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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
Q

methylphenidate patch vs methylphenidate PO

A

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)

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26
Q

MOA of dextroamphetamine/mixed amphetamine salts/lisdexamfetamine

A

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

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27
Q

what are the names of the amphetamine meds?

A

Dextroamphetamine (Dexedrine)

Mixed amphetamine (Adderall)

Lisdexamfetamine (Vyvanse)

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28
Q

when would you add short-acting stimulant for ADHD?

A

for intermittent evening activities

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29
Q

what is an adr of the amphetamines that isn’t an adr of methylphenidate that you must monitor for?

A

tics - monitor for worsening or onset of new tics

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30
Q

by what system are the amphetamines metabolized by?

A

CYP450 system - SPECIFICALLY CYP2D6

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31
Q

what 2 SSRIs inhibit CYP2D6? what does this mean in relation to prescribing patient with depression/anxiety an amphetamine for ADHD?

A

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

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32
Q

what is safer to use for ADHd, amphetamines or methylphenidate?

A

methylphenidate

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33
Q

are stimulants C/I in seizure d/o’s? what have studies shown for stimulant use with seizure d/o?

A

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
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34
Q

what children are more likely to have an abuse problem, children with ADHD/ADD or children without ADHD/ADD?

A

children with ADHD/ADD

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35
Q

do stimulants induce someone to abuse drugs?

A

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
Q

what effect do stimulants have on child’s growth?

A

2cm shorter at 3 years, but no differences after 10 years

37
Q

what shows elimination of growth loss with stimulants?

A

cessation of the stimulants

38
Q

what may provide some benefit for stimulants causing some growth loss?

A

drug holidays

  • stopping drug on the weekend (if can tolerate ADHD symptoms)
  • stopping stimulant over the summer (if can tolerate)
39
Q

what does stopping stimulant over the summer allow for besides benefit for them causing growth loss?

A

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
Q

are there any significant effects of stimulants on CV (BP, HR, ECG)? what about untreated ADHD?

A

NO

Untreated ADHD has significant CV risks associated with it d/t more cigarette smoking and substance use

41
Q

according to FDA/AHA, children with known CV risk and taking stimulants should be what? what should you get a baseline?

A

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
Q

does atomoxetine have any risk on CV events?

A

no increased risk

43
Q

MOA of Atomoxetine?

A

Blocks the re-uptake of NE

-this results in benefits of both alpha-2 receptors and small increases in DA

44
Q

what’s the onset of Atomoxetine compared to the stimulants? is it as effective as stimulants?

A

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
Q

ADRs of Atomoxetine

A

GI upset, dry mouth, reduced appetite, insomnia, erectile dysfunction

Has some initial effects at slowing growth (no differences at 36 months)

46
Q

Atomoxetine DDIs

A

Any meds with NE effects (e.g. MAOIs, SNRIs, alpha-1 antagonists, vasoconstrictors, albuterol)

47
Q

what is Atomoxetine metabolized by? what SSRI increased Atomoxetine?

A

Metabolized by CYP2D6

***Paroxetine increased Atomoxetine by 600%

48
Q

what 2 medications for ADHD are affected by CYP2D6?

A

AMPHETAMINES AND ATOMOXETINE ARE BOTH AFFECTED BY CYP2D6

49
Q

if have patient with ADHD and substance abuse problems, what medication for ADHD will you use for tx?

A

Atomoxetine

50
Q

in what situation would you definitely use Atomoxetine in ADHD?

A

if patient also has substance abuse problem

51
Q

MOA of Guanfacine?

A

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
Q

Guanfacine is a useful __ to stimulants?

A

useful adjunct to stimulants

53
Q

how long may it take for Guanfacine to have full effects?

A

up to 4 weeks

54
Q

Guanfacine may be better for what 2 disorders?

A

oppositional defiant disorder, conduct disorder

55
Q

Guanfacine is safe regarding ___

A

tics

56
Q

ADRs of Guanfacine?

A

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
Q

Guanfacine CV effects

A

decreased both HR and BP

58
Q

MOA of Clonidine? half-life?

A

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
Q

ADRs of Clonidine?

A

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
Q

Clonidine is good if have what?

A

anxiety and ADHD

61
Q

CV Effects of Clonidine?

A

decreased BP and HR when combined with stimulants

BETTER EFFECTS ON CV WITH STIMULANTS VS ALONE

62
Q

what ADHD med has greatest improvement of tics without worsening of tic?

A

methylphenidate

63
Q

Guanfacine and Clonidine effect on tics?

A

reduce tic but have less benefit on ADHD than methylphenidate

64
Q

Atomoxetine and effects tics

A

helps ADHD w/out worsening tics (less of a benefit than methylphenidate)

65
Q

what stimulant in high doses may worsen tics?

A

amphetamines

66
Q

what do the guidelines recommend about tics and treating ADHD?

A

trying methylphenidate first and monitoring tic frequency

If tics get worse, then give clonidine

67
Q

what must you treat FIRST in adults before diagnosing them with ADHD?

A

All other factors that can worsen attention:

-Pain, anxiety, depression, sleep disorders, adjustment disorders, medications, etc.

68
Q

what settings does stimulant misuse frequently occur in?

A

college settings, more competitive schools

69
Q

what’s the most common reason for stimulant misuse? second most common?

A

performance enhancement = MC

second most common is for recreation

70
Q

what must you assess in patient before starting stimulant if pt also has substance use d/o?

A

patient misuse or patient diversion

71
Q

how do you treat substance use d/o and ADHD?

A

concurrently

72
Q

what stimulants have been shown to have less abuse potential, but can still be used to induce a euphoria?

A

transdermal methylphenidate and lisdexamfetamine

73
Q

___ acting stimulants are safer for patient with ADHD and substance use

A

long acting stimulants

74
Q

are stimulants recommended for patients with ADHD and substance use d/o?

A

NO

75
Q

what are legitimate first choices for adult ADHD d/t frequent comorbidities of anxiety, depression?

A

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
Q

what nutritional supplement is preferred to prescribe for ADHD if prescribe one at all?

A

Omega-3 fatty acid

77
Q

what is critical for successful child outcomes with ADHD tx?

A

parent counseling and training

78
Q

do nonpharmacologic tx’s help with ADHD?

A

meditation and stability balls may, but nonpharmacologic tx inconsistently shows benefit

79
Q

what medication is NOT recommended under ANY circumstances for tx of ADHD?

A

Methamphetamine

-as effective as other stimulants, but because of significant risk of abuse and neurotoxicity it is NOT recommended under any circumstance

80
Q

what other medication for ADHD tx is NOT FDA approved? what is it as effective as?

A

Bupropion

-as effective as Atomoxetine

81
Q

is Venlafaxine effective for tx of ADHD?

A

Effective, but avoid if possible d/t mood changes in children

82
Q

are TCAs effective for tx of ADHD?

A

Effective, but avoid if possible due to cardiac risks in children (sudden death has been reported)

83
Q

why didn’t modafinil get FDA approval for tx of ADHD?

A

d/t occurrence of SJS rash

84
Q

what are the FIRST LINE treatment recommendation for ADHD?

A

Use a stimulant - long-acting preferred

85
Q

if first stimulant not effective in tx of ADHD, then try what med?

A

try the other stimulant class

86
Q

if 2nd stimulant not effective in tx of ADHD, then try what med?

A

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
Q

what meds for ADHD are preferred adjuncts to stimulants?

A

alpha-2 agonists (Guanfacine and Clonidine)

Clinical Therapeutics 2 (11 decks)

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