ADHD and Tics Flashcards
Pathophysiology of ADHD
reduced activity of dopamine and norepinephrine in the prefrontal cortex, alterations in the default mode attention network, less cortical mass has been detected in patients
Symptoms of inattention
inattentive to details or activities, difficulty sustaining attention, does not appear to listen when spoken to, lack follow through, difficulty w/ organization, avoidance of task requiring mental effort, frequently losing things, forgetfulness
Symptoms of hyperactivity
frequent fidgeting and squirming, inappropriately leaves seat in class, inappropriately runs or climbs, difficulty playing or performing activities quietly, often on the go, talks excessively
Symptoms of impulsivity
blurts out, difficulty waiting turn, often interrupts or intrudes on others
ADHD diagnosis
dec attention and inc levels of impulsivity, DSM-V diagnostic criteria, at least 5-6 symptoms of inattention or hyperactivity, impulsiveity present for >6 months, some 2 settings, observed by parents and clinician
Differential diagnoses of ADHD
Biomedical problems (metabolic, neurologic, chronic illness), speech/lang probs, academic/learning probs, emotional/psychiatric probs (anxiety, bipolar), family probs (abuse)
Consequences of ADHD
social difficulties, behavioral issues, impaired academic performances, strained familial relationships, inc risk for development of conduct disorders, abuse, psych disorders
Treatment goals of ADHD
alleviate target sx, imp relationships, imp academia, imp rule following, imp QOL, minimize ADRs
Non pharm interventions of ADHD
maintain daily schedule, minimize distractions, set reachable goals, limit choices, encourage hobbies, use calm disciplines, use check lists
Stimulants MOA
all serve to inc [NT], block reuptake, act as agonists
Stimulants PEARLS
first line, onset several weeks, imp behavior in all children, 70-80% response rate, trial w/ alternative stimulant warranted if lack of effectiveness, intolerable ADRs
Stimulants imporve
over activity, attention span, impulsivity and self-control, physical/verbal aggression, social interactions, academic productivity
Stimulants may not improve
academic performance, learning problems, social skills, oppositional behavior, emotional probs, long-term cog, academic, behavioral, emotional and social functions
Stimulant ADRs
loss of appetitie, insomnia, wt loss, possible tachy, HTN, anxiety, irritability, HA, tics, stunted growth, generally mild or short duration, often reversible
Stimulant abuse potential
risk of misuse/diversion by pts, family, prevent by open discussion w/ pts and family, utilize long-acting preparations, monitor refill dates
Stimulant IR
immediate release, duration 4 hrs, up to 3x/day, adderal may be BID, beneficial when first titrating dose, can see wearing off during the day
Methylphenidate IR
Ritalin, methylin; duration 3-4 hrs, adjust every 1-2 weeks as needed, schedule II, contraindications tics, marked agitation
Methylphenidate IR dosage
children 5-15 mg PO BID before breakfast and lunch, adults 10-20 mg PO BID-TID 30-45 mins before meals
Dexmethylphenidate (Focalin)
Duration 4-5 hrs, conversion from methylphenidate: initiate at 1/2 the total daily does of methylphenidate, BID>4-5 hrs apart w/out regard to meals, children >6 y/o and adults
Dextroamhetamine (Dexedrine, Dextrostat)
typically half the methylphenidate dose, rarely used
Stimulants er
extended, controlled, sustained release, long acting formulation, once daily dosing, 8-12 hr duration, preferred dosage form due to diminished rebound ADR and wearing off, convert when stable on IR dose, adolescents and adults may require dose of IR for evening coverage
Methylphenidate ER (Ritalin LA, SR)
schedule II, dosed 1-2x daily w/ breakfast, lunch, 1/2 IR, 1/2 ER, duration 6-10 hrs, switching from IR: usually same daily dose
Daytrana patch
10-30 mg/ 9hrs, apply patch 2 hrs before desired effect, leave on for 9 hrs, dose may be increased weekly, duration 12 hrs, must ensure the pt will leave patch alone, apply to hip, do not cut
Metadate CD
10-60 mg, dose 1 x daily, formulations=30% IR coating, 70% ER center, duration 8-9, may sprinkle over apple sauce
Concerta
18, 27, 54, 72(adolescents) mg dosed daily, duration 12 hrs,
Dexmethylphenidate ER (Focalin XR)
duration 12 hrs, may take whole or sprinkle over applesauce, schedule II
Dextroamphetamine SR
Dexedrine Apansule (5,10,15 mg) dosse 1-2x daily, formulation IR and ER beads, duration 6-10 hrs schedule II
Adderall
Dose 10-20 mg PO BID, as dose inc doa inc, duration 6-8 hrs, schedule 2
Adderall XR
dose 10-60 mg PO Daily, duration 10-12 hrs, may sprinkle over applesauce, schedule 2
Lisdexamfetamine (Vyvanse)
Schedule II, dose 1x daily, duration 13-14 hrs, potentially less abuse potential
Non-stimulants
alternative therapy to stimulants and can be used when comorbid conditions/diseases (anxiety, drug abuse issue, HTN, CVD), intolerable ADRs, therapeutic failure of first line agents, current substance abuse issue
Atomoxetine (Strattera) MOA
NE reuptake inhibitor, selectively inhibits presynaptic NE transporter, not a stimulant, not a controlled medication
Atomoxetine (Strattera) uses and ADRs
approved for pediatric and adults, decreased abuse potential, good option if ADRs w/ stimulants, ADRs- N/V/C, dizziness, irritability, sleep disturbances, dec appetitie, upset stomach, abdominal pain
Atomoxetine (Strattera) dosage
given 20-40 mg PO BID, may take 2-4 weeks to see full benefit
Atomoxetine (Strattera) advantages
shown to improve inattention and hyperactivity impulsive sx, not controlled substances, no abuse potential
Atomoxetine (Strattera) disadvantages
black box warning- inc suicidal thinking in children adolescents and young adults, poor metabolizers of Cyp2D6 which inc cardiac ADR and must dec in liver function impairment, prolonged doa
Antidepressants
Buproprion (Wellbutrin), TCAs, 2nd line agents to stimulant and atomoxetine, option if substance abuse a problem
Buproprion (Wellbutrin)
ne/DA reuptake inhibitor, dec hyperactivity and aggressive behavior, reserved for adults if stimulant or atomoxetine fails, ADRs- insomnia, HA, restlessness, tics, seizures
Buproprion (Wellbutrin) advantages
safer CV profile compared to stimulants, atoxetine and TCAs, less toxicity in overdose compared to TCAs, less appetitie suppression, useful if comorbid depression, IR- 150 mg PO BID, XL- 300 mg PO daily
Buproprion (Wellbutrin) disadvantages
less effective for distractibility compared to stimulants, inc time to show therapetic benefit, can worsen tics, dose dependent risk seizures
TCAs
NE/serotonin reuptake inhibitor, reserved for older children who do not respond to stimulants, use limited, baseline EcG required, may be used to manage stimulant induced insomnia
TCA options
Impiramine (Tofranil), Desipramine (Norpramine)
TCA advantages
usefel in coexisting depression/anxiety, no anorexia, no rebound symptoms, studies indicate a dec in impulsivity&hyperactivity
TCA disadvantages
inc sedation which may impair function at school, CV side effects, anticholinergic side effects, toxic if overdose, inc time to show therapeutic benefit (4 weeks)
TCA toxicity
risk adverse CV events, screen for fam hx of heart disease, baseline ECG and monitoring, do not use or d/c if resting HR> 130 BPM, ECG abnormalities, ADRs- anticholinergic
Alpha-2 agonists
mediate effects of NE in frontal cortex, used for mono-therapy or add-on, dec efficacy compared to stimulants, beneficial in over-aroused, easily-frustrated, highly-active or aggressive individuals, don’t stop abruptly 6-8 weeks for max benefit, not controlled substance
Guanfacine (Intuniv, Tenex)
longer t1/2 and fewer ADRs compared to clonidine, use peds 6-17 y/o, may be beneficial in those w/ tics, intolerance to stimulants, or as add-on therapy, absorption inc w/ high fat meal
Clonidine (Catapres, Kapvay)
.2 mg PO BID, catapres available as patch
Types of tics simple
motor: eye blinking, neck jerking, shoulder shrugging, facial grimacing, vocal: coughing, throat clearing, grunting, sniffling, snorting, barking
Types of tics complex
grooming behaviors, smelling, jumping, touching vocal: repeating words
Types of tic disorders
tourette’s disorder, chronic motor or vocal tic disorder last>year, transient tic disorder (goes away by themselves), tic disorder not otherwise specified
Tourette’s disorder
multiple motor tics and > 1 vocal tic, tics occur many times per day, occur nearly every day or intermittently for >1year, onset before age 18, not due to substance abuse or stimulant use, prevalence
Treatment of tics
Evaluate overall ability of function, mild tics may not require treatment, mod to severe tics often interfere w/ social and academic functioning, behavioral interventions, pharm interventions, comb treatment
Pharm treatment of tics
dopamine antagonist (typical and atypical), alpha-2 agonist
Typical antipsychotics for tics
haloperidol, fluphenazine, risk of extrapyramidal effects, risk of inc QT interval, monitor
Atypical antipsychotics for tics
Risperidone (Risperdal), Olanzapine (Zyprexa), may be preferred due to dec risk of EPS, ADR- wt gain, metabolic abnormalities, sedation, FPS
Alpha-2 agonist for tics
clinidine, guanfacine, in pt w/ concurrent ADHD reevaluation use of stimulants
