos, opioids
47
Alpha 2s
Clonidine ER, Guanfacine ER - IR ok but more frequent - Heart block**, sedation, constipation - ER don't take with high fat meal - 1-2 month trial
48
Bupropion
Not FDA approved - Off label, adolescents with ADHD and depression - DO NOT USE WITH SEIZURES, EATING DISORDERS, ALCOHOL ABUSE - Metabolized faster in prepuberty (BID dosing optimal) - 6 week trial
49
TCAs
- Overdose toxicity*** -> heart block (avoid in suicidal) - 4 weeks for max effect - Sedating
50
APS in ADHD
- 1st gens suck (EPS) - 2nd gens good for severe aggression, but have metabolic syndrome
51
T/F: Early use of stimulants increases risk of substance abuse
FALSE: more abuse reported with LATER onset of treatment - Atomoxetine, a2 agonists, or bupropion preferred in substance abuse
52
T/F: Stimulants are effective for oppositional defiant/conduct disorder with ADHD
TRUE: start treatment early to avoid APS usage later - Higher doses are needed

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