ADHD Flashcards
What are risk/prognostic factors of ADHD?
- males»_space; females
- whites»_space; blacks > hispanics
- 1st degree relative w/ ADHD
- minor physical anomalies (hypertelorism, highly arched palate, low set ears)
-motor delays/neurological soft signs - very low birthweight
What are some patho features of ADHD?
- decreased total brain volume
- decreased activity
- lack of connectivity
- default mode = network overactivity
What are the main ADHD symptoms?
- inattention
- hyperactivity
- impulsivity
What are the general requirements to diagnosis ADHD?
- symptom onset BEFORE 12 yo
- significant impairment in 2 or more settings with documented symptoms
- symptoms interfere with or dec quality of social, academic or occupational functioning
- 6 or more symptoms for at least 6 months (if 17 or older only need 5 symptoms)
What is the general treatment algorithm for a patient with predominant ADHD?
- stimulant —– MPH or AMP
(try both before 2nd line) - atomoxetine, viloxazine, guanfacine ER, clonidine ER, bupropion
(1st line if pt has active SUD) - combo therapy or TCA
What is the general treatment algorithm for ADHD in a patient with predominant Tourette’s?
- dopamine antagonist or alpha agonist
- haloperidol, risperidone, aripiprazole
- clonidine or guanfacine
if some response….
- ADD stimulant, atomoxetine or alpha agonist
if still inadequate….
- try alternative dopamine antagonist or alpha agonist
What is the general treatment algorithm for ADHD in a patient with predominant bipolar/severe aggression?
- atypical antipsychotic, lithium, or anticonvulsants
(mood stabilizers)
If some response…
- ADD stimulant
if still inadequate…
- try alternative or additional mood stabilizer
What is the general treatment algorithm for ADHD in a patient with predominant anxiety/depression?
- antidepressant
If some response…
- ADD stimulant
if still inadequate…
- try alternative antidepressant
What adjustment should be made when moving from AMP to MPH?
increase dose
What adjustment should be made when moving from MPH to AMP?
decrease dose
Which is more potent? AMP or MPH?
AMP!
What needs to be monitored at baseline and then every 3 months on stimulant therapy?
height, weight appetite and sleeping patterns
What ADR are common for stimulants?
- psychiatric
- cardiac (inc BP & HR)
- growth inhibition
- reduced appetite/weight loss
- insomnia
How are psychiatric ADR of stimulants managed?
decrease dose or D/C
+ supportive therapy
T or F: A contraindication to stimulant use is cardiac issues.
FALSE, cardiac issues are NOT CI for stimulant use
How is the growth inhibition ADR of stimulants managed?
yearly drug free trials (i.e. no stimulants over school breaks)
How is the reduced appetite/weight loss ADR of stimulants managed?
eating high fat meals when stimulant effect is low (fat will delay abs, keep consistent)
ADD cyprohepatdine QHS
How is the insomnia ADR of stimulants managed?
give dose earlier
lower last dose of day/give it earlier
ADD sedating medication QHS
(guanfacine, clonidine, melatonin, cyproheptadine)
What agents increase MPH absorption and decrease the delayed effect of ER formulations?
antacids, PPIs, H2RAs
What agent decreases the excretion of AMP?
antacids
What agent increases the absorption of AMP?
PPIs
What agent decreases the absorption of AMP?
acidic agents
What stimulant has a DDI with CYP2D6 inhibitors (i.e. some psych agents)/what happens?
Which stimulant is preferred in patients on concurrent psych agents?
increases exposure of mixed AMP salts
MPH is preferred
What is the issue with alcohol when using stimulants?
alcohol can cause stimulant dumping
What does adjustment is needed when going from Dex-MPH to MPH?
What about MPH to Dex-MPH?
Which is more potent?
double the dose
half the dose
Dex-MPH is 2x more potent
What stimulant is preferred & first line in children?
MPH!
What stimulant is FDA approved in children?
AMP!
Which MPH products are 30% IR/70% ER?
- MPH ER (Metadate ER, Quillivant XR)
- MPH ER chew (Quillichew)
- MPH CD (Metadate CD)
Which MPH products are 50% IR/50% ER?
- MPH LA (Ritalin LA)
- Dex-MPH ER (Focalin XR)
Which MPH extended release product is preferred in patients with severe AM symptoms?
50% IR/50% ER —– MPH LA (Ritalin LA)
Which MPH extended release products are beads and the capsules can be opened to put in apple sauce?
- MPH CD (Metadate CD)
- MPH LA (Ritalin LA)
Which MPH product needs to be shaked vigorously prior to administration?
MPH XR suspension (Quillivant XR)
What is an important counseling point for the MPH OROS (Concerta, Relexxii)?
shell of the tablet will appear in stool
Which MPH extended release products require complete restarting of dose titration when switching to them?
- MPH MLR (Aptensio XR)
- MPH MLR-02 (Adhansia XR)
- Dex-MPH/Ser-Dex-MPH (Aztarys)
Which stimulant product MUST be administered between 6:30-9:30 pm?
MPH PM (Jornay PM)
What is Ser-Dex-MPH?
prodrug pf Dex-MPH
What is an important counseling point for Dex-MPH/Ser-Dex-MPH (Aztarys)?
risk of suicidal ideation
What is the protocol when you miss a dose of MPH PM (Jornay PM)?
skip it and take the following dose at usual PM/HS time
Which stimulant products are available as ODT?
- MPH XR-ODT (Cotempla XR-ODT)
- AMP sulfate IR-ODT (Evekeo ODT)
- AMP sulfate XR-ODT (Adzenys XR-ODT)
What are the available MPH immediate release products?
- MPH IR (Ritalin, Methylin)
- Dex-MPH IR (Focalin)
Which transdermal stimulant product has a BBW for permanent skin reactions?
MPH transdermal patch (Daytrana)
Which stimulant agent is preferred in patients with a history of cardiovascular disease?
MPH
Which AMP products are 50% IR/50% ER?
Mixed AMP-XR salts (Adderall XR)
What stimulant agents are FDA approved for 3 and up?
IR AMPs!!!
- Mixed AMP-IR salts (Adderall)
- AMP sulfate IR (Evekeo)
- dextroAMP IR (Dexedrine, Zenzedi)
Which AMP product is beads and the caps can be opened up to sprinkle on applesauce?
Mixed AMP-XR salts (Adderall XR)
What AMP liquid formulations are available?
- AMP sulfate XR solution (Dyanavel XR)
- AMP sulfate ER suspension (Adzenys ER)
- dextroAMP IR liquid (ProCentra)
Which AMP extended release product does not cause peaks/troughs?
Why???
AMP sulfate XR (Mydayis)
it has triple time release beads that decrease med wearing off effect
What AMP product was designed for less abuse potential?
Lisdexamfetamine (Vyvanse)
How long do transdermal stimulant products need to be applied before effect is needed?
How early should they be removed before bedtime?
2 hours prior to needed effect
3 hours or more before bedtime
Which transdermal stimulant product is approved for 6 & up?
dextroAMP transdermal patch (Xelstrym)
Which transdermal stimulant product is approved for 6-17 yo as it has not been studied in adults?
MPH transdermal patch (Daytrana)
Which transdermal stimulant product needs to be disposed of safely because 50% of drug remains in the patch after use?
MPH transdermal patch (Daytrana)
Which transdermal stimulant product can only be applied to the hip?
MPH transdermal patch (Daytrana)
What are the 4 generalities of ADHD therapy in patients under 6 years old?
- NO ER formulations
- NO non-stimulants
- NO patches
- try non-pharm first
When can effectiveness of norepinephrine reuptake inhibitors for ADHD be assessed?
need 6-8 weeks at max tolerated dose
What are the class ADR of norepinephrine reuptake inhibitors used in ADHD?
risk of inducing mania
QT prolongation
What are the norepinephrine reuptake inhibitors used in ADHD?
atomoxetine (Strattera)
viloxazine ER (Qelbree)
What is the BBW for norepinephrine reuptake inhibitors used in ADHD?
suicidality
What is an important counseling point for atomoxetine (Strattera)?
it may worsen behavior initially
How is atomoxetine (Strattera) dosed?
MDD?
BID
40 mg
How is viloxazine ER (Qelbree) dosed?
MDD?
QAM
< 17 yo —– 400 mg
adults —– 600 mg
What effect does viloxazine ER (Qelbree) have on CYP metabolism?
Its a strong CYP1A2 inhibitors and interacts with many psych & pain meds
Which norepinephrine reuptake inhibitors used in ADHD is associated with liver toxicity w/ long term use?
atomoxetine (Strattera)
Which norepinephrine reuptake inhibitors used in ADHD needs renal dose adjustments?
viloxazine ER (Qelbree)
What is the effect of concurrent paroxetine or fluoxetine on atomoxetine (Strattera) use?
increases the concentration of atomoxetine (Strattera)
What are the alpha adrenergic agonists FDA approved for ADHD?
clonidine ER (Kapvay)
guanfacine ER (Intuniv)
**can also use IR versions but not FDA approved
What are the class ADR of alpha adrenergic agonists used in ADHD?
sedation, dizziness, hypotension, constipation & heart block
What is an important counseling point for the extended release formulations of alpha adrenergic agonists used in ADHD?
do not take with high fat meal
When can effectiveness of alpha adrenergic agonists for ADHD be assessed?
1-2 months
What are some benefits of using bupropion for ADHD?
- beneficial in patients with comborbid depression
- has less appetite suppression/weight loss compared to stimulants
What is an important dosing consideration for bupropion?
prepubertal children have faster metabolism, need to dose BID
When can effectiveness of bupropion for ADHD be assessed?
after 6 weeks at max tolerated dose
What is the use of TCAs in ADHD?
VERY LAST LINE!
What TCAs are used for ADHD?
imipramine, desipramine, nortriptyline
What are lithium/AEDs (i.e. valproate & carbamazepine) effective for in ADHD therapy?
aggression, explosive behavior, impulsivity
When are What are lithium/AEDs (i.e. valproate & carbamazepine) typically used in ADHD therapy?
childhood onset bipolar OR comorbid ADHD/bipolar
What is the use of antipsychotics in ADHD therapy?
adjunct for severe aggression, comorbid conduct disorder or bipolar disorder
DO NO TREAT ADHD SYMPTOMS, pt needs ADHD therapy as well
What are the preferred antipsychotics for use in ADHD patients?
2nd gen: aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone
(avoided b/c EPS -> chlorpromazine, haloperidol)
