ADHD & Neuropathic Pain Flashcards by Sara Bojarski

diagnosis of ADHD is made with onset of symptoms before age __ with how many symptoms for children vs older adolescents/adults

before age 12
children- 6 or more symptoms
older adolescents/adults- 5 symptoms

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symptoms of adhd with wandering off task, lacking persistence, having difficulty remaining focused, and being disorganized

inattention

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symptom of adhd with excessive motor activity, fidgeting, tapping, talkativeness, extreme restlessness, and wearing others out

hyperactivity

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adhd symptoms with desire for immediate rewards, social intrusiveness, making decisions without considering long term

impulsivity

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if predominant ADHD diagnosis, which agents are first line? if poor response to one of these?

MPH, d-MPH, or AMP/mixed AMP

poor response- switch to another

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if poor response to 1st line ADHD agents, what is next step?
and if that fails?

atomoxetine, viloxazine, guanfacine, clonidine, bupropion

fails –> combo treatment or TCA

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what is used 1st line for ADHD if sub abuse disorder

atomoxetine, viloxazine, guanfacine, clonidine, bupropion

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what is 1st line for ADHD diagnosis with predominant TOURETTES? if that fails?

DA antagonist or a2 agonist
add stim, atomoxetine, a2 agonist
alternatives of 1

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what is 1st line for ADHD diagnosis with predominant BPD/AGGRESSION? if that fails?

atypical APS, lithium, anticonv
add stim
alt or add mood stabilizer

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what is 1st line for ADHD diagnosis with predominant ANZIETY/DEPRESSION? if that fails?

antidepressant
add stim
alt antidepressant

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which is more potent? MPH or AMP?

AMP more potent (smaller dose needed if switch from MPH)

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benefits of IR stimulants

low cost, less insomnia, less growth AEs

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psychiatric AEs of stimulants include

psychosis, aggression, severe anxiety

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cardiac AEs of stimulants
which agent may be preferred

inc HR & BP
caution with CV conditions- MPH may be preferred

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growth AEs of stimulants include

slow height inc, weight deficit
appetite suppression

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how to manage reduced appetite/weight loss with stimulants

high cal meal when stim effect low
cyproheptadine at bedtime

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how to manage stomachache with stimulants

take on full stomach, lower dose

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how to manage insomnia with stimulants

dose earlier, lower last dose, add sedating QHS med (guan, clon, melatonin, cyprohep)

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how to manage HA with stimulants

divide dose, give with food, analgesic

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how to manage irritability with stimulants

assess comorbidities, reduce dose, add mood stabilizer/APS

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how to manage euphoria, zombie-like, tics, HTN with stimulants

reduce dose, change med

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how to manage hallucinations with stimulants

d/c stim, reassess diagnosis, mood stabilizer/APS

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some DDI of MPH include

TCAs, antacids, PPI, H2RA

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some DDI of AMP include

antacids, PPI, acidic agents, cyp2D6

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DDI for both AMP and MPH

MAOI, psychostimulants, alcohol

MPH is only FDA APPROVED for those how old? can it be used in younger anyways?

6 and up ok to use in 3 and up anyways

which stimulant is preferred in children

MPH

which stimulant has less DDIs

MPH

do males or females have increased bioavailability of MPH

males

which MPH products are 30IR/70ER (3)?

ER, ER chewable, CD (Metadate ER, Quillichew, Metadate CD)

which MPH products are 50IR/50ER (2)?

Long acting (LA), dex-MPH XR (Ritalin LA, Focalin XR)

which MPH product is best for severe AM symptoms

MPH LA (Ritalin LA)

MPH XR suspension (quillivant XR) requires

vigorous shaking, reconstitution

MPH product with less symptom rebound and is hard to abuse

OROS (Concerta, Relexxii)

which MPH product is best for rebound afternoon symptoms

ER multilayer bead (MLR) (Aptensio XR)

MPH ER capsule (Jornay PM) must be administered

between 6:30 and 9:30 pm

which MPH have no easy 1:1 dosing conversion

XR ODT (Contempla) ER capsule (Jornay PM)

MPH patch (Daytrana) can be applied where? how long?

hip only for 9 hours

MPH and d-AMP patches should be removed at least __ hrs before bed

which stimulant patch retains >50% drug after removal, which should be kept in mind for disposal

MPH (daytrana)

which AE is more common in the MPH transderm patch

tics

MPH patch (daytrana) BBW

skin reactions

dex-MPH is how much of a dose of MPH?

1/2 the MPH dose

which MPH agent has a risk for suicidal ideation

dex-MPH/Ser-Dex-MPH (Aztarys)

which 3 AMP products are approved in 3 and up

mixed AMP IR salts (adderall) AMP sulfate IR (Evekeo) d-AMP IR (Dexedrine, zenzedi)

which AMP product is approved only in 13 and older

AMP sulfate XR (mydayis)

which AMP product is 50IR/50ER

mixed amp XR salts (adderall XR)

which 4 AMP products do not have 1:1 dose conversion

amp sulfate XR soln (dyanavel XR) amp sulfate XR ODT, ER suspension (Adzenys XR-ODT,ER) amp sulfate XR (mydayis)

AE of amp sulf xr solution (dyanavel xr)

epistaxis, upper abd pain, allergic rhinitis

which amp product has low abuse potential

lisdexamfetamine (vyvanse)

where can d-AMP patch be applied and for how long

hip, upper arm, chest, upper back, flank 9 hours

2 NE reuptake inhibitors used for ADHD

atomoxetine (strattera) viloxazine ER (qelbree)

AE of NE reuptake inhibitors (atomoxetine, viloxazine)

upset stomach, psych, CV, fatigue, sedation, dizziness

BBW for NE reuptake inhibitors (atomoxetine, viloxazine)

new onset suicidality

2 potential effects of atomoxetine

initial worsening of behavior potential for liver tox w/ long term use

what may require dose adjustment for viloxazine

renal dysfunction

effect of NE reuptake inhibitors (atomoxetine, viloxazine) is seen in

~6 weeks

alpha agonists used for adhd

clonidine ER guanfacine ER

adhd alpha agonists take how long to work

1-2 months

AE of clonidine and guanfacine

hypotension, heart block, sedation, dizzy, constipation

bupropion is good for adhd with concomitant __? should be tried for?

depression try 6 weeks

major AE/CI of bupropion

seizures

3 TCAs used for adhd? how long of trial to work?

desipramine, imipramine, nortriptyline 4 weeks

AEs of TCAs

heart block, dizzy, constipation, overdose toc, rapid heartbeat, weight gain

which APS can be used for adhd w/ concomitant bpd/conduct disorder

chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole

TCAs used for neuro pain (4)

nortriptyline, desipramine, amitriptyline, imipramine

important counseling point when initiating neuro pain treatment

onset of action may be days to weeks

advantages of TCAs for neuro pain

lots of data concomitant insomnia or depression

disadvantages of TCAs for neuro pain

anticholinergic, cardiotoxic avoid in elderly

3 SNRIs used for neuro pain

duloxetine, venlafaxine, milnacipran

advantages of duloxetine and venlafaxine for neuro pain

good AE profile good for concomitant depression

disadvantages of duloxetine and venlafaxine for neuro pain

serotonin syndrome

duloxetine CI for use in

hepatic impairment and ESRD

advantages of milnacipran for neuro pain

well tolerated improves fatigue

disadvantages of milnacipran for neuro pain

HTN AE

2 gabapentinoids use for neuro pain

gabapentin pregabalin

advantages of gabapentin for neuro pain

low DDI and AE incidence

disadvantages of gabapentin for neuro pain? what requires special dosing?

CNS depression, renal dysfunction dosing

advantages of pregabalin for neuro pain

low AE and DDI incidence, good for concomitant anxiety

disadvantages of pregabalin for neuro pain

CV (euphoria, dependency), CNS depression, renal insufficiency

2 opiate options used for neuro pain

tramadol, tapentadol

DDIs with tramadol

carbamazepine, quinidine, TCAs, SSRIs

AEs of tramadol

dizzy, GI, constipation, abuse potential, seizure risk

advantages and disadvantages of tapentadol for neuro pain

+ no active metabolites - CII, weak anticholinergic

2 topical options for neuro pain

capsaicin, lidocaine

counseling for capsaicin

GLOVES OR WASH HANDS DONT GET IT INTO A BAD PLACE ITLL BURN

RX 8% Qutenza (capsaicin) is used how often? pretreat?

pretreat w/ local anesthetic used Q3M

lidocaine works for neuro pain in

5-10 mins

what 4 classes are 1st line for neuro pain

TCA, SNRI, gabapentinoids, topicals

2nd line options for neuro pain

tramadol or combo 1st line

4 major types of neuropathic pain

painful diabetic neuropathy post-herpetic neuralgia low back pain fibromyalgia

preferred treatment options for PDN (5)

TCA, SNRI, gabapentinoids, Na channel blocker, topicals

do not use what for PDN

opioids, tramadol, tapentadol

what is preferred for post-herp neuralgia treatment (5)

TCA, antiepileptics, tramadol, lidocaine, capsaicin

topicals should only be used for neuro pain if the pain is

focal

agents for acute low back pain (2)

NSAIDs, skeletal muscle relaxants

agents for chronic low back pain

1st- NSAIDs 2nd- tramadol, duloxetine

3 agents for severe pain in fibromyalgia

duloxetine, pregabalin, tramadol

3 agents for sleep problems with fibromyalgia

low dose amitriptyline, pregabalin, cyclobenzaprine

what should not be used to treat neuro pain

opioids