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ADHD Flashcards

1
Q

What is ADHD?

A

neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and hyperactivity-impulsivity

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2
Q

What does the inattention and disorganization of ADHD entail?

A

inability to stay on task
seeming not to listen
losing materials
at levels that are inconsistent with age or developmental level

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3
Q

What does the hyperactivity-impulsivity of ADHD entail?

A

overactivity
fidgeting
inability to stay seated
intruding into other peoples activities
inability to wait
symptoms that are excessive for age or developmental level

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4
Q

Is ADHD only a disorder of children?

A

can persist into adulthood
-with resultant impairments of social, academic, and occupational functioning

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5
Q

What is the biomarker or imaging study that is diagnostic of ADHD?

A

there is no biological marker or imaging study that is diagnostic for ADHD
-a clinical diagnosis

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6
Q

What is the essential feature of ADHD?

A

persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development

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7
Q

Describe the diagnostic criteria for the inattention side of ADHD.

A

6+ sx persist for 6+ mo and inconsistent with development and impact social and occupational/academic activities
1. fails to pay attention to details or makes careless mistakes
2. difficulty sustaining attention
3. does not seem to listen when spoken to
4. does not follow through on instructions or tasks
5. difficulty organizing
6. dislikes/reluctant to tasks requiring mental effort
7. loses things
8. easily distracted by extraneous stimuli
9. often forgetful in daily activities

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8
Q

Describe the diagnostic criteria for the hyperactivity-impulsivity side of ADHD.

A

6+ sx persist for 6+ mo and inconsistent with development and impact social and occupational/academic activities
1. fidgety
2. leaves seat when seating expected
3. runs around when inappropriate
4. unable to engage in activities quietly
5. often “on the go”
6. often talks excessively
7. blurting answer before question is done
8. difficulty waiting for turn
9. interrupts or intrudes on others

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9
Q

What is key regarding the diagnosis of ADHD in regards to age and setting?

A

several inattentive or hyperactive-impulsive symptoms were present prior to age of 12 and are present in two or more settings

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10
Q

Describe the etiology of ADHD.

A

not entirely known
multifactorial:
-genetics (heritability, NT dysfunction - mainly DA & NE)
-non genetic factors (20-25%)

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11
Q

What are the risk factors for ADHD?

A

low birth weight/prematurity
exposure to smoking during pregnancy
family history of ADHD
perinatal stress
FAS
lead poisoning
traumatic brain injury
severe early oxygenation deprivation
adverse parent-child relationships

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12
Q

Describe the pathophysiology of ADHD.

A

anatomical structures
-delay and rate of cortical thickening contributes to difficulty prioritizing tasks
-lack of connectivity between prefrontal cortex is associated with lapses in attention & poor impulse control
EEG abnormalities
-90% with ADHD (not diagnostic)
DA and NE abnormalities
-DA: impairs brains ability to maintain attention to dull or repetitive tasks, postpone indulgence, regulate mood and arousal, resist distractions
-NE: inability to modulate attention, arousal, and mood

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13
Q

Describe the ability of the PFC when catecholamine levels fluctuate between low to high.

A

low: fatigued
moderate: alert
high: stressed

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14
Q

Which assessment forms are recommended for initial information gathering for children/adolescents suspected of ADHD?

A

SNAP-IV 26
CADDRA Teacher Assessment Form

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15
Q

What are some comorbidities often seen with ADHD?

A

conduct or behavioral problems
anxiety
MDD
OCD
SUD 2.5x more likely
learning disorders
epilepsy 2-3x more likely
autism
Tourettes
oppositional defiant disorder

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16
Q

What are the consequences of untreated ADHD?

A

decreased social, educational, vocational, and self-care functioning
increased rates of accidental injury
increased time and energy to cope with ADHD related challenges

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17
Q

What are the goals of therapy for ADHD?

A

eliminate or significantly decrease the core ADHD sx
improve behavioral, academic, and/or occupational performance
improve self-esteem
improve social functioning
minimize drug AEs
improve QoL

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18
Q

What should the treatment of ADHD be based on?

A

current evidence, family, and clinician preference

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19
Q

When can behavioral therapies be considered as the initial treatment of ADHD?

A

if symptoms are mild, diagnosis is unclear, or medication is not preferred by parents

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20
Q

What is the most effective treatment for ADHD?

A

behavioral therapies + medication

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21
Q

What are the non-pharm treatment options for ADHD?

A

family-focused interventions
-behavioral parent training
school-focused interventions
-behavioral classroom management
child-focused interventions
-behavior peer interventions
CBT

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22
Q

What should the meds target in ADHD?

A

the symptoms that cause impairment

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23
Q

What did the landmark study of atomoxetine vs Concerta find regarding adverse events?

A

similar in between groups

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24
Q

What is the bottom line of the landmark study of atomoxetine vs Concerta?

A

in treatment of ADHD without comorbidities (besides ODD), Concerta is 1st line option
-ATX is 2nd line option for Concerta non-responders
-however, if pts family is hesitant to start a stimulant then ATX is an option although not as effective as MPH
-also if pt doesnt respond to MPH than ATX could be an option

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25
What was the MTA study?
second landmark ADHD study RCT comparing behavioral therapy, intensive medication management, combination behavioral therapy + intensive med management
26
What were the results of the MTA study?
combined behavioral + pharm tx = pharm alone for core ADHD sx pharm tx > behavioral tx for core ADHD tx combined behavioral + pharm tx > pharm alone or behavioral alone for reducing oppositional behaviors/anxiety and improving social interactions/self-esteem
27
What are examples of ADHD medications?
stimulants: -methylphenidate products -amphetamine products non-stimulants: -atomoxetine -guanfacine -clonidine -bupropion
28
What is the MOA of methylphenidate?
inhibits presynaptic reuptake of DA and NE by blocking transport proteins -DA appears to have a larger role than NE -leads to increased sympathomimetic activity in CNS -limited peripheral activity
29
What is the MOA of amphetamines?
increase release of NE and DA into synapses from presynaptic nerve terminal -enhance NE release in periphery from adrenergic nerve terminals -may stimulate release of 5HT and act as a 5HT agonist (higher doses) -inhibit the reuptake of monoamines in extraneuronal space
30
What is the MOA of atomoxetine?
inhibits the presynaptic reuptake of NE in CNS
31
What is the MOA of guanfacine and clonidine?
alpha-2 adrenergic receptor agonists peripherally block sympathetic nerve impulses=decreased vasomotor tone (BP) and heart rate
32
How does guanfacines MOA differ from clonidines?
guanfacine more selective for alpha2a receptor than clonidine -binds to postsynaptic alpha2a receptors in PFC --> improves delay related firing of PC neurons -leads to improvements in underlying working memory and behavioral functions
33
What is the 1st line pharmacotherapy for ADHD?
long-acting stimulants -Adderall XR, Concerta, Vyvanse, Biphentin, Foquest, Quillivant
34
What is the benefit of the 1st line drugs for ADHD?
reduces core ADHD sx by 30-40% in 70%+ of treated pts
35
When is response seen from the 1st line drugs for ADHD?
1 week in some but an adequate trial is 3-4 wks
36
Which stimulant is more efficacious for ADHD?
MPH and amphetamines are equally efficacious
37
What is the method used to predict which stimulant class a patient will respond to?
there is no method
38
What should be done after treatment failure on a stimulant?
try the other stimulant class before moving to non-stimulant
39
What is the benefit of sustained release products for the patient and family?
maintains privacy for patients and family in context of school, work, and social situations
40
What is the benefit of sustained release products when compared to IR products?
may diminish diversion and rebound better tolerability
41
What is the 2nd line pharmacotherapy for ADHD?
non-stimulants -guanfacine XR, atomoxetine short/intermediate acting psychostimulants -dextroamphetamine, dextroamphetamine Spansules, MPH, MPH SR
42
What is the benefit of atomoxetine for ADHD?
core ADHD sx reduced by 25-30% in 60-70% treated with atomoxetine
43
What is the onset of non-stimulants?
2 weeks max effect seen at 6-8 weeks (slower than stimulants)
44
When are non-stimulants used 1st line for ADHD?
stimulant contraindicated active substance use intolerable AE develop to stimulants severe anxiety or tic disorder parents hesitant to use stimulant
45
What should be done if there is a partial response to non-stimulants?
combine with behavioral therapy or stimulant
46
What is the use of short/intermediate stimulants?
augment long-acting formulations early or late in day or early evening dextroamphetamine products used to augment long-acting amphetamine products and lisdexamfetamine MPH products used to augment MPH extended and controlled release products
47
What are the 3rd line pharmacotherapy options for ADHD?
bupropion, clonidine, imipramine, modafinil AAPs for comorbidities commonly seen with ADHD exceeding max doses may be considered after regular doses *agents who use is off-label, have higher risks, more AE's, and/or lower efficacy profile*
48
What is an important consideration if switching from brand to generic with ADHD meds?
advising patient/family of the switch and to watch for clinical changes in efficacy and tolerability
49
What is a contraindication to any ADHD med?
hypersensitivity or allergy to products
50
What are precautions for all ADHD meds?
cardiac disease bipolar psychosis pregnancy and lactation
51
What are monitoring parameters for all ADHD meds?
ht and wt new mood/anxiety/SUD/psychotic/manic sx irritability/mood swings sleep or appetite changes suicidal behavior or ideation aggressive behavior
52
What are contraindications to stimulants?
history of mania or psychosis mod-severe HTN symptomatic CVD pheochromocytoma untreated hyperthyroidism narrow angle glaucoma MAOI tx, up to 14 days after d/c
53
What are precautions to stimulants?
history of SUD anxiety renal impairment epilepsy tic disorder Raynauds
54
What are some monitoring parameters specific to stimulants?
BP, HR growth issues Raynauds priapism
55
What are the contraindications to atomoxetine?
MAOI tx, up to 14 days after d/c] narrow angle glaucoma mod-severe HTN symptomatic CVD severe CV disorders uncontrolled hyperthyroidism pheochromocytoma advanced atherosclerosis
56
What are the precautions of atomoxetine?
asthma CYP 2D6 poor metabolizers Raynauds
57
What are some monitoring parameters specific to atomoxetine?
priapism and urinary retention signs and sx of liver injury growth retardation Raynauds
58
What are the contraindications to alpha-2 agonists?
inability to take regular daily dosage -risk of rebound HTN
59
What are the precautions to alpha-2 agonists?
hepatic impairment kidney impairment
60
What are some monitoring parameters specific to alpha-2 agonsits?
BP (hypotension) bradycardia, syncope sedation and somnolence increased BP and HR upon dc QTc
61
What are some examples of drug interactions with amphetamines and MPH?
antidepressants -increased risk of serotonin syndrome -hypertensive crisis with MAOI -CV and stimulatory effect increased with TCA antihypertensives -decreased hypotensive effect of antihypertensive antipsychotics -increased risk of psychosis, decreased effect of AMP decongestants -increased hypertensive and tachycardic effect of decongestant
62
What are the CV AE's of ADHD meds?
increase BP and HR: stims, ATX, a2a if abrupt dc decrease BP and HR: a2a
63
What are the GI AE's of ADHD meds?
appetite suppression: stims, ATX constipation/diarrhea: all nausea/vomiting: all dry mouth: all GI upset: all
64
What are the CNS/psych AE's of ADHD meds?
anxiety: stims, ATX dizziness: all dysphoria/irritability: stims, ATX HA: all initial insomnia: stims, ATX somnolence: a2a rebound effect: stims tics: stims
65
Which ADHD meds cause decrease in weight?
stims and ATX
66
Which ADHD med can cause sexual dysfunction?
ATX
67
Which ADHD meds can cause skin reactions?
stims and ATX
68
How should ADHD meds be initiated?
start low and go slow
69
What are dose increases based upon in ADHD?
continue dose increases until reached desired goals of treatment, side effects occurring, or max dose reached
70
What is the optimal dose?
dose above which there is no further improvement

PHAR358 (20 decks)

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