ADHD

Question 1

what is ADHD and what are the symptoms?

Answer 1

1) Behavioural disorder characterised by hyperactivity, impulsivity and inattention
2) can lead to functional impairment such as psychological, social, educational or occupational difficulties.

Question 2

1) when do symptoms of ADHD typically appear?

2) is it more common in males or females?

Answer 2

1) Children aged 3–7 years,may not be recognised until after 7 years of age if hyperactivity not present
2) More common in males

Question 3

Although ADHD is persisting disorder, which symptoms tend to recede over time in adulthood?

Answer 3

inattentive symptoms tend to persist, and hyperactive-impulsive symptoms tend to recede

Question 4

ADHD is also associated with an increased risk of which disorders? (4)

Answer 4

1) Oppositional defiant disorder (ODD)
2) Conduct disorder,
3) Mood disorders e.g. Depression, mania, and anxiety
4) Substance misuse

Question 5

Environmental modifications can be trialed before drug treatment is initiated in individuals as they can help reduce the impact of symptoms of daily life. Give some examples of environmental modifications (5)

Answer 5

1) Seating arrangements
2) lighting and noise
3) reducing distractions
4) optimising education by having shorter sessions with movement breaks
5) reinforcing verbal requests with written instructions

Question 6

ADHD focused psychological interventions which may involve a complete course of CBT. Who might this type of treatment be suitable for? (2)

Answer 6

1) refused drug treatment, inadherent, intolerant, or unresponsive to drug treatment.
2) benefited from drug treatment, but symptoms a persist in at least one area of function. Combination of non-drug treatment with drug treatment is tried here.

Question 7

when should pharmacological treatment be initiated in those with ADHD?

Answer 7

Diagnosed by specialist- Initiated when symptoms persist in at least one area of function, despite environmental modifications.
(Patients with ADHD and anxiety disorder, tic disorder, or autism spectrum offered same treatment)

Question 8

1) which two drugs are used as first line treatment for ADHD?
2) when should symptoms be reviewed initially, and what if symptoms persist?

Answer 8

1) Lisdexamfetamine or methylphenidate

2) 6-week trial of either drug- switch to the alternative first-line treatment if symptoms do not improve

Question 9

what is the difference in properties of Lisdexamfetamine vs methylphenidate?

Answer 9

Lisdexamfetamine has a longer duration of effect

↳(magnitude, duration of effect, and side-effects of stimulants vary between patients)

Question 10

Explain why modified-release preparations of stimulants are preferred in ADHD (5)

Answer 10

1) Pharmacokinetic profile
2) convenience
3) Improved adherence
4) Reduced risk of drug diversion
5) the lack of need to be taken to work

Question 11

1) what is the next option in patients who have tried methylphenidate and lisdexamfetamine and have not responded to separate 6-week trials of both drugs?
2) what if this option fails or is insufficient?

Answer 11

1) Non-stimulant Atomoxetine
2) if above fails - Ganfacine or an atypical antipsychotic in addition to stimulants in patients with ADHD- refer to specialist
↳bupropion , modafinil, TCAs, and venlafaxine - offered but little evidence

Question 12

what side effects can occur with the use of guanfacine and how can this be managed?

Answer 12

1) Sustained orthostatic hypotension or fainting episodes

2) Dose reduced or an alternative treatment offered

Question 13

what should be monitored in those with ADHD?

Answer 13

1) Effectiveness, side-effects, changes in sleep pattern, sexual dysfunction, and stimulant diversion or misuse
2) Monitor patients for the development of tics associated with stimulant use

Question 14

what side effect can atomoxetine (sch 3) cause in males?

Answer 14

sexual dysfunction

Question 15

How often should treatment be reviewed in those with ADHD?

Answer 15

reviewed by a specialist at least once a year and trials of treatment-free periods, or dose reductions considered

Question 16

what should be monitored in those taking atomoxetine?

Answer 16

1) Monitor for appearance of worsening of anxiety, depression or tics
2) Pulse, BP, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter

Question 17

what patient and carer advice should be given to those taking atomoxetine? (2)

Answer 17

1) Suicidal ideation: Report worsening, suicidal thoughts or behaviour, irritability, agitation, or depression
2) Hepatic impairment: prompt medical attention with the following: Abdominal pain, unexplained nausea, malaise, darkening of the urine, or jaundice

Question 18

What are the characteristic symptoms of an amfetamine overdose? (6)

Answer 18

1) Wakefulness
2) Excessive activity
3) Paranoia
4) Hallucinations
5) Hypertension followed by exhaustion
6) Convulsions, hyperthermia, and coma

Question 19

what can dexamfetamine cause in children and how should this be managed?

Answer 19

1) Growth restriction in children- Monitor height and weight as growth restriction may occur during prolonged therapy
2) drug-free periods may allow catch-up in growth (withdraw slowly)

Question 20

what are the monitoring requirements for amfetamines? (sch 2)

Answer 20

1) Monitor growth in children.
2) Monitor for aggressive behaviour or hostility during initial treatment.
3) Pulse, BP, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter

Question 21

Dexsamfetamine and Lisdexamfetamine (prodrug of dexam) should be discontinued if which syndrome develops in patients?

Answer 21

Tics and Tourette syndrome- discontinue if tics appear

Question 22

what patient and carer advice should be given to those prescribed amphetamines?

Answer 22

Treatment is likely to affect their ability to perform skilled tasks (e.g. driving) check DVLA website

Question 23

what condition in particular should amphetamines be used in caution with?

Answer 23

Cardiovascular disease- underlying conditions that might be compromised by increases in blood pressure or heart rate