ADHD Management Flashcards
What are the requirements for an ADHD diagnosis?
Hyperactivity/ impulsivity or inattention:
- Occur often
- Present more than one setting
- Present before age 12
- Impair function
- Be excessive
What are examples of ADHD that require attention of a specialist to treat ADHD?
- Intellectual disability
- History of abuse
- Developmental disorder
- Visual or hearing impairment
- Severe aggression
- Children unresponsive to treatment
Who is to be involved and what target goals are to be set?
- Include pt, family, and school personnel
- 3-6 targetable outcomes at 1 time that are realistic, achieveable, and measureable
What type of therapy is 1st line for kids diagnosed at 4-5 (preschool age)?
- Behavioral therapy (administered by parents or teachers)
- Add medications if target goals not met (Methylphenidate)
What is the recommended 1st line tx for school age kids (>6) for ADHD?
Stimulant plus behavioral therapy
What is monitoring schedule for ADHD drugs?
Weekly to once every 3-6 months based on stage of pharmacology treatment
What are important considerations of initiating pharmacotherapy in children with ADHD?
- Child is 6 or older
- School will cooperate in administration and monitoring
- Child has normal heart rate and normal blood pressure
- Child is seizure free
- Substance abuse among household members is not a concern (IR stimulants)
If there are risk factors to ADHD pharm treatment what should be done?
-Comprehensive CV focused pt history, family Hx, and physical exam
Before starting adolescents on ADHD pharm treatment what should be done?
Assess them for substance use/abuse
What considerations must be taken when deciding on drug agents to assist in pharm tx of ADHD?
- Time of day target sx
- Duration of desired coverage
- Coexisting tic D/O (avoid stimulant)
- Substance abuse in family member at residence
- Expense
What three stages exist for pharm treatment in ADHD?
- Titration
- Maintenance
- Termination
What is the most common practice for a pt to start pharm therapy for ADHD?
On the weekend
What is good good practice for prescription writing for ADHD kids?
Writing multiple prescriptions so pharmacy supplies multiple bottles for administration at school
What is the general titration period for ADHD med and monitoring of patients on these drugs?
- 1 to 3 months
- Close follow-up usually every week
What is the recommended way to titrate with ADHD drugs?
Start lowest dose and titrate every 3-7 days until core sxs improve to 4-50% or until ADRs unacceptable
What is the thought on drug holidays with stimulant medication?
Not routinely recommended; Case by case basis
What are the ADRs associated w/ stimulant use?
- Decreased appetite
- Poor growth
- Dizziness
- Insomnia/nightmare
- Mood lability
- Rebound sx
- Tics
- Psychosis
How should ADHD pts take their medication to avoid decreased appetite?
- Administer at or after a meal
- Nutrient dense meals; high fat meals delay onset and increase peak concentrations of some formulations
How is poor growth controlled w/ stimulant use?
Drug holidays IF growth trajectory crosses 2 major percentiles for growth
How is dizziness managed with stimulant use?
Ensure adequate hydration/ fluid intake and try long-acting formulations if associated only at peak concentrations
How is insomnia/nightmares managed when using stimulants?
Change in dosing schedule (change to short acting, take earlier in the day, or omit)
How is mood lability managed in ADHD stimulant use?
Switch to long acting formulation; If still present referral for mood disorder evaluation
How is rebound managed in stimulant use?
Sx/ ADRs occur as medication wears off; Step down to lower dose late in day
How are tics managed w/ stimulant use?
Try different dose or stop medication to see if drug-related
How is psychosis managed w/ stimulant use?
Verify appropriate dose and adherence; if correct stop drug and send to mental health for evaluation
How is diversion/misuse managed w/ stimulant use?
- Monitor prescription refills
- Try long- acting preparations
How is termination of therapy monitored?
Similar to starting, every few days/weeks to check for sx return
What is important to know about stimulants as a drug class?
Controlled substance (II)
What are severe ADRs associated w/ stimulant use?
Cardiac arrhythmia (especially during 1st few days) BP/Hr elevation
If an ADHD pt has a CV risk, how should they be managed?
work-up and/or referral should occur
What are contraindications of stimulant use?
- Symptomatic CV disease
- Moderate/severe HTN
- Seizure disorders
- Hyperthyroidism
- Motor tics or tourettes syndrome
- Glaucoma
- Agitated states
- Anxiety
- Drug abuse hx
- Concurrent use/ use w/in 14 days of MOAI
What are the type of stimulants?
- Methylphenidate -dexmethylphenidate
- Amphetamines
What is the MOA of the stimulants to treat ADHD?
Block reuptake of NE and DA into presynaptic neurons
What is the PK information for short acting methylphenidate?
- Initial effect 20-60 minutes
- Duration of action 3-5 hours
What is the PK information for long acting methylphenidate?
Onset and duration very by formulation
What are types of methylphenidate long acting drugs?
Metadate, Concerta, Quilivant, Ritalin
What are types of methylphenidate short acting drugs?
Methylin, Ritalin
What type of drug is available of dexmethylphenidate?
Focalin
What drugs are amphetamines?
Adenzys, Dexedrine, Procentra & Adderall
What amphetamine drug is useful in use to discourage misuse? How does it work?
Lisdexamfetamine, prodrug activated after oral ingestion
What non-stimulant drug is used to treat ADHD?
Atomoxetine
When would Atomoxetine be preferred over stimulants?
Those w/ or family w/ substance abuse, tics, significant ADRs w/ stimulants
What is important PK/management information about Atomoxetine?
- Requires 1-2 weeks for initial response and up to 4 weeks for maximal effect
- Dose every day and do not use drug holidays
What ADRs are associated with Atomoxetine?
- Weight loss
- Suicidal thinking (BBW)
- Abd pain/N/V
- Decreased appetite
- Rare sudden death
- CV issues
What are contraindication of Atomoxetine?
- Concurrent use/ use w/in 14 days of MAOI
- Glaucoma
- Current/ past pheochromocytoma
- Severe CV disorder
When would alpha-2-adrenergic agonists be used to treat ADHD?
When stimulants or Atomoxetine can not be used or are not effective
What are the alpha-2-adrenergic agonists used to treat ADHD?
- ER Clonidine
- ER Guanfacine
What is useful about ER Clonidine/ Guanifacine?
They can be used as adjuncts to stimulants
When would antidepressants be used to treat ADHD?
Nothing else works use TCAs or Bupropion
What is important to know about stimulant use in adults w/ ADHD?
-Are not as effective and have greater potential for ADR CV risk than in children
How are adults managed with ADHD?
-Normally stimulants unless substance abuse and tx w/ Atomoxetine or Bupropion
