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Integrated Drug Structure, Action, and Therapeutics > ADHD Therapeutics - Brian Haggblom > Flashcards

ADHD Therapeutics - Brian Haggblom Flashcards

1
Q

What are the three core types of ADHD?

A
  • Inattention (20-30%)
  • Hyperactivity (5-15%)
  • Combination (55-65%)
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2
Q

What are some characteristics of the inattention type of ADHD?

A

Inability to complete tasks, sustain attention, organize work

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3
Q

What are some of the characteristics of the hyperactive type of ADHD?

A

Inability to inhibit motor behaviors or responses.

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4
Q

What is the percent of people in the US who have ADHD?

A

4.4%

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5
Q

What percentage of children in the US have ADHD in 2011? When is it diagnosed?

A

11%. It is diagnosed at ages 4-17 years old.

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6
Q

Where in the US is the greater concentration of these recent diagnoses?

A

In the South

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7
Q

What abnormalities in the brain are exhibited in those with ADHD?

A

Executive function
Memory impairments
Information processing speed deficits
Decrease in catecholaminergic nature of brain circuits (low dopamine and NE in frontal)

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8
Q

Is there a genetic link in ADHD?

A

Yes, there seems to be. Risk is increased 2-8 times in parents/siblings/children.

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9
Q

What possible causes of ADHD are being researched?

A
  • Brain injury
  • Exposure to environmental (lead) during pregnancy/at young age
  • Alcohol/tobacco use during pregnancy
  • Low birth weight
  • Premature birth
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10
Q

Is it thought that eating too much sugar or watching too much TV causes ADHD?

A

No, but they might make symptoms worse.

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11
Q

What are requirements for diagnosis common to all three types of ADHD?

A
  • Symptoms need to be present prior to age 12
  • must be present in 2 or more settings
  • must significantly interfere with reduced level of functioning
  • Rule out other causes for symptoms (other mental disorders)
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12
Q

As you get older and have ADHD, what types of things are you more at risk for?

A
  • Increased risk of self-injury
  • Driving mistakes
  • Education hardships
  • Substance use
  • Persistence of symptoms
  • Employment hardships
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13
Q

What are the goals of ADHD treatment?

A
  • Improved relationships, improved academic performance, improved rule following
  • Decreased hyperactivity symptoms, impulsivity symptoms, inattention symptoms.
  • Promote independence
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14
Q

What non-pharmalogical treatment modalities are available for treating ADHD?

A
  • Behavioral interventions (apps that block out social media)
  • School based interventions (sit next to teacher)
  • Social skills training (help with fighting, impulsiveness)
  • Dietary interventions (fatty acid supplementation?)
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15
Q

What are the first line therapy for ADHD?

A

Stimulants, including methylphenidate and amphetamines.

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16
Q

What are the second-line therapy for ADHD?

A

Non-stimulants, such as atomoxetine, alpha-2 agonists, bupropion, TCA’s

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17
Q

Methylphenidate

A
  • CNS stimulant
  • blocks reuptake of NE and dopamine
  • Fast onset
  • CYP3A4 metabolism
  • interacts with carbazepines, MAOIs, TCAs
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18
Q

Amphetamines

A
  • CNS stimulant
  • blocks reuptake of NE and dopamine
  • Fast onset
  • CYP2D6 metabolism
  • interacts with paroxetine, fluoxetine, bupropion, MAOIs
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19
Q

What interval should you titrate by for stimulants in ADHD treatment?

A

Weekly to monthly to evaluate dose.

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20
Q

What is the latest in the day that you should take an IR stimulant?

A

4pm. Can also take a morning and a noon dose. ER can take only once a day in the morning.

21
Q

How many stimulants should you try before moving on to a second-line agent?

A

Probably two stimulants, but it really depends on the patient.

22
Q

What dosage forms are available for stimulants?

A
  • Capsules (swallowed or sprinkled)
  • Suspension
  • Solution
  • Chewable tablets
  • Transdermal patch (Daytrana - place on hip and alternate each day. Wear for 9 hours)
23
Q

What are some side effects that you can experience with stimulants? What can help?

A
  • Dry mouth (chew gum)
  • Insomnia (give as early as possible, d/c evening dose, sedating drug @ bedtime)
  • Irritability (evaluate for comorbid bipolar disorder, reduce dose, consider mood stabilizer)
  • Diminished appetite (eat a high calorie meal when the stimulant effects are low)
  • Increased BP/HR (monitor closely)
  • Hallucinations (d/c stimulant)
24
Q

How much does HR and BP usually increase with a stimulant?

A

3-5mmHG increase in BP and 5bpm increase in heart rate

25
Q

When should BP and HR be monitored for stimulant treatment?

A

At induction and throughout the course of treatment.

26
Q

In kids especially, what should you watch out for with stimulants?

A

Decreases in height and weight (Decreased appetite and alteration of secretion of growth hormone)

27
Q

What does amphetamine/methylphenidate have a black box warning for?

A

Misuse or addiction. Prolonged use or abuse may lead to drug dependence. Serious adverse cardiovascular reactions may occur or sudden death

28
Q

What monitoring should be in place for stimulants?

A
  • Safety (BP and HR, weight, height, AE)
  • Adherence to treatment plan
  • meeting treatment goals
  • Occurrence of core ADHD symptoms
  • Adverse effects of therapy
29
Q

What are some thoughts about drug holidays from stimulants?

A
  • They may be helpful to assess efficacy of dose and treatment
  • Maybe not, because the symptoms would still be present without school.
  • May cause negative side effects on learning, socialization, and self-image
  • Can allow catch-up for growth/weight
  • Can help manage tolerable side effects
30
Q

Atomoxetine

A
  • No/little abuse potential
  • May take 4-6 weeks for full effect
  • Inhibits NE reuptake, which increases NE and dopamine synaptically
  • Black box warning for suicidality, increase ddepression
31
Q

What is atomoxetine indicated for first-line?

A

For substance abuse problems, with comorbid anxiety, or tics

32
Q

What kind of side effects does atomoxetine cause?

A

Similar to stimulant side effects… same mechanism.

33
Q

Bupropion

A
  • 2nd line
  • No abuse potential
  • Inhibits neuronal uptake of dopamine and NE
  • CYP2D6, lowers seizure threshold
  • excreted through kidneys
  • may cause insomnia, takes several weeks for full effect
34
Q

How do you dose bupropion in children?

A

By weight. 6mg/kg/day, BID. Start low at 37.5mg/day

35
Q

What is the response to bupropion typically?

A

Only 40% reduction in symptoms, and 70-80% respond

36
Q

What may be used in conjunction with stimulants?

A

Bupropion can be used with methylphenidate, but has a drug interaction with amphetamines.

37
Q

What is a positive SE associated with bupropion?

A

Decrease in weight/appetite

38
Q

What TCA’s are sed 2nd or 3rd line for ADHD?

A

Imipramine, desipramine, amitriptyline, nortiptyline

39
Q

TCA’s

A
  • Slow onset (up to 6 weeks)
  • 40-50% reduction in symptoms
  • Inhibits reuptake of serotonin and NE
  • Useful in comorbid depression, anxiety, compulsions
  • Adjunct for treating tics or insomnia from stimulants
40
Q

What monitoring should you have in place for TCAs? What bad SEs are there?

A
  • EKG
  • Anticholinergic effects monitoring, dizziness
  • overdose can be fatal
41
Q

Guanfacine ER (intuniv)

A
  • mostly used for children
  • originally used to treat hypertension
  • alpha2 adrenergic receptor agonist (decrease heart rate , block baroreflex). Increased stimulation of these receptors in the prefrontal cortex results in enhanced executive function, improvements in memory
  • slow onset
42
Q

Is guanfacine best in adjunctive or mono therapy?

A

Either one. it is less effective than stimulants, and more effective against hyperactive/impulsive symptoms than inattention.

43
Q

How do you dose guanfacine? How do you start and taper off?

A

By weight. Start at 0.05-0.12mg/kg/day and titrate weekly. When stopping, titrate downward 1mg every 3-7 days.

44
Q

What are some side effects of guanfacine?

A

Hypotension, sedation, dizziness

45
Q

Clonidine ER

A
  • central alpha2 adrenergic receptors stimulated, causes decrease in HR
  • slow onset, may take weeks.
  • hepatic metabolism
  • blocks baroreflex
  • IR used off-label
46
Q

When is clonidine useful

A
  • As adjunct with stimulants for treating hyperactive symptoms or stimulant AEs
  • Treats hyperactivity symptoms over inattention
47
Q

What off-label medications can be used to treat ADHD?

A
  • Guanfacine IR
  • Clonidine IR
  • Clonidine patches
48
Q

What drug interactions are involved with alpha-2 agonists? What increases their effects and what decreases their effects?

A
  • Increases effects: Antipsychotics, opioids may enhance hypotension. CNS depressants, beta blockers (rebound hypertension when removed)
  • Decrease effects: TCAs (may decrease antihypertensive effect)
49
Q

What is CHADD?

A

An ADHD help group for parents, a national resource center

Integrated Drug Structure, Action, and Therapeutics (20 decks)

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