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psych 1166 > ADHD & Stimulant Agents > Flashcards

ADHD & Stimulant Agents Flashcards

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1
Q

Are primary sx the same?

A

No, primary sx vary.

Some pts are more inattentive, while others are more impulsive

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2
Q

What’s the primary tx for ADHD?

A

Stimulant meds, primarily methylphenidate formulations (Concerta, others) and lisdexamfetamine (Vyvanse )

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3
Q

What’s the rationale behind using stimulants in ADHD?

A

Is to raise dopamine and norepinephrine levels.

Cuz in ADHD, it is thot there is a lack of dopamine/ a lack of functioning dopamine receptors/ some defects in the dopamine pathway

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4
Q

What’s dopamine catalyzed into?

A

2 primary catecholamines

Epinephrine

Norepinephrine

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5
Q

Other than genetics, what may alter the brains pattern of catecholamines use in some pts, which leads to ADHD sx?

A

Stressors

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6
Q

What class of controlled substance are stimulants?

A

C II

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7
Q

How long are the scripts usually for? Advantage of this duration?

A

Scripts are usually written for a month at a time.

Makes it convenient to check:
BP
HR
Weight & height (in children)

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8
Q

What should counseling of stimulants include?

A

Don’t share with others

Store in a safe place

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9
Q

What other conditions are ADHD meds used for?

A

Narcolepsy

Shift work sleep disorder

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10
Q

Which of the ADHD sx remain as the child grows up? Which can decrease?

A

Inattention and impulsivity often remain as pt ages

Hyperactivity can be decreased

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11
Q

List inattention sx

A 
Fails to pay attention
Has trouble holding attention
Doesn't pay attention when someone is talking 
Doesn't follow through on instructions
Fails to finish school work
Has difficulty organizing tasks
Avoids or dislikes tasks which require mental effort
Loses things 
Is easily distraction
Forgetful
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12
Q

Howz the diagnosis of inattention made?
A) children up to 16 yrs
B) 17 yrs to adults

A

A) 6 or more inattention sx

B) 5 or more inattention sx

+

Sx of inattention has been present for at least 6 months
Sx of inattention are inappropriate for developmental level

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13
Q

Sx of hyperactivity and Impulsivity

A 
Often fidget and squirms
Leaves seat unexpectedly
Runs about when not appropriate
Unable to play quietly
Is "on the go" as if "driven by a motor"
Talks excessively
Blurts out answers
Has trouble waiting his/her turn
Interrupts or intrudes others
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14
Q

Howz the diagnosis of hyperactivity and Impulsivity made?
A) children up to 16 yrs
B) 17 yrs to adults

A

A) 6 or more inattention sx

B) 5 or more inattention sx

+

Sx of hyperactivity-Impulsivity has been present for at least 6 months
Sx of hyperactivity-Impulsivity are inappropriate for developmental level and are deemed disruptive

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15
Q

What other conditions need to be met to be diagnosed with ADHD?

A

Several inattentive or hyperactive sx we’re present before 12 yrs

Sx must have been present in 2 or more setting (at home, work, with friends or relatives)

Sx interfere with functioning

Sx not caused by another psychiatric disorder

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16
Q

What’s the first line tx for ADHD?

A

Stimulants

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17
Q

When stimulants don’t work well enough (after trials of 2-3 agents) whats the alternative?

A

atomoxetine (Strattera)

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18
Q

Whens atomoxetine (Strattera) used as first line?

A

When prescribers are concerned about possibility of abuse by patient or family

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19
Q

Which stimulants are tried first?

A

Methylphenidate

OR

Lisdexamfetamine (Vyvanse) - prodrug of dextroamphetamine

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20
Q

Which meds are often used as adjunctive tx?

A

Guanfacine (approved in extended-release formulation “Intuniv”)

OR

Clonidine (in the extended-release formulation “Kapvay”)

(It’s common to see Concerta + Intuniv OR Vyvanse + Kapvay

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21
Q

Howz the immediate-release formulation of Clonidine used?

A

To help pts sleep at night

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22
Q

Which med is more commonly used for ADHD pts to sleep at night?

A

Diphenhydramine

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23
Q

List natural pdts that are used for ADHD?

A

Fish oils with/without Primrose oil

SAMe

St. John’s wort

Ginkgo

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24
Q

What should be considered if St. John’s wort is used?

A

Induces CYP450 enzymes and will lower the conc of majority of other drugs

It’s serotonergic and has phototoxicity risk

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25
Q

List stimulants used for ADHD

A

Methylphenidate

Dexmethylphenidate

Dextroamphetamine and Amphetamine

Lisdexamfetamine (prodrug of dextroamphetamine)

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26
Q

What’s the brand name of:

Methylphenidate IR

Methylyphenidate IR-ext-release

Methylphenidate transdermal patch

A

Methylphenidate IR (Ritalin)

Methylyphenidate IR-ext-release (Concerta)

Methylphenidate transdermal patch (Daytrana)

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27
Q

SE of methylphenidate (and all ADHD stimulants)

A

Nausea

Loss of appetite

Insomnia

Dizziness

Headache

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28
Q

Effects of methylphenidate (and all ADHD stimulants) on BP and HR?

A

Stimulants increase BP about 2-4mmHg

Increase HR about 3-8 BPM

T/4 monitor extreme caution with any cardiovascular dx

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29
Q

When is the use methylphenidate (and all ADHD stimulants) avoided?

A

In pts with known cardiac issues/defects

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30
Q

Effect of methylphenidate (and all ADHD stimulants) on pre-existing psychiatric condition?

A

Exacerbation of mixed/mania episodes if bipolar disorder

May exacerbate depression, aggressive behavior, hostility

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31
Q

Effect of methylphenidate (and all ADHD stimulants) on seizure?

A

Risk of seizures (use caution with seizure hx)

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32
Q

Monitoring parameters of methylphenidate (and other ADHD stimulants)?

A

Consider ECG prior to tx

Monitor BP and HR during tx

Height and weight (for children)

Conduct cardiac evaluation, if chest pain, unexplained syncope

Monitor CNS activity in all pts

Signs of peripheral vasculopathy e.g. Digital changes

Signs if misuse, abuse or addiction

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33
Q

Which methylphenidate can be taken whole or the capsules sprinkled on applesauce (if not warm and used right away, don’t chew)?

A

Focalin XR

Ritalin LA

Metadate CD

Adderal XR

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34
Q

Howz Concerta OROS delivered?

A

The capsule’s outer coat dissolves fast to give immediate action and the rest is released slowly

35
Q

Which of the methylphenidate brands are used in the morning only?

A

Concerta

Metadate CD

Ritalin LA

Daytrana patch

36
Q

Howz Daytrana patch used?

A

Applied in the morning

Applied to alternate hips 2 hrs before desired effect (or as soon as child awakens)

Remove after 9 hrs (at night, so pt can sleep)

37
Q

List brand names of dexmethylphenidate IR and ER

A

Focalin (dexmethylphenidate IR)

Focalin XR (dexmethylphenidate ER)

38
Q

What’s the brand name of dextroamphetamine and amphetamine IR?

A

Adderall

39
Q

What’s the brand name of dextroamphetamine and amphetamine ER?

A

Adderall XR

40
Q

What’s the brand name of dextroamphetamine IR?

A

Dexedrine

Dextrostat

41
Q

What’s lisdexamfetamine?

A

A prodrug of dextroamphetamine

42
Q

What’s the brand name of lisdexamfetamine (prodrug of dextroamphetamine)?

A

Vyvanse

43
Q

What’s unique about the dosage design of lisdexamfetamine (Vyvanse)?

A

Lisdexamfetamine is hydrolysed in the blood to active d-amphetamine.

If injected or snorted the fast effect would be muted. The design may reduce abuse potential

44
Q

How long is the wash out period after MAOI use?

A

14-day wash out period

45
Q

In what conditions should stimulants not be used?

A

Heart problems and serious psychiatric conditions

46
Q

How are minor SEs of stimulants dealt with?

A

Minor SEs usually disappear when dosage levels are lowered

47
Q

What pdts are used if children have problem falling asleep?

A

Diphenhydramine or Clonidine

48
Q

If tics (sudden repetitive movements or sounds) occur, Howz this treated?

A

Usually by changing medication dosages

49
Q

Which ADHD meds can be mixed with applesauce? (Applesauce should not be warm, a small spoonful works well and must be swallowed immediately without chewing)

A

Focalin XR (Dexmethylphenidate IR)

Ritalin LA (Methylyphenidate long-acting)

Metadate CD (Methylphenidate IR-ext-release)

Adderal XR (Dextroamphetamine + Amphetamine ER)

50
Q

Which ADHD med can be mixed with water (it must be taken right after putting it in water)?

A

Vyvanse (Lisdexamfetamine)

51
Q

What area is Daytrane patch applied?

A

Hip area in the morning

52
Q

How long before desired effect should the patch be applied?

A

2 hours

53
Q

Should patch be applied to applied to same spot?

A

No. Alternate application site daily

54
Q

How long should the Daytrana patch be worn?

A

For 9 hours (so child can sleep at night)

55
Q

How should Daytrana patch be discarded?

A

Fold in half (after peeling off), put down the toilet or lidded trash can

56
Q

List agents under non-stimulants for ADHD (2nd line; not controlled)

A

Atomoxetine (Strattera)

Guanfacine ext-release (Intuniv)

Clonidine ext-release (Kapvay)

57
Q

Whats the brand name of Atomoxetine?

A

Strattera

58
Q

SEs of atomoxetine (Strattera)?

A

Headache

Insomnia

Somnolence

Xerostomia

Nausea

Abdominal pain

Reduced appetite

Nausea

Psychiatric effects (hallucinations and mania- discontinue drug)

59
Q

Can the capsule of atomoxetine (Strattera) be opened?

A

No. It’s an irritant

60
Q

What’s the brand name of guanfacine?

A

Intuniv

61
Q

How should guanfacine (Intuniv) dosing be changed if used with CYP3A4 inducers?

A

Increase dose… Max daily dose = 8mg/day

62
Q

How should guanfacine (Intuniv) dosing be changed if used with CYP3A4 inhibitors?

A

Reduce daily dose….max daily dose = 2mg/day

63
Q

How should guanfacine (Intuniv) be used with food?

A

Don’t take with high-fat meal (increases absorption)

64
Q

SEs of guanfacine (Intuniv)?

A

Somnolence

Dizziness

Headache

Fatigue

Xerostomia

Constipation

Abdominal pain

Skin rash

65
Q

Should Intuniv be crushed?

A

No

66
Q

Can Intuniv be interchanged with other guanfacine formulations?

A

No

67
Q

When should Kapvay be started? At what dose?

A

Start 0.1mg QHS…titrate weekly…using bid dosing

68
Q

When should the dose of atomoxetine (Strattera) be decreased?

A

If pt is on strong CYP 2D6 inhibitors e.g.
Paroxetine
Fluoxetine
Quinidine

69
Q

What’s the max dose if pt is poor 2D6 metabolizer OR if pt is on strong CYP 2D6 inhibitors?

A

80mg/day

70
Q

What does medguide of atomoxetine (Strattera) include?

A

Risk of suicidal ideation in children

AND

Risk of liver injury (t/4 monitor for sx of liver damage, such as weakness, abdominal pain, yellowed skin, light colored stool or darkened urine)

71
Q

What’s the effect of both Kapvay (Clonidine) and Guanfacine (Intuniv) on the CNS?

A

Sedating

72
Q

What’s the effect of both Kapvay (Clonidine) and Guanfacine (Intuniv) on BP?

A

Both lower BP

Use caution with other anti-hypertensives

73
Q

For both Kapvay (Clonidine) and Guanfacine (Intuniv) can you use them with the other formulations of both drugs available?

A

Don’t use concurrently

74
Q

What substrate is guanfacine (Intuniv)?

A

CYP 3A4 substrate

75
Q

What are shift workers at increased risk of?

A

Variety of chronic illnesses including cardiovascular and GI disorders

76
Q

How do some shift workers regulate their sleep cycles?

A

Melatonin

OR

Non-BZD e.g. Zolpidem

77
Q

How do some shift workers stay alert during work shift?

A

With the use of stimulants

78
Q

List the stimulants used to improve wakefulness in adult pts with excessive sleepiness associated with narcolepsy, obstructive sleep apnea/hypopnea syndrome and shift work sleep disorder

A

Modafinil (Provigil)

Armodafanil (Nuvigil)

79
Q

What control substance class is Modafinil (Provigil) and Armodafanil (Nuvigil) in?

A

C IV

80
Q

SEs of both Modafinil (Provigil) and Armodafanil (Nuvigil)

A

Headache

Dizziness

Anxiety

Agitation

Risk if severe rash

81
Q

Do both Modafinil (Provigil) and Armodafanil (Nuvigil) require a MedGuide? Why or why not?

A

Yes, they req MedGuide

Bcuz of the risk of life-threatening rash

82
Q

Effect of Modafinil (Provigil) and Armodafanil (Nuvigil) on estrogen-containing birth control?

A

May decease efficacy of estrogen-containing birth control

83
Q

What’s the manufacturers recommendation for use of birth control with Modafinil (Provigil) and Armodafanil (Nuvigil)?

A

Use nonhormonal contraceptive (in addition to or in place of ECBC) during and for 1 month ff tx

84
Q

What’s are the core sx of ADHD?

A

Inattention

Hyperactivity

Impulsivity

psych 1166 (20 decks)

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