ADHD & Neuropathic Pain Flashcards
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
symptoms of adhd with wandering off task, lacking persistence, having difficulty remaining focused, and being disorganized
inattention
symptom of adhd with excessive motor activity, fidgeting, tapping, talkativeness, extreme restlessness, and wearing others out
hyperactivity
adhd symptoms with desire for immediate rewards, social intrusiveness, making decisions without considering long term
impulsivity
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
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
what is used 1st line for ADHD if sub abuse disorder
atomoxetine, viloxazine, guanfacine, clonidine, bupropion
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
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
what is 1st line for ADHD diagnosis with predominant ANZIETY/DEPRESSION? if that fails?
- antidepressant
- add stim
- alt antidepressant
which is more potent? MPH or AMP?
AMP more potent (smaller dose needed if switch from MPH)
benefits of IR stimulants
low cost, less insomnia, less growth AEs
psychiatric AEs of stimulants include
psychosis, aggression, severe anxiety
cardiac AEs of stimulants
which agent may be preferred
inc HR & BP
caution with CV conditions- MPH may be preferred
growth AEs of stimulants include
slow height inc, weight deficit
appetite suppression
how to manage reduced appetite/weight loss with stimulants
high cal meal when stim effect low
cyproheptadine at bedtime
how to manage stomachache with stimulants
take on full stomach, lower dose
how to manage insomnia with stimulants
dose earlier, lower last dose, add sedating QHS med (guan, clon, melatonin, cyprohep)
how to manage HA with stimulants
divide dose, give with food, analgesic
how to manage irritability with stimulants
assess comorbidities, reduce dose, add mood stabilizer/APS
how to manage euphoria, zombie-like, tics, HTN with stimulants
reduce dose, change med
how to manage hallucinations with stimulants
d/c stim, reassess diagnosis, mood stabilizer/APS
some DDI of MPH include
TCAs, antacids, PPI, H2RA
some DDI of AMP include
antacids, PPI, acidic agents, cyp2D6
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
3
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
