ADHD Flashcards
What are the three hallmark symptoms of ADHD?
Inattention, hyperactivity, impulsivity
What are the two subtypes of ADHD?
Inattentive
Hyperactive/impulsive
What is the most common subtype of ADHD?
Combo of inattentive and hyperactive/impulsive
Are there any objective tests that diagnose ADHD?
No
What is first line therapy for pre-schooled age children with ADHD?
behaviour modification programs
When do we add on methylphenidate to preschoolers?
Moderate to severe ADHD
Do not respond to behavioural therapy
When is pharmacological choices reserved for?
Patients with clear diagnosis of ADHD
Impairment in learning
Which drug classes are used in treatment of ADHD?
Stimulants and non-stimulants
What are long acting stimulant medications?
Lisdexamfetamine
Methylphenidate
Mixed salts amphetamine
(amphetamine/dexamphetamine)
What is the brand name of lisdexamfetamine?
Vyvanse
What is the brand name of methylphenidate?
Biphentin
Concerta
Foquest
What is the brand name of amphetamine/dexamphetamine?
Adderall XR
What formulations do long acting stimulant medications come in?
Immediate, intermediate, and extended release
Is there a difference in efficacy in the first line agents?
Minimal differences
What are the non-stimulant drug options?
Atomoxetine
Guanfacine XR
What is the preferable first line agent for adults?
Amphetamines
What is the preferable first line agent in children?
Methylphenidate
Is there concrete evidence for these recommendations?
No, therefore, choice of stimulant depends on patient and physician preference
If patient requires more flexibility with dosing, minimal hours/day of medication, or need an add-on therapy option, what formulations are recommended?
Intermediate to immediate release formulations
What is the typical duration of action of stimulants?
0.5-2h
What is the immediate release/delayed release % of Adderall XR?
50/50
What is the immediate-release/delayed release of Vyvnase?
Sustained
Which brand name of methylphenidate has the largest delayed release % proportion?
Foquest
Which brand name of methylphenidate has the smallest delayed release % proportion?
Biphentin
What are second line or adjunctive agents for ADHD?
Atomoxetine
Dexamphetamine
Methylphenidate
Gaunfacine
What does CADDRA recommend as first-line therapy?
Long acting agents
What is a reasonable trial period for stimulants
3-4 weeks
When should patients expect to see some improvement in core ADHD symptoms?
First week of therapy
Patients who do not tolerate or respond adequately to the optimal dose of the initial stimulant after ____ ________ of therapy should be switched to an alternative stimulant.
4 weeks
Is re-titration necessary following the introduction of a new agent?
Yes
What is the best time to introduce a switch if needed?
During school holidays or after a report card period to minimize disruption of aid
What are contraindications to stimulants?
- Hypersensitivity to sympathomimetic amines
- Symptomatic cardiovascular disease (moderate to severe hypertension, advanced atherosclerosis)
- Uncontrolled hyperthyroidism
- History of drug abuse and concurrent use with an MAOI
Is modafinil approved for the use in ADHD?
No
Less effective than other stimulants and is not often used.
Which agents are intermediate-release stimulants? Where do they come into play in therapy?
Ritalin SR
Dextroamphetamine SR
Second-line treatment
What are the most common adverse effects of stimulants?
Increased heart rate
Increased blood pressure
GI upset
Appetite suppression
Anxiety
Irritability
Insomnia
Is there a relationship between stimulant use in children and growth suppression?
No, new data from 2023 has shown no relationship.
However, still good to monitor use in children for growth suppression
What must we counsel patients on when starting ADHD meds?
Slight increased risk of suicidal thoughts and behaviour
Monitor patients for suicidal thoughts and mood changes
When is the highest risk of suicide related events in patients?
Start or end of treatment
What risk is associated with methylphenidate and amphetamines?
Increased risk of psychosis
Is this risk higher in amphetamines or methylphenidate?
Amphetamines
If patient has a history of psychosis, how should we adjust therapy?
Consider non-stimulant options (atomoxetine and/or guanfacine)
What is another rare event that can occur in males that patients should be aware of?
Priapism (prolonged erection >2 hours)
There is a possible association of stimulants (and atomoxetine) with cardiovascular risks such as _________.
Sudden cardiac death
Stimulant use has its risk of substance abuse. However, it was found that children with ADHD who are treated with stimulants had a lower risk of substance use disorder later in life.
If diversion of stimulant medications is suspected, what can we do?
Consider switching to an agent with less abuse potential
- atomoxetine
- guanfacine
At what age are stimulants indicated for?
> 6 years
What type of inhibitor is atomexetine?
Norepinephrine reuptake inhibitor
Where does atomoxetine come into play?
Second line agent
- Particularly useful for patient with tics
- Good if patient has substance abuse disorder or anxiety
- indicated for ≥6
How long does it take for patients to see beneficial effects when on atomoxetine?
3-4 weeks
When is optimal reduction of core ADHD symptoms achieved?
6-12 weeks
What are contraindications to atomoxetine?
- Hypersensitivity to atomoxetine
- Narrow angle glaucoma
- History of severe cardiac or vascular disorders
- Pheochromocytoma
- Concurrent use with an MAOI
When do alpha2-adrenergic agonists come into play?
As an add-on treatment options to reduce symptoms of aggression, impulsivity, hyperactivity, sleep disruption
- not as much benefit for the inattention aspect
Also good as second-line monotherapy
What are the two agents that are under the class of alpha-2 adrenergic agonists?
Guanfacine
Clonidine
Between clonidine and guanfacine, which agent has more selective neuronal activity and a longer duration of action?
Guanfacine
- less sedation and less hypotension
What are the most common adverse effects with guanfacine?
Sedation and headache
Where does clonidine come into play in ADHD?
Third line agent
Where do antidepressants come into play in the management of ADHD?
Third line or adjunctive therapy
Benefits patients with comorbid depression, anxiety, enuresis, or tic disorder
Which antidepressants are possible options for ADHD?
Bupropion
Venlafaxine
When do TCAs come into play for treatment of ADHD?
Short term treatment of ADHD
- For patients who cannot take stimulants, atomoxetine, or bupropion
When do antipsychotics come into play in ADHD?
Used to decrease behaviours in children with comorbid ODD, autistic disorders, impulse control disorders and Tourette syndrome
Risk often outweighs benefit
Increased risk of unexpected mortality, EPS, and metabolic syndrome
Which natural health product herbs may have benefit for restless children with sleep difficulty?
Chamomile
Valerian
Melatonin
Are there any natural health products that may benefit ADHD?
No concrete evidence
If we are switching from immediate release methylphenidate to extended release methylphenidate, how do we manage?
Stop the first medication and start the second at an equivalent dose (refer to methylphenidate monograph)
If we are switching between any other psychostimulant, how do we manage?
No direct equivalent dosing. Stop the first medications and begin the second at starting dose (re-titrate)
Appetite suppression is a common side effect with ADHD treatment? How often should we monitor weight?
Monitor weight every 2 weeks for the first 2 months, then every 6 months
How can we manage appetite suppression?
Administer medications during or after meals, not before.
Increase snacking
Nutritional meal supplement
Consider shorter acting stimulant to allow for appetite return
Which medications have the most issue with appetite suppression?
Stimulants
Atomoxetine
Bupropion
Increased heart rate and blood pressure is a common side effect with ADHD treatment? How often should we monitor cardiac markers?
Monitor BP and HR in first 2 weeks, then every 3 months.
ECG not needed.
How can we manage cardiovascular side effects?
If significant changes occur in BP, HR or on ECG, discontinue and consult with cardiologist.
What is considered a significant change in cardiovascular factors?
Heart rate increase greater than 10 beats per minute
Blood pressure increase greater than 4-6mmHg
Which drug classes affect cardiovascular the most?
Stimulants= increase HR/BP
Alpha-2 agonists= decreased HR/BP
TCA= tachycardia
If we are to discontinue stimulants or alpha-2-agonists, what is the discontinuation protocol?
Stimulants= tapering over several weeks is recommended (especially for high doses or if on therapy for longer than 3 months) to avoid withdrawal symptoms
Alpha2 agonists= tapering to avoid hypertensive crisis
How slowly do we need to taper alpha 2 adrenergic agonists?
Clonidine= 0.1mg/week
Guanfacine= 1mg/week
Psychiatric side effects like anxiety, irritability, insomnia, and tics are common side effects. How often do we monitor for these?
Daily in first week, then monthly for first 3 months, then every 6 months.
When are these side effects worse and do they go away with time?
Psychiatric side effects are often worse upon initiation and resolves after 1-2 weeks of therapy.
How do we manage insomnia side effect with stimulants?
Lower the stimulant dose
Change to earlier administration
Shorter acting formulation
Adding sedating med at bed
Minimize use of caffeine and other psychostimulant
Which agents are associated with these psychiatric side effects?
Stimulants
Atomoxetine
Bupropion
Venlafaxine
Is ADHD medications lifelong?
While ADHD is a lifelong condition, drug holiday may be acceptable.
Symptoms may dissipate in adolescence.
Try weaning med for 2-3 weeks period once a year (preferably around work or school holiday) and assess if still needed for next school term
When is extended drug holiday not recommended? (several months over summer)
Children with moderate to severe ADHD who are doing well on medication
Do we need to taper atomoxetine if we want to discontinue?
No- less withdrawal compared to other agents
How do we manage ADHD in pregnancy?
Mild-moderate symptoms= non-pharm preferred
If stimulant is preferred, amphetamines is preferred
- no increased risk of cardiac or major congenital malformation
Methylphenidate is associated with increased risk of cardiac malformation
- Caution in first trimester
No data for lisdexamfetamine
Is atomoxetine safe for pregnancy?
Avoid, especially during first trimester
How do we manage ADHD in breastfeeding?
Non-pharm is preferred
If stimulant is preferred, methylphenidate is preferred (low transfer into breast milk). Does not appear to affect nursing infant (monitor for agitation and poor weight gain)
Amphetamines are transferred into milk, and impact is unknown. Monitor.
Is TCAs, bupropion and venlafaxine ok for breastfeeding?
If treatment was already existing, patient may remain on therapy. Monitor infant.
Which drugs should be avoided in breastfeeding?
- Atomoxetine (no reports)
- Clonidine/guanfacine (decreases milk production)
- Risperidone= limited experience
If we need to switch from stimulant therapy to atomoxetine or antidepressant, how do we manage?
Lower dose of stimulant can be continued and tapered over ~3 weeks while new drug takes effect
Which ADHD medication can be opened and mixed with water?
Vyvanse
Can you crush Concerta tablets?
No
Which ADHD medications can be taken with orange juice? Which medication cannot?
Yes: Vyvanse, Concerta, Foquest
No: Dexedrine
In what medical condition should we avoid the use of stimulants in?
Seizures or epilepsy, as stimulants can lower the seizure threshold
If patient has short gut syndrome, which of the stimulants should be avoided? Why?
Concerta
Tablet does not change shape in GI so there is risk of adhesion, decreased transit time, or obstruction
What’s a counselling point we should mention to patients for the excretion of concerta?
Concerta tablet shell may appear in the feces
