ADHD Flashcards
Treatment
Stimulants
Methylphenidate dexmethylphenidate
Amphetamine dextroamphetamine lisdexamfetamine
Non-stimulant
Atomoxetine
Guanfacine
Clonidine
Other agents
Bupropion
Tri-cyclic antidepressants (TCAs)
Methylphenidate DOC
MOA: blocks reuptake of NE and DA
Other uses: narcolepsy, fatigue, post-anesthesia shivering, traumatic brain injury
Renal cleared
Regulatory - Schedule II
Dexmethylphenidate (Focalin and Focalin XR ®
d-threo-enantioner of methylphenidate – more active
Dosage forms:
Short acting (Ritalin, Methylin)
Intermediate acting (Ritalin SR, Metadate ER, Methylin ER)
Long Acting **Daytrana (patch)
Methylphenidate
Warnings
Not FDA-approved for children <6 yrs
75-80% improvement
Black box warning: abuse potential, may lead to tolerance and dependence. Severe depression may occur upon withdrawal, avoid abrupt discontinuation.
FDA continues to recommend that a careful CV history be obtained – esp for arrhythmias, hypertension, CAD
ADER- common
Common
Decreased appetite, weight loss
RARe- dysphoria, tics, HTN, nightmares
Methylphenidate
Drug-drug interactions (DDIs)
Moderate
TCAs: HTN, CNS stimulation
Carbamazepine: ↓ methylphenidate efficacy
Methylphenidate causes ↑ phenobarbital, phenytoin, warfarin levels
Contraindicated: ***MAOIs
MAOI must be discontinued for at least 14 days
Dextroamphetamine/amphetamine and Lisdexamfetamine DOC and 2nd
Not FDA-approved for children <3 yrs
Other uses: narcolepsy
Black box warning: abuse and dependence potential;
Regulatory: Schedule II
MOA: Releases norepinephrine from storage vesicles in adrenergic nerve terminals and blocks NE reuptake
ADE: same as methylphenidate
Lisdexamfetamine (Vyvanse®) – prodrug of dextroamphetamine; requires hydrolysis in gut for activation, may reduce abuse
Immediate release (Dexedrine, Dextrostat, Procentra soln, Adderall (mixed)) Extended release (Adderall
DDI
Citalopram, venlafaxine: increased risk of serotonin syndrome**
Contraindicated
MAOIs: increased risk of hypertensive crisis
Atomoxetine- non stimulang
Consider in patients with anxiety, insomnia, substance abuse disorder
Black Box warning: increased risk of suicidal ideation
No effect in the nucleus accumbens
No addictive properties
Contraindicated
MAOIs: increased risk of serotonin syndrome
Dose Adjustments needed: hepatic insufficiency
Common
Increased BP, HR
Rash
Weight loss, loss of appetite
rare Injury of liver Seizure Suicidal ideation Priaprism
Guanfacine (Intuniv)-New
MOA: SELECTIVE alpha 2A receptor agonist – less SE’s, mediate inattentive, hyperactive and impulsive symptoms of ADHD
add-on to stimulant
ADE: somnolence, dizziness, headache, low blood pressure, xerostomia, constipation
ER new-Clonidine (Kapvay)
MOA: NON-selective binds to Alpha 2A, TB, and 2C receptors. more SE
Alternative for children intolerant to amphetamines (children with tics); or add-on
ADEs: Sedation, hypotension (
Other agents ADHD
Bupropion
Less appetite suppression than stimulants, less toxicity in overdose than TCAs
rash and seizures
TCAs
Amitriptyline, imipramine, desipramine, nortriptyline
Caution- AntiACHdaytime sedation affecting cognition; assess baseline ECG d/t arrhythmia risk
Other Agents (not FDA approved for ADHD
Modafinil (Provigil)
Armodafinil (Nuvigil)
MOA: Uncertain; CNS stimulation in discrete brain regions; no alpha adrenergic stimulation but actions attenuated by prazosin
Use: narcolepsy, obstructive sleep apnea,
ADE: dizziness, nausea, anxiety, insomnia, headache,*** (Stevens-Johnson)
Schedule IV Controlled Substance
Non-pharmacologic therapy
Positive reinforcement
Time-out
Removing access to positive reinforcement
Response cost
Withdrawing rewards/privileges based on unwanted/problem behavior
Token economy
Positive reinforcement + response cost
