ADHD Flashcards
Stimulants :
1) MOA
2) Quick __ and ___
3) all classified as?
4) 2 categories of these products?
- inhibit dopamine transporter and norepi transporter; incr release of DA and NE into synapse
- onset of action and effect
- C2
- Methylphenidate products , Amphetamine products
- what distinguishing dosage forms are available for methylphenidate products?
- What distinguishing dosage forms are available for addy products?
- Patient education for :
TD Patch
ODT
Capsules - Methylphenidate LA (RITALIN LA)
-Bimodal Release Bead Delivery system
-each capsule contains what ? - Methylphenidate (METADATE CD)
-Biphasic release bead delivery system thats contained of? - Methylphenidate (CONCERTA)
-Uses what kind of system?
- Capsules, liquids/suspensions, chew tabs, TD patch!!! , tabs
- Caps, liquids/suspensions, tabs, ODT!!!, Chew tabs
- caution with heat sources, disposal and rotate sites
-handle with dry hands
-many available to open and sprinkle on food - 50% IR beads and 50% ER beads
- 30% of dose RAPIDLY released, 70% of dose CONTINOUSLY released
- OROS System
Methylphenidate Transdermal (Daytrana)
1. Whats mixed with adhesive?
2. Where do u apply the patch ?
3. AE’s?
Methylphenidate (JORNAY PM)
1. Approved for ?
2. When is it dosed ?
3. Why is it dosed this way ?
4. When should u initiate dosing?
- methylphenidate
- hip area for 9 hrs (2 hrs delay in onset)
- Milder (N/V, Insomnia) , except rash
- kids >= 6 yrs and adults
- evening
- <5% of drug available within first 10 hrs of dosing, peak absorption at 14-16 hrs after dosing
- 8PM (adjust to 630PM-930PM depending on the patient)
Mixed Amphetamines : Adderall XR
1. What kind of delivery system ?
2. How is the capsule constructed?
Stimulant suspensions
1. Name the methylphenidate one
-Name some admin techniques (3)
- Name amphetamine suspension one
- Dosing and admin techniques
- Pulsed delivery system
- Immediate release pellet and delayed release pellet (50% and 50%)
- Quillivant XR
-Comes as powder, needs reconstitution prior to dispensing
-Shake virgorously for 10 secs b4 use
-Store at room temp - Adzenys ER , Dyanavel XR
-Premixed suspension
-Shake well
-Store at room temp
Lisdexamfetamine (Vyvanse)
1. May deter abuse by ?
2. what kinda drug?
3. Dosing?
- injection or snorting
-96% lower levels if snorted, 75% lower if injected - prodrug
- 30 mg daily
Adverse effects of Stimulants
1. Common ? (6 major, 5 minor)
- Less common ?
- Boxed warning for stimulants?
- Boxed warning for Adderall products ?
- When would you need to get an ECG prior to stim tx?
- Insomnia
* Loss of appetite
* GI upset
* Headache
* Anxiety
* Weight loss
* Increased blood pressure
* Growth suppression
* Circulation problems in extremities
* Irritability/dysphoria
* Hyperfocus - Tics , seizures, priapism, SI, sudden death in those w/pre existing cardiac abnorms,
- Abuse and misuse potential of CNS stims that can lead to OD and death, espeically in high doses or unapproved methods of admin
- Association w/serious cardiovasc events including sudden death in pt’s w/pre existing structural cardiac abnormalities or other serious heart problems
- Hx of congenital heart disease or previous cardiac surgery
-History of sudden cardiac death in a 1st degree relative under 40yrs old
-SOB on exertion or in reponse to fright or noise
-rapid reg palps that start and stop suddenly
-chest pain suggesting cardiac origin
-signs of HF
-Hypertensive BP for adults
Tx differences between :
1) Methylphenidate (Dopaminergic)
-Reduces __ and __
-Highly efficacious with ___
-Seems more efficacious for?
2) Amphetamine (Dopaminergic)
-__ probs
-___ lability
-__ seems to be more common
-Highly efficacious w/mult dose formulations
-although addy is approved for ___ and older, shouldnt be used!
-Seems to be more efficiacous for ?
Challenges :
1) Scheduled ?
2) 30% dont adequately ___ or ___
3) Effects not sustained if?
4) AE profile can adversely impact ?
5) Concerns about ?
- irritability and anxiety
- mult dosing forms
-children - sleep
-emotional
-dysphoria
-3 yo
-adults - 2 (abuse liability, diversion, medical and legal concerns)
- respond, cant tolerate stims
- dont take meds
- sleep, appetite, mood and anxiety
- growth suppression and tic devel
Non Stims : Selective Norepi Reuptake Inhibitor
1. name 2 products
Atomoxetine (Strattera)
1. FDA approved for ?
2. Dosing guidelines?
3. metab in ?
4. ADR?
5. BBW?
6. may be good for ?
7. DONT
8. Onset as compared to stims?
Viloxazine (Qelbree)
1. no ____
2. Metab in liver using which enzyme
3. ADR?
4. BBW?
5. different from strattera is that ?
6. ___ onset than stims, but may be faster than ?
- Atomoxetine (Strattera) and Viloxazine (Qelbree)
- > = 6 yrs including adults
- weight based
- liver CYP2d6
- GI, dry mouth, fatigue, headache, insomnia, sedation, dizziness, increased BP/HR, liver dysfunction, aggressive behavior, mania, priapism, decreased libido, urinary problems
- Suicidal thoughts and behaviors
- comorbid anxiety (social phobia)
- open capsules
- slower
- weight based dosing
- CYP2D6
- sedation , decr appetite, incr BP/HR
- suicidal thoughts and behaviors (irritability and anger)
- can break open capsules and sprinkle on food
- slower. strattera
Alpha 2 Adrenergic Agonists :
1. USeful in combo with stimulants especially in setting of? (4)
2. Need to ___ instead of abrupt discontinuation
3. approved for use in ?
4. Onset of stims ?
- CLONIDINE XR (KAPVAY)
-Which form approved for monotherapy and adjunctiev use? (6-17 yrs) - Guanfacine (Intuniv)
-Less ___ than Clonidine
-Which formulation approved for mono and adjunctive use? (6-17 yrs) - Common AE’s : Alpha 2 Agonists
A. CNS, GI, Cardiac, GU, Hepatic, Skin, and Sexual dysfunction!
B. RARE : cardiac, CNS, GU, Blurred ___, G__
- Tics, sleep disturbances, aggression, impulsivity, conduct disorder
- taper slowly
- children and adolescents
- slower than stims
- ER
- Sedation , ER
- CNS : SEDATION, drowsiness, depression, agitation, anxiety, headache, fatigue
GI : dry mouth, constipation, WEIGHT GAIN
CARDIAC : Ortho hypo, decr BP/HR, rebound hypertension w/abrupt D/C
GU : nocturia
Hepatic : Abnorm LFTS
SKin : Rash
SEXUAL DYSFUNCTION
B. Palps, tachycard, bradycard, CHF
Vivid dreams, nightmares, insomnia, delirium
-Urinary retention
-Blurred vision
-Gynecomastia
ANtidepressants : Bupropion (Wellbutrin )
Advantages:
1. May decr __ and __
2. May be beneficial in ? (3) !
3. May improve ___
4. NO _____
Disadvantages :
1. Positive results reported with ? can lead to ?
2. May decr ___
3. May exacerbate ___
4. AVOID IN PT”S with ?
5. This is not ___ for ADHD
6. Reserved for ?
7. Warning for?
- Hyperactivity and aggression
- comorbid depression!, cardiac issues!, comorbid nicotine use disorder!
- cognitive performance
- Sexual dysfunction
- higher doses (400-450 mg/day) , tolerability issues
- Seizure threshold
- tics
- ED’s and seizures
- FDA INDICATED
- those who dont tolerate other ADHD meds
- suicidal behavior warning
Side efffects mitigation strategy
See chart
DOSING :
1. Adderall
2. Adderall XR
3. RITALIN
4. COncerta
5. Strattera
6. Vyvanse
- 2.5-5 mg daily (max 40)
- 10 mg daily (30 mg)
- 5-10 mg daily or BID (max 60)
- 18 or 36 mg daily (max 72 mg)
- ≥ 6 years old (≤70kg): 0.5 mg/kg
daily, increase after 3 days to 1.2mg/kg daily or in 2 divided doses
≥ 6 years old (≥70kg) or adults: 40 mg/day, increase after 3 days to 80mg daily or in 2 divided
doses (max 100 mg)
- 30 mg daily (max 70mg)
