ADHD Flashcards
pharmacology of amphetamines
indirect-acting sympathomimetic substrate for transporter blocks VMAT (degradation of Da) DAT runs backwards works on NET and SERT too non-selective activation of monoamines wakefulness, alertness, increased ability to concentrate high doses = psychotic behaviors (Da)
consequences of ADHD
poor academic performance, low self-esteem, poor interpersonal relationships, employment difficulties, if left untreated increased risk of substance abuse and antisocial personality disorder (incarceration)
inattention
must have 6:
Fails to give close attention to details/ careless mistakes
difficulty sustainig attention in tasks or play activities
Does not seem to listen when directly spoken to
does not follow through on instruction/finish schoolwork/chores
difficulty organizing tasks/activities
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
loses things necessary for tasks/activities
easily distracted by extraneous stimuli
forgetful in daily activities
hyperactivity/impulsivity
must have 6:
Fidgets with hands/feet, squirms in chair
often leaves seat when expected to stay seated
Runs or climbs in inappropriate situations
unable to play or engage in leisurely activities quietly
“on the go” or “driven by a motor”
Talks excessively
blurts out answers before questions have been completed
Difficulty waiting turns
interrupts or intrudes on others
nonpharm treatment
Family-focused interventions: education, support groups, parent management training
School-focused: classroom modifications (sitting in front), tutoring, calendars or electronic organization devices
Child-focused: education about ADHD, psychosocial therapy
drug therapy
Stimulants: Methylphenidate, Dexmethylphenidate, Dextroamphetamine, mixed amphetamine salts, lisdexamphetamine
Non-stimulant: atomoxetine, TCAs, clonidine, guanfacine, bupropion, modafinil, mood stabilizers
treatment guidelines
First Line: Methylphenidate or amphetamine (can switch to other if needing a different response)
Second line: Atomoxetine
Third line: Bupropion, TCAs, alpha-agonist
Behavioral therapy is first line for kids aged 4-5
Dual treatment has not been shown to be effective and is not considered appropriate therapy
stimulant side effects and management
Reduced appetite, weight loss: take after high-calorie breakfast, or ensure dinner is high-calorie after effect has worn out
Stomach Ache: Give on full stomach
Insomnia: dose earlier in the day, consider sedating med at bedtime
Headache: divide dose, give with food, give analgesic
Rebound symptoms: longer-acting stimulant trial, atomoxetine, antidepressant
Irritability, jitteriness: assess for co-morbid condition, reduce dose, consider mood stabilizer or atypical antipsychotic
recent stimulant warnings
Priapism: specific to methylphenidate; considered rare ADR; consider switch to amphetamine Peripheral vasculopathy (Raynaud’s): associated with methylphenidate and amphetamine stimulants - NOT non-stimulants, Consider switch to non-stimulant
daytrana
Patch applied to outside of hip 2 hours prior to needed effect, remove after 9 hour, will have residual effects for 3 hours
*Must be a responder to methylphenidate
vyvanse
Must be swallowed whole
Theoretically reduces abuse potential (prodrug)
Not useful if lack of past response to dextroamphetamine
atomoxetine
Adverse Effects: GI upset, anorexia, weight loss
Warning for liver toxicity and suicidal thinking in children and adolescents
Reserved for 2nd line treatment if failure of stimulants or concern for abuse - will take weeks to take effect (SSRI)
For patients under 70kg = weight based dosing
TCAs
Not commonly used for ADHD, if used, mostly for insomnia related to stimulants
Used most often for nocturnal enuresis
imipramine is the most common then desipramine
Lethal in overdose (cardiac arrythmias)
alpha 2 adrenergic agonists
Clonidine, guanfacine
Decrease arousal caused by NE
More commonly used to treat impulsivity, persistent conduct problems, or insomnia
Monitor for cardiac effects: baseline EKG recommended
Guanfacine IR: also 24 hour effect but more adverse effects can occur like orthostasis or sedation due to dose-dumping effect
Can be sedating - take at night if other ADHD meds cause insomnia
bupropion and ADHD
not FDA approved and not as useful as stimulant agent, but may be considered in certain situations
