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Nurs 5229 Clinical Pharmacotherapeutics > ADHD and Enuresis > Flashcards

ADHD and Enuresis Flashcards

1
Q

DSM-V (Diagnostic and Statistical Manual of Mental

Disorders, 5th edition) diagnostic criteria

A

Persistent pattern across settings of inattention,

hyperactivity, or impulsivity

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2
Q

Validated screening tools - ADHD

A

Children: Vanderbilt® Connor©
• Adults: World Health Organization Adult ADHD SelfReport Scale and the Diagnostic Interview for ADHD in
adults (DIVA 2.0)

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3
Q

Neurobiology of ADHD

A
  • Complex; has genetic and environmental factors
  • Genetic
  • Heritability 60% to 90%
  • 28% of ADHD cases accounted for by genetics
  • Environmental factors
  • Low birth weight and prenatal complications
  • Malnutrition
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4
Q

Evidence-Based Treatment of ADHD

• Two sets of guidelines

A

American Academy of Pediatrics (AAP)

• American Association of Child and Adolescent Psychiatrists (AACAP)

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5
Q

AAP Guidenlines

A

Behavioral therapy first line for children 5 years of age or younger
• Stimulants first-line therapy

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6
Q

AACP guidelines

A

Stimulants first line therapy for children 6 years of age or older

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7
Q

ADHD (cont.)

• Goals of Pharmacotherapy

A

Modulate Dopamine (DA) and Norepinephrine (NE) to improve executive function
and regulate arousal to improve performance (Dipiro p. 1145)
• *multimodal therapy most successful
• * remember ADHD often coexists with other mood and behavior disorders which
increases the challenge of prescribing pharmacotherapy\

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8
Q

ADHD Options

A 
Options
• Stimulants
• Methylphenidate
• Amphetamines
• Non-Stimulants
• SNRI
• Alpha-Agonist
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9
Q

Stimulants Methylphenidate - MOA

A 
Absorption: readily absorbed
Distribution: variable by age
Protein-Binding: variable; low
Metabolism: Liver
Elimination: Renal
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10
Q

Stimulants Methylphenidate - PK/PD

A

Onset 1h. Peak 3-11h (depends on formulation). ½ life: 2-4h

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11
Q

Stimulants Methylphenidate - + Effects

A

Low doses: reduce movement, impulsivity, and increase cognitive function including sustained attention and working
memory

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12
Q

Stimulants Methylphenidate - Neg Effects

A

higher doses: impaired cognition and locomotor-activating effects.
Black Box Warning: abuse potential
LT use: growth suppression
CV risk: sudden death
Psych risk: increases Tics in comorbid tic condition
Appetite suppression, tachycardia, dizziness, headache (HA), insomnia, growth suppression

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13
Q

Stimulants Methylphenidate - Monitoring

A

Screen for CVD: congenital, arrhythmia, other disease; MH: psychosis, bipolar, aggression; Neuro: Seizures, Vision disturbance, GI
Labs: CBC with differential, Platelets (maybe); Growth parameters

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14
Q

Stimulants Methylphenidate Interactions

A

ncreases serum concentrations of: TCAs, SSRIs, phenylbutazone, warfarin, phenytoin, phenobarbital, and primidone
Caution: clonidine, anticonvulsants, antihypertensives. Contraindicated: MAOI
Pregnancy: risk vs. benefit: lower weight NB; old category C

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15
Q

Stimulants Amphetamines - MOA

A

Elevates extracellular dopamine (DA) and prolongs DA receptor signaling in the striatum
Inhibits the reuptake of monoamine oxidase which acts synergistically to produce a significant increase in the
monoamine concentration
Weak dopamine reuptake inhibitor, moderate noradrenaline reuptake inhibitor and very weak serotonin reuptake
inhibitor.

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16
Q

Stimulants Amphetamines - PK/PD

A 
Absorption: Well absorbed
Distribution: high volume
Protein-binding: low
Metabolism: Liver CYP2D6
Elimination: renal
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17
Q

Stimulants Amphetamines - Action

A

Peak 1-3h (o) 15” Inject. ½ life: varies, 9-14h

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18
Q

Stimulants Amphetamines - POS Effects

A

Improve the core symptoms of ADHD in the short term

Gains in social and classroom behaviors

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19
Q

Stimulants Amphetamines - NEG Effects

A

Black Box warning: abuse potential
Linked to a higher risk of experiencing adverse events such as sleep problems, decreased appetite, and stomach pain
Appetite suppression, tachycardia, dizziness, headache (HA), insomnia, growth suppression, masks exercise fatigue

20
Q

Stimulants Amphetamines - Monitoring

A

Screen for CVD: congenital, arrhythmia, other disease; MH: psychosis, bipolar, aggression; Neuro: Seizures,
Vision disturbance, GI
Labs: CBC with differential, Platelets (maybe); Growth parameters

21
Q

Stimulants Amphetamines - Interactions

A

MAOIs AND those listed under Methylphenidate

22
Q

Long-acting stimulant medications are generally preferred for

A

school-age children

23
Q

Start with a 1st line medication from the methylphenidate or dextroamphetamine-amphetamine class, depending
on patient’s age. - 1st, 2nd, and 3rd line examples

A

1
st Line: Methylphenidate (Ritalin LA, Metadate CD; dextroamphetamine/amphetamine, LA: Adderall XL
• 2
nd Line: Methylphenidate, LA: Concerta; Dexmethylphenidate, LA: Focalin XR
• 3
rd Line: Lisdexamfetamine, LA: Vyvanse

24
Q

Maximize dosing of one agent before

A

moving to the next. If ineffective or side effects develop, switch classes,
then move to second line medication if needed.

25
Q

Before considering a stimulant medication, obtain

A

cardiac history, including sudden cardiac death in first degree
relative under age 50, history of congenital heart defect, or conduction defect.

26
Q

• Maximize dosing of long-acting

A

stimulant before adding an immediate release formulation medication

27
Q

Insufficient evidence exists for switching

A

methylphenidate to amphetamines. Consider switching from methylphenidate to amphetamines at
half of the dose.

28
Q

When switching dexmethylphenidate to methylphenidate, the methylphenidate dose should be

A

twice the dexmethylphenidate dose.

29
Q

Concerta® (methylphenidate ER) and Vyvanse® (lisdexamfetamine) are uniquely

A

dosed. The table below provides an initial dose which

may require additional titration.

30
Q

Non-Stimulants: Atomoxetine - MOA

A

Selective inhibitor of Norepinephrinereuptake; Increases the amount of norepinephrine in the brain

31
Q

Non-Stimulants: Atomoxetine - Action

A

Plasma levels peak within 1-3h; 6 weeks before it reaches maximum effect

32
Q

Non-Stimulants: Atomoxetine Pos effects

A

No abuse potential; not a schedule II
Works around the clock
Useful inpatients with comorbid anxiety

33
Q

Non-Stimulants: Atomoxetine Neg Effects

A

2/3 as effective as stimulants
Black Box Warning: May increase suicidal thoughts at initiation
GI effects: decreased appetite, upset stomach, nausea or vomiting, jaundice; GEN: tiredness, problems sleeping; CV: CV
events; NEURO: dizziness; Mental Health: negative.

34
Q

Non-Stimulants: Atomoxetine Monitoring

A

CVD and health, Growth parameters, Mental health, GI status, LFTs; MH status

35
Q

Non-Stimulants: Atomoxetine Interactions

A

Lower doses if patient on SSRIs: paroxetine or fluoxetine. Avoid: CYP2D6 inhibitors
Contraindicated: MAOIs, glaucoma, Pheochromocytoma
Pregnancy: Risk versus benefit

36
Q

Guanfacine LA

• Used to treat

A

children with ADHD who have tics, sleep problems, and/or

aggression

37
Q

Guanfacine LA activates

A

Activates presynaptic alpha2

-adrenergic receptors in the brain

38
Q

Guanfacine LA does not

A

Does not cause much appetite suppression

39
Q

Guanfacine LA may cuase

A

May cause sleepiness, headaches, fatigue, stomachaches, nausea, lethargy,
dizziness, irritability, decreased blood pressure, and decreased appetite

40
Q

Guanfacine LA takes up to

A

Takes up to 3-4 weeks to see effect

41
Q

Long-Acting Clonidine (Kapvay) FDA approved

• Principal side effects

A

Somnolence, fatigue, and hypotension

42
Q

Enuresis DX

A

Diagnosis: voiding history/pattern, consider age, rule out physical

43
Q

Enuresis Epidemiology

A 
Epidemiology
• 4 years:25% of children
• 7 years, only 5-10%
• 10 years, fewer than 5% of children
• Spontaneous resolution rate = 15% per year
44
Q

Enuresis Treatment

A

Nonpharm first
• Lifestyle, behavioral modification, reassurance, education, wet alarm
• Medication consideration
• Over age 7 years
• No improvement after 3 months of other therapies
• Can be used intermittently for special occasions

45
Q

Desmopressin Oral or disintegrating tablet

A
  • 1 hour before bed
  • 0.2 mg initiall, titrate as necessary to a maximum dose of 0.6 mg
  • Reduces bedwetting 1.3 fewer nights/wk
  • Serious SE: water intoxication; counsel on fluid restriction when taking
46
Q

Anticholinergic (oxybutynin 2.5-5 mg at HS, tolteridine>12 y)

A

• Indications: dysfunctional voiding, overactive bladder, neurogenic bladder
• MOA: Reduce uninhibited detrusor contractions, increase the threshold volume at
which an uninhibited detrusor contraction occurs, and enlarge the functional bladder
capacity
• Anticholinergic SE: dry mouth, constipation
• Useful in some if daytime wetting
• Can be combined with desmopressin

47
Q

Imipramine (TCA)

A
  • Dose at HS: 25 mg for patients aged 6-8 years and 50-75 mg older children
  • One fewer wet night per week
  • High relapse rate
  • SE profile: WHO no longer recommends

Nurs 5229 Clinical Pharmacotherapeutics (78 decks)

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