ADHD

Question 1

Methylphenidate, Amphetamine

Answer 1

ADHD
Stimulants
• First-line therapy
• Behavioral Tx—cannot directly improve academic or social fxn
FDA approved Indications 
─ ADHD 
─ Narcolepsy
MOA
─ NorEpi and DA reuptake inhibition
─ Week MAOI effects
ADE
─ Weight loss, ↓appetite
─ Insomnia
─ Growth suppression
─ Sudden death (controversial)
─ Slight ↑risk of seizures (avoid in epileptics)
-  ↑ BP and/or HR
• Drug Interactions
─ Avoid MAOIs
─ Additive and contradicting effects
• Warnings for psychosis/mania, aggression/violence, anxiety/panic, and cardiovascular concerns

Question 2

Atomoxetine (Strattera)

Answer 2

ADHD
FDA approved indications
─ ADHD
MOA
─ NorEpi reuptake inhibition
ADE
─ Nausea, anorexia, insomnia or fatigue, 
- some ↑BP or ↑HR, possibility of ↑↑LFT
Drug Interactions
─ MAOIs
─ Additive effects
─ Possible if combined with a *strong 2D6 inhibitor

Question 3

Bupropion (Wellbutrin)

Answer 3

ADHD
FDA approved indications
1) Depression
2) smoking cessation
3) seasonal affective disorder
─ not approved for ADHD
ADE
─ Agitation, ↑ HR/BP, headache, dizziness
─ Less appetite changes than others
─ Risks of overdose toxicity, Tic exacerbation (Tics = common Comorbity in ADHD), and ↓ seizure threshold 
Drug Interactions
─ Minimal, avoid MAOIs
Important concepts
─ *Pediatric metabolism: may be faster than adults

Question 4

Tricyclic Antidepressants (TCAs)

Answer 4

ADHD
FDA approved indications
1) Primarily depression,
2) some may have an add’l T/I such as insomnia
─ None are approved for ADHD
MOA
─ Serotonin and norepi reuptake inhibitors
ADE (Known for Many ☹)
─ Varies based on drug
─ Anticholinergic effects, sedation, potential for cardiac conduction (EKG) changes (concerning in an overdose)
Drug Interactions
─ Varies based on drug, MAOIs
─ Additive effects
Important concepts
- *Obtain a baseline EKG prior to initiation

Question 5

Clonidine (Catapres, Kapvay), Guanfacine (Tenex, Intuniv)

Answer 5

ADHD
Alpha2 Agonists
FDA approved indications:
1) ADHD (ER form only; “ER”= “Extended Release/long-acting),
2) HTN (non-ER form)
MOA
─ α2 agonists, theorized to regulate activity in prefrontal cortex
ADE
─ *Sedation, *hypotension, bradycardia, syncope, *rebound hypertension (taper slowly)
─ *Guanfacine =less sedating and has less hypotension (more selective)
Drug Interactions
─ Additive effects
─ Possibility with Guanfacine when combined with strong 3A4 inhibitors/inducers

Question 6

Adjunct Medications

Answer 6

ADHD
• Primarily based on other comorbid conditions
─ *Mood stabilizers
─ *Antipsychotics (“typicals” limited by A/Es)
─ *Benzodiazepines
• Overall, these have less reported efficacy in inattentive subtype