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Pharmacology > ADHD and Tics > Flashcards

ADHD and Tics Flashcards

1
Q

Pathophysiology of ADHD

A

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

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2
Q

Symptoms of inattention

A

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

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3
Q

Symptoms of hyperactivity

A

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

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4
Q

Symptoms of impulsivity

A

blurts out, difficulty waiting turn, often interrupts or intrudes on others

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5
Q

ADHD diagnosis

A

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

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6
Q

Differential diagnoses of ADHD

A

Biomedical problems (metabolic, neurologic, chronic illness), speech/lang probs, academic/learning probs, emotional/psychiatric probs (anxiety, bipolar), family probs (abuse)

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7
Q

Consequences of ADHD

A

social difficulties, behavioral issues, impaired academic performances, strained familial relationships, inc risk for development of conduct disorders, abuse, psych disorders

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8
Q

Treatment goals of ADHD

A

alleviate target sx, imp relationships, imp academia, imp rule following, imp QOL, minimize ADRs

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9
Q

Non pharm interventions of ADHD

A

maintain daily schedule, minimize distractions, set reachable goals, limit choices, encourage hobbies, use calm disciplines, use check lists

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10
Q

Stimulants MOA

A

all serve to inc [NT], block reuptake, act as agonists

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11
Q

Stimulants PEARLS

A

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

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12
Q

Stimulants imporve

A

over activity, attention span, impulsivity and self-control, physical/verbal aggression, social interactions, academic productivity

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13
Q

Stimulants may not improve

A

academic performance, learning problems, social skills, oppositional behavior, emotional probs, long-term cog, academic, behavioral, emotional and social functions

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14
Q

Stimulant ADRs

A

loss of appetitie, insomnia, wt loss, possible tachy, HTN, anxiety, irritability, HA, tics, stunted growth, generally mild or short duration, often reversible

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15
Q

Stimulant abuse potential

A

risk of misuse/diversion by pts, family, prevent by open discussion w/ pts and family, utilize long-acting preparations, monitor refill dates

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16
Q

Stimulant IR

A

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

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17
Q

Methylphenidate IR

A

Ritalin, methylin; duration 3-4 hrs, adjust every 1-2 weeks as needed, schedule II, contraindications tics, marked agitation

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18
Q

Methylphenidate IR dosage

A

children 5-15 mg PO BID before breakfast and lunch, adults 10-20 mg PO BID-TID 30-45 mins before meals

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19
Q

Dexmethylphenidate (Focalin)

A

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

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20
Q

Dextroamhetamine (Dexedrine, Dextrostat)

A

typically half the methylphenidate dose, rarely used

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21
Q

Stimulants er

A

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

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22
Q

Methylphenidate ER (Ritalin LA, SR)

A

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

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23
Q

Daytrana patch

A

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

24
Q

Metadate CD

A

10-60 mg, dose 1 x daily, formulations=30% IR coating, 70% ER center, duration 8-9, may sprinkle over apple sauce

25
Q

Concerta

A

18, 27, 54, 72(adolescents) mg dosed daily, duration 12 hrs,

26
Q

Dexmethylphenidate ER (Focalin XR)

A

duration 12 hrs, may take whole or sprinkle over applesauce, schedule II

27
Q

Dextroamphetamine SR

A

Dexedrine Apansule (5,10,15 mg) dosse 1-2x daily, formulation IR and ER beads, duration 6-10 hrs schedule II

28
Q

Adderall

A

Dose 10-20 mg PO BID, as dose inc doa inc, duration 6-8 hrs, schedule 2

29
Q

Adderall XR

A

dose 10-60 mg PO Daily, duration 10-12 hrs, may sprinkle over applesauce, schedule 2

30
Q

Lisdexamfetamine (Vyvanse)

A

Schedule II, dose 1x daily, duration 13-14 hrs, potentially less abuse potential

31
Q

Non-stimulants

A

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

32
Q

Atomoxetine (Strattera) MOA

A

NE reuptake inhibitor, selectively inhibits presynaptic NE transporter, not a stimulant, not a controlled medication

33
Q

Atomoxetine (Strattera) uses and ADRs

A

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

34
Q

Atomoxetine (Strattera) dosage

A

given 20-40 mg PO BID, may take 2-4 weeks to see full benefit

35
Q

Atomoxetine (Strattera) advantages

A

shown to improve inattention and hyperactivity impulsive sx, not controlled substances, no abuse potential

36
Q

Atomoxetine (Strattera) disadvantages

A

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

37
Q

Antidepressants

A

Buproprion (Wellbutrin), TCAs, 2nd line agents to stimulant and atomoxetine, option if substance abuse a problem

38
Q

Buproprion (Wellbutrin)

A

ne/DA reuptake inhibitor, dec hyperactivity and aggressive behavior, reserved for adults if stimulant or atomoxetine fails, ADRs- insomnia, HA, restlessness, tics, seizures

39
Q

Buproprion (Wellbutrin) advantages

A

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

40
Q

Buproprion (Wellbutrin) disadvantages

A

less effective for distractibility compared to stimulants, inc time to show therapetic benefit, can worsen tics, dose dependent risk seizures

41
Q

TCAs

A

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

42
Q

TCA options

A

Impiramine (Tofranil), Desipramine (Norpramine)

43
Q

TCA advantages

A

usefel in coexisting depression/anxiety, no anorexia, no rebound symptoms, studies indicate a dec in impulsivity&hyperactivity

44
Q

TCA disadvantages

A

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)

45
Q

TCA toxicity

A

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

46
Q

Alpha-2 agonists

A

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

47
Q

Guanfacine (Intuniv, Tenex)

A

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

48
Q

Clonidine (Catapres, Kapvay)

A

.2 mg PO BID, catapres available as patch

49
Q

Types of tics simple

A

motor: eye blinking, neck jerking, shoulder shrugging, facial grimacing, vocal: coughing, throat clearing, grunting, sniffling, snorting, barking

50
Q

Types of tics complex

A

grooming behaviors, smelling, jumping, touching vocal: repeating words

51
Q

Types of tic disorders

A

tourette’s disorder, chronic motor or vocal tic disorder last>year, transient tic disorder (goes away by themselves), tic disorder not otherwise specified

52
Q

Tourette’s disorder

A

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

53
Q

Treatment of tics

A

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

54
Q

Pharm treatment of tics

A

dopamine antagonist (typical and atypical), alpha-2 agonist

55
Q

Typical antipsychotics for tics

A

haloperidol, fluphenazine, risk of extrapyramidal effects, risk of inc QT interval, monitor

56
Q

Atypical antipsychotics for tics

A

Risperidone (Risperdal), Olanzapine (Zyprexa), may be preferred due to dec risk of EPS, ADR- wt gain, metabolic abnormalities, sedation, FPS

57
Q

Alpha-2 agonist for tics

A

clinidine, guanfacine, in pt w/ concurrent ADHD reevaluation use of stimulants

Pharmacology (61 decks)

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