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701 > ADHD > Flashcards

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
Q

Stimulant ADEs

A
  • 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
Q

How do you manage weight loss in ADHD?

A

Take high calorie meals when stimulant effect is low
Cyproheptadine at bedtime

27
Q

How do you manage stomachache in ADHD?

A

Take on full stomach
Lower dose

28
Q

How do you manage insomnia in ADHD?

A

Give dose earlier in the day
Lower last dose
Add sedating medication (not melatonin in prepuberty)

29
Q

How do you manage headache in ADHD?

A

Divide dose, give with food, analgesic

30
Q

How do you manage rebound in ADHD?

A

Long acting stimulant
Atomoxetine, antidepressant

31
Q

How do you manage irritability jitteriness

A

Comorbid?
Reduce dose
Consider mood stabilizer or atypical antipsychotic

32
Q

Methylphenidate

A

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
Q

Amphetamine

A

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
Q

Patches for MPH and AMP

A
  • 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
Q

What MPH formulation is best for severe morning symptoms?

A

MPH LA (50IR/50ER)

36
Q

What are most MPH ER products composed of?

A

30% IR / 70% ER

37
Q

What MPH formulation is best for afternoon rebound symptoms?

A

MPH MLR (larger ER ratio)

38
Q

T/F: DexMPH is more potent than MPH

A

TRUE: give 1/2 dose of MPH for same effect

39
Q

What is important about Ser-DexMPH

A

Prodrug -> less abuse potential but suicide risk

40
Q

How do you take MPH PM?

A

At bedtime, 10h time to effect

Do NOT let patients take in the morning if they forget, it will mess everything up

41
Q

What to use in a >3 y/o for ADHD

A

Try behavioral interventions first (obvi)
IR MPH preferred***
IR AMPs FDA approved

42
Q

What to use in >6 y/o for ADHD

A

Anything basically (most studied group)

43
Q

What to use in >13 years for ADHD

A

Mydayis (ER AMP/DexAMP)

44
Q

SNRIs in ADHD

A
  • 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
Q

Atomoxetine DDIs

A

CYP2D6 (paroxetine, fluoxetine)

46
Q

Viloxazine DDIs

A

CYP1A2, CYP 2D6, CYP3A4
- Antidepressants, antipsychotics, benzos, opioids

47
Q

Alpha 2s

A

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
Q

Bupropion

A

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
Q

TCAs

A
  • Overdose toxicity*** -> heart block (avoid in suicidal)
  • 4 weeks for max effect
  • Sedating
50
Q

APS in ADHD

A
  • 1st gens suck (EPS)
  • 2nd gens good for severe aggression, but have metabolic syndrome
51
Q

T/F: Early use of stimulants increases risk of substance abuse

A

FALSE: more abuse reported with LATER onset of treatment
- Atomoxetine, a2 agonists, or bupropion preferred in substance abuse

52
Q

T/F: Stimulants are effective for oppositional defiant/conduct disorder with ADHD

A

TRUE: start treatment early to avoid APS usage later
- Higher doses are needed

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