ADHD Flashcards
What are s/sx of ADHD?
- inattention
- hyperactivity
- impulsivity
- difficulty focusing
- easily distracted
- trouble staying still
Who are stimulant medications considered first line for?
patients >/= 6 years old
What conditions must be met for a diagnosis of ADHD?
- > /=6 inattentive symptoms up to 16 or >/=5 for 17+ present for at least 6 months
- > /=6 hyperactive-impulsive symptoms up to 16 y/o or >/=5 for 17+ for at least 6 months
- symptoms present before the age of 12
- symptoms present in 2 or more settings (work, home, school, friends, etc)
- symptoms interfere with functioning and are not cause by another disorder
What are symptoms of inattention?
- fails to/trouble paying attention
- does not follow through on instructions
- fails to finish work
- difficulty organizing tasks
- avoids/dislikes tasks that require mental effort
- loses things
- easily distracted
- forgetful
What are symptoms of hyperactivity/impulsivity?
- fidgets/squirms
- leaves seat unexpectedly
- runs around when inappropriate
- unable to play quietly
- “on the go” as if “driven by a motor”
- talks excessively
- blurts out answers
- has trouble waiting his/her turn
- interrupts/intrudes on others
What natural products can be used for ADHD?
- fish oils
- Melatonin for sleep onset insomnia in those taking stimulants
When should non-stimulant medications be tried?
when stimulants do not work after 2-3 medication trials
What type of stimulants are preferred in children?
long-acting
How can Vyvanse be given for children who have difficulty swallowing?
capsule contents can be mixed with water, orange juice, or yogurt
What formulations of stimulants are useful for children that cannot swallow capsules?
- capsules that can be opened
- chewable tablets
- ODT
- Patches
- Suspensions
What non-stimulant medications can be dosed at night for ADHD?
- guanfacine ER (Intuniv)
- clonidine ER (Kapvay)
What medications can be used to help sleep at night?
- clonidine IR
- diphenhydramine
- melatonin
What are safety concerns with all stimulants?
- C-II meds require MedGuide
- High potential for abuse/dependence
- Increased HR and BP can cause serious CV events
- Exacerbation of psychosis
- Loss of appetite in children can decrease growth trajectory
- Risk of serotonin syndrome
- vascular problems (Priapism, Raynaud’s,) requiring dose adjustment
- increase risk of seizure
- visual problems (difficulty with accommodation/blurry vision)
What are CIs for all stimulants?
Do not use with within 14 days of an MAOi due to risk of HTN crisis
What is the MOA of stimulants?
blocks the reuptake of NE and DA can be titrated every 7 days
How are stimulants tapered off?
do not need to be tapered off when used as directed
How is IR methylphenidate (Ritalin) dosed?
Start at 5mg BID 30 minutes before breakfast and lunch; max. 60mg/day
How is ER methylphenidate (Concerta) tablets dosed?
Start 18-36mg QAM; max 72mg/d
What is OROS delivery?
Outer coat dissolves fast to provide immediate action and the rest dissolves slowly; can see a ghost tablet in stool; is harder to crush decreasing abuse potential
What are warnings with methylphenidate?
- Daytrana: loss of skin pigmentation at application site and areas distant from the application site (can resemble vitiligo); allergic contact dermatitis with local reactions (edema, papules)
- Concerta, Relexxii: do not use with GI narrowing conditions (motility issues, small bowel disease)
What are SEs with stimulants?
- Insomnia
- Decreased appetite/ Weight loss
- Headache
- Irritability
- N/V
- blurry vision
- dry mouth
What should be monitored with stimulant therapy?
- ECG prior to treatment
- BP and HR
- cardiac symptoms
- CNS effects
- abuse potential
- Height and Weight in children
Which patients should not use chewable methylphenidate tablets? Why?
those with Phenylkentonuria because the contain phenylalanine
How is Jornay PM administered?
Dose at night; outer coating delays initial drug release 10 hours to allow for evening dosing; inner coating controls slow release during the day
How is Daytrana administered?
- Apply to the hip 2 hours before desired effect (or as soon as child wakes up to deliver prior to school)
- Remove after 9 hours
- Alternate hips daily
- Discard patches by flushing down the toilet
Methylphenidate
Ritalin (IR tablet, chewable tablet)
Methylin (IR oral solution)
Concerta (ER tablet)
Relexxii (ER tablet)
Ritalin LA (ER capsule)
Aptensio XR (ER capsule)
Jornay PM (ER capsule)
Quillivant XR (ER oral suspension)
QuilliChew ER (ER chewable tablet)
Cotempla XR-ODT (ER ODT)
Daytrana (transdermal patch)
Dexmethylphenidate
Focalin (IR tablet)
Focalin XR (ER capsule)
How is methylphenidate converted to dexmethylphenidate?
dexmethylphenidate is the active isomer of methylphenidate; use half of the total daily dose of methylphenidate
How is dexmethylphenidate dosed?
IR: 2.5mg BID at least 4 hours apart; max 20mg/d
ER: 5mg (children)-10mg(adults) QAM; max 30-40mg/d
Serdexmethylphenidate/dexmethylphenidate
Azstarys (capsule)
What is the difference between serdexmethylphenidate and dexmethylphenidate?
serdexmethylphenidate is the prodrug of dexmethylphenidate and provides extended duration of action following faster-acting dexmethylphenidate
Dextroamphetamine/amphetamine
Adderall (IR tablet)
Adderall XR (ER capsules)
Mydayis (ER capsules)
How is dextroamphetamine/amphetamine dosed?
IR: 5mg QAM or BID with 2nd dose 4-6 hr after 1st dose; max 40mg/day
ER: 5-10mg (6-12y) or 10mg (13-17y) or 10-20mg (adults) QAM; max 30mg/day (children) or 40mg/d (adults)
Amphetamine
Adzenys XR-ODT
Dyanavel XR (ER tablet that can be chewed or ER oral suspension)
Evekeo (IR tablet)
Evekeo ODT (IR ODT)
What is the max dose of amphetamine daily?
ER tablet: 20mg/day
IR: 40mg/day
Dextroamphetamine
Dexedrine (ER capsule)
ProCentra (IR oral solution)
Zenzedi (IR tablet)
Xelstrym (ER patch)
What is the max dose of dextroamphetamine?
40mg/d
What age are amphetamine/dextroamphetamine products approved in?
IR products approved for ages >/=3y (except Evekeo ODT)
When do the AAP guidelines suggest use of dextroamphetamine?
children >5 years
How are IR doses converted to ER doses of amphetaine/dextroamphetamine?
cannot be substituted on a mg per mg basis; follow dosing schedule based on manufacturer
How should Dyanavel be prepared for administration?
shake suspension prior to use
What may decrease the absorption of amphetamine/dextramphetamine?
acidic foods/juice or vitamin C
What is a benefit of lisdexamphetamine formulation?
Low abuse potential; prodrug composed of l-lysine bonded to dextroamphetamine; it is hydrolyzed in the blood to active dextroamphetamine; if injected/snorted the rush is muted
Methamphetamine
Desoxyn (tablet)
What is the MOA of atomoxetine?
selective NE reuptake inhibitor
What are BBW with atomoxetine?
risk of suicidal ideation; monitor for suicidal thinking or behavior, worsening mood, or unusual behavior
What are CIs with atomoxetine/ viloxazine?
MAOi use within 14 days
Atomoxetine: glaucoma, pheochromocytoma. severe CV disorders
Viloxazine: concurrent use of CYP1A2 substrates
What are warnings with atomoxetine/ viloxazine?
Atomoxetine: aggressive behavior, hepatotoxicity, priapism, urinary hesitancy/retention, growth delays
1. CV events
2. psychosis/mania (assess at baseline and during treatment)
What are SEs with atomoxetine/viloxazine?
- Decreased appetite
- Insomnia
- Somnolence
- Dry mouth
- High BP/HR
- headache
- nausea
- abdominal pain
What should be monitored with atomoxetine and viloxazine?
- BP/HR
- ECG
- mood
- weight
How should atomoxetine be administered?
- Do not open the capsule-ocular irritant
- can take in divided doses if needed (morning and late afternoon/early evening)
- max dose 100mg
- max dose 80 when taking strong CYP2D6 inhibitors
How is atomoxetine dosed?
> 70kg: start with 40mg QD
</= 70kg: start with 0.5mg/kg/d
How should viloxazine be administered?
- capsule can be opened and contents sprinkled on 1 tsp of pudding/applesauce, must be swallowed without chewing
- dose reductions required in severe renal impairment
- max. 400mg/d children or 600mg/d adults
Atomoxetine
Strattera
Viloxazine
Qelbree
What centrally acting alpha-2 adrenergic receptor agonists are used with stimulants or alone for ADHD?
- Clonidine ER
- Guanfacine ER
What are warnings with centrally acting alpha-2 adrenergic agonists?
- Dose-dependent CV effects (bradycardia, hypotension, orthostasis, syncope)
- Sedation/Drowsiness
- Do not D/C abruptly (rebound HTN)
- Guanfacine; skin rash (rare, D/C if occurs), dose adjustments required with CYP3A4 inducers/inhibitors
What are SEs with centrally acting alpha-2 adrenergic agonists?
- Dry mouth
- Somnolence
- Fatigue
- Constipation
- Decreased HR
- Hypotension
- headache
- nausea
- abdominal pain
What should be monitored with centrally acting alpha-2 adrenergic agonists?
HR/BP
How should clonidine/guanfacine be tapered?
Decrease dose every 3-7 days
Clonidine: decrease by </=0.1mg/d
Guanfacine: decrease by </=1mg/day
How is clonidine dosed?
Start 0.1mg QHS and increase by 0.1mg weekly and take BID (if uneven dosing take larger dose QHS)
Max: 0.4mg/d
Cannot interchange ER and IR doses
IR/patch generally used for HTN
How is guanfacine dosed?
Start 1mg QD and increase by </=1mg weekly
DO NOT take with high fat meal (will increase absorption)
Cannot interchange ER and IR dosing
IR used for HTN
Double the dose if used with strong CYP3A4 inducers and cut in half with inhibitors
Clonidine ER
Kapvay (ER tablet)
Nexiclon XR (ER tablet)
Guanfacine ER
Intuniv (tablet)
What are DIs with atomoxetine?
CYP2D6 substrate; may need dose adjustment with inducers/inhibitors
What are Dis with viloxazine?
- strong CYP1A2 inhibitor
- weak CYP 2D6/3A4 inhibitor
What are DIs with clonidine/guanfacine?
- additive sedation with other CNS depressants
- caution with other drugs that decrease BP
- Guanfacine requires dose adjustment with strong CYP3A4 inducers (double dose)/inhibitors (half dose)
