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Clinical Therapeutics 2 > ADHD > Flashcards

ADHD Flashcards

1
Q

what increases risk of ADHD persistency of child into adulthood?

A

psychiatric comorbidity

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2
Q

what’s the biggest problem/sx with ADHD?

A

worsening functioning

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3
Q

cause of ADHD?

A

Genetics

  • likely multiple DA and NE related genes are involved
  • ADHD in 1st degree relatives is 4-10x greater
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4
Q

blocking what receptors results in ADHD-like behavior?

A

blocking NE alpha-2 receptors

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5
Q

people with ADHD have delayed ___. how long is the days in children?

A

delayed brain maturation (cortical thickness and cortical surface area are delayed)

2-3 year delay in children

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6
Q

diagnosing ADHD takes who?

A

everyone involved in person’s life

-Parent, Teacher, Physician

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7
Q

what is the #1 medication for tx of ADHD?

A

stimulants (amphetamine, methylphenidate)

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8
Q

what 3 other meds are used to treat ADHD?

A

Atomoxetine

Guanfacine or Clonidine

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9
Q

what is the MOA of methylphenidate/dexmethylphenidate?

A

blocks the reuptake of DA and NE (increases DA and NE)

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10
Q

dexmethylphenidate NE effect vs methylphenidate NE effect

A

Dexmethylphenidate has less NE effects potentially resulting in better tolerability

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11
Q

onset of methylphenidate and the amphetamines?

A

very quick, w/in first day of dosing

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12
Q

common ADRs of methylphenidate and the amphetamines?

A

insomnia, reduced appetite, diversion/misuse

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13
Q

what causes the appetite suppressant effect of stimulants?

A

increase of DA

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14
Q

what meds does methylphenidate interact with and the amphetamines? what effect does it cause?

A

TCAs, MAOIs, other stimulants, antipsychotics

Can have hypertensive urgency b/c working on NE

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15
Q

what pathway is methylphenidate metabolized by? what pathway does it NOT get metabolized by that amphetamines do?

A

Metabolized into ritalinic acid via carboxylesterase CES1A1, a non-CYP450 enzymatic pathway

DOESN’T WORK ON CYP450 PATHWAY

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16
Q

what are the precautions for methylphenidate and the amphetamines?

A

CV, psychosis, glaucoma

seizures (in amphetamines)

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17
Q

what is a unique formulation of methylphenidate?

A

transdermal patch

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18
Q

where is the methylphenidate transdermal patch applied? how long is it distributed for?

A

to hip - distributes med over 9 hrs application period

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19
Q

how long is the delay in therapeutic serum concentration of the methylphenidate transdermal patch? peak?

A

3 hours delay, peak at 7hrs

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20
Q

when is there big increase in absorption of the methylphenidate transdermal patch?

A

with inflamed skin or heated area

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21
Q

what does removal of methylphenidate patch result in? how long are lingering stimulant effects for it?

A

abrupt cessation of methylphenidate absorption

expect a 1 hour lingering stimulant effect

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22
Q

who is the methylphenidate transdermal patch commonly given to?

A

autistic kids

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23
Q

what is not so good about the methylphenidate transdermal patch/patch meds in general?

A

always have variability in absorption

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24
Q

leaving the methylphenidate patch on for too long can cause what symptoms?

A

psychotic symptoms b/c of too much DA

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25
methylphenidate patch vs methylphenidate PO
Similar side effects b/w the two, but having the patch increases the adrs especially decreased appetite and insomnia Skin irritation unique to the transdermal formulation (time and dose dependent)
26
MOA of dextroamphetamine/mixed amphetamine salts/lisdexamfetamine
Block the reuptake of DA and NE and enhances its release into the synapse Also inhibits MAO and may have direct stimulatory effects on alpha and beta receptors
27
what are the names of the amphetamine meds?
Dextroamphetamine (Dexedrine) Mixed amphetamine (Adderall) Lisdexamfetamine (Vyvanse)
28
when would you add short-acting stimulant for ADHD?
for intermittent evening activities
29
what is an adr of the amphetamines that isn't an adr of methylphenidate that you must monitor for?
tics - monitor for worsening or onset of new tics
30
by what system are the amphetamines metabolized by?
CYP450 system - SPECIFICALLY CYP2D6
31
what 2 SSRIs inhibit CYP2D6? what does this mean in relation to prescribing patient with depression/anxiety an amphetamine for ADHD?
Paroxetine and Fluoxetine If giving SSRI and also need to give stimulant, give methylphenidate (b/c doesn’t go through CYP450 system) or different give SSRI that doesn’t interact with CYP2D6
32
what is safer to use for ADHd, amphetamines or methylphenidate?
methylphenidate
33
are stimulants C/I in seizure d/o's? what have studies shown for stimulant use with seizure d/o?
NO!!! - studies have actually shown benefit of methylphenidate for alertness in epileptic patients, that they don't increase seizure risk - studies have also shown a reduction in epileptiform activity when use stimulants
34
what children are more likely to have an abuse problem, children with ADHD/ADD or children without ADHD/ADD?
children with ADHD/ADD
35
do stimulants induce someone to abuse drugs?
NO!!! - b/c when children treated for ADHD/ADD with a stimulant they had the same rate of substance abuse as children without ADHD/ADD
36
what effect do stimulants have on child's growth?
2cm shorter at 3 years, but no differences after 10 years
37
what shows elimination of growth loss with stimulants?
cessation of the stimulants
38
what may provide some benefit for stimulants causing some growth loss?
drug holidays - stopping drug on the weekend (if can tolerate ADHD symptoms) - stopping stimulant over the summer (if can tolerate)
39
what does stopping stimulant over the summer allow for besides benefit for them causing growth loss?
Allows for the family/clinician to assess patient for need to continue therapy once the school year resumes in September -Brain maturation/symptoms reduction may be enough so that stimulant can be stopped permanently
40
are there any significant effects of stimulants on CV (BP, HR, ECG)? what about untreated ADHD?
NO Untreated ADHD has significant CV risks associated with it d/t more cigarette smoking and substance use
41
according to FDA/AHA, children with known CV risk and taking stimulants should be what? what should you get a baseline?
cautioned and monitored carefully -> BP and HR should be routinely monitored should get ECG baseline, but not mandatory unless a known CV risk exists
42
does atomoxetine have any risk on CV events?
no increased risk
43
MOA of Atomoxetine?
Blocks the re-uptake of NE | -this results in benefits of both alpha-2 receptors and small increases in DA
44
what's the onset of Atomoxetine compared to the stimulants? is it as effective as stimulants?
Onset of efficacy is very quick, within days of initiation -has continued improvements up to 6 weeks (vs stimulant doesn’t) very effective, but not as effective as stimulants
45
ADRs of Atomoxetine
GI upset, dry mouth, reduced appetite, insomnia, erectile dysfunction Has some initial effects at slowing growth (no differences at 36 months)
46
Atomoxetine DDIs
Any meds with NE effects (e.g. MAOIs, SNRIs, alpha-1 antagonists, vasoconstrictors, albuterol)
47
what is Atomoxetine metabolized by? what SSRI increased Atomoxetine?
Metabolized by CYP2D6 ***Paroxetine increased Atomoxetine by 600%
48
what 2 medications for ADHD are affected by CYP2D6?
AMPHETAMINES AND ATOMOXETINE ARE BOTH AFFECTED BY CYP2D6
49
if have patient with ADHD and substance abuse problems, what medication for ADHD will you use for tx?
Atomoxetine
50
in what situation would you definitely use Atomoxetine in ADHD?
if patient also has substance abuse problem
51
MOA of Guanfacine?
Alpha-2 agonist which stimulates alpha-2a post synaptic receptors in the prefrontal areas -This results in strengthening the relevant connections for attention Compared to DA enhancement which weakens irrelevant connections
52
Guanfacine is a useful __ to stimulants?
useful adjunct to stimulants
53
how long may it take for Guanfacine to have full effects?
up to 4 weeks
54
Guanfacine may be better for what 2 disorders?
oppositional defiant disorder, conduct disorder
55
Guanfacine is safe regarding ___
tics
56
ADRs of Guanfacine?
Decrease in BP and pulse Sedation/somnolence/fatigue -If give at night, doesn’t help with ADHD sx’s, just helps with sleep -> need to dose in the morning
57
Guanfacine CV effects
decreased both HR and BP
58
MOA of Clonidine? half-life?
Compared to guanfacine, is less specific and will stimulate alpha-2a, b, and c receptors resulting in more sedation and greater decrease in BP Has shorter half-life requiring increased frequency in dosing
59
ADRs of Clonidine?
Somnolence and fatigue will occur in up to 50% (this will drop in half if given with a stimulant) ***A little more side effects than guanfacine Data shows it is an anxiolytic (guanfacine doesn't)
60
Clonidine is good if have what?
anxiety and ADHD
61
CV Effects of Clonidine?
decreased BP and HR when combined with stimulants BETTER EFFECTS ON CV WITH STIMULANTS VS ALONE
62
what ADHD med has greatest improvement of tics without worsening of tic?
methylphenidate
63
Guanfacine and Clonidine effect on tics?
reduce tic but have less benefit on ADHD than methylphenidate
64
Atomoxetine and effects tics
helps ADHD w/out worsening tics (less of a benefit than methylphenidate)
65
what stimulant in high doses may worsen tics?
amphetamines
66
what do the guidelines recommend about tics and treating ADHD?
trying methylphenidate first and monitoring tic frequency If tics get worse, then give clonidine
67
what must you treat FIRST in adults before diagnosing them with ADHD?
All other factors that can worsen attention: | -Pain, anxiety, depression, sleep disorders, adjustment disorders, medications, etc.
68
what settings does stimulant misuse frequently occur in?
college settings, more competitive schools
69
what's the most common reason for stimulant misuse? second most common?
performance enhancement = MC second most common is for recreation
70
what must you assess in patient before starting stimulant if pt also has substance use d/o?
patient misuse or patient diversion
71
how do you treat substance use d/o and ADHD?
concurrently
72
what stimulants have been shown to have less abuse potential, but can still be used to induce a euphoria?
transdermal methylphenidate and lisdexamfetamine
73
___ acting stimulants are safer for patient with ADHD and substance use
long acting stimulants
74
are stimulants recommended for patients with ADHD and substance use d/o?
NO
75
what are legitimate first choices for adult ADHD d/t frequent comorbidities of anxiety, depression?
Venlafaxine, TCAs, and other SNRIs are legitimate first choices due to frequent comorbidities of anxiety, depression Atomoxetine may be better than stimulants for anxiety Bupropion helpful in depression but not anxiety
76
what nutritional supplement is preferred to prescribe for ADHD if prescribe one at all?
Omega-3 fatty acid
77
what is critical for successful child outcomes with ADHD tx?
parent counseling and training
78
do nonpharmacologic tx's help with ADHD?
meditation and stability balls may, but nonpharmacologic tx inconsistently shows benefit
79
what medication is NOT recommended under ANY circumstances for tx of ADHD?
Methamphetamine -as effective as other stimulants, but because of significant risk of abuse and neurotoxicity it is NOT recommended under any circumstance
80
what other medication for ADHD tx is NOT FDA approved? what is it as effective as?
Bupropion -as effective as Atomoxetine
81
is Venlafaxine effective for tx of ADHD?
Effective, but avoid if possible d/t mood changes in children
82
are TCAs effective for tx of ADHD?
Effective, but avoid if possible due to cardiac risks in children (sudden death has been reported)
83
why didn't modafinil get FDA approval for tx of ADHD?
d/t occurrence of SJS rash
84
what are the FIRST LINE treatment recommendation for ADHD?
Use a stimulant - long-acting preferred
85
if first stimulant not effective in tx of ADHD, then try what med?
try the other stimulant class
86
if 2nd stimulant not effective in tx of ADHD, then try what med?
try atomoxetine or alpha-2 agonists Atomoxetine is considered 1st line if patient has specific stimulant risks -CV abnormalities, known diversion, substance use disorder Alpha-2 agonists are preferred adjuncts to stimulants
87
what meds for ADHD are preferred adjuncts to stimulants?
alpha-2 agonists (Guanfacine and Clonidine)

Clinical Therapeutics 2 (11 decks)

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