ADHD Treatment Flashcards
Goals of therapy for ADHD include…
Eliminate/significantly decrease core ADHD symptoms
Improve behavioural, academic, and/or occupational performance
Improve self-esteem and social functioning
Minimize drug adverse effects
Improve quality of life
Initial treatment of ADHD can be ____, if…
Behavioural therapy - if symptoms are mild, diagnosis unclear, or medication not preferred
The most effective treatment for ADHD involves a combination of…
Medication and behavioural therapy
Non-pharm treatment for ADHD can include…
Family-focused interventions (behavioural parent training)
School-focused interventions (behavioural classroom management)
Child-focused interventions (behavioural peer interventions)
CBT - helpful with maladaptive coping strategies
One of the first landmark studies for ADHD guidelines trialed…
Atomoxetine vs. Concerta
The landmark study that evaluated atomoxetine vs. concerta found that…
In treating ADHD without comorbidities, concerta = 1st line option, ATX 2nd line option for concerta non-responders. If hesistant to use stimulant, ATX an option although not as effective.
A multimodal treatment study of children with ADHD found that…
ADHD treatment SHOULD include some form of medication management, either alone or combined with behavioural therapy
Combined behavioural + pharm tx = pharm alone for core ADHD sx’s, better for reducing oppositional behaviours/anxiety + improving social interactions
Pharm tx > behavioural tx for core ADHD sx’s
The MOA of methylphenidates are to…
Inhibit presynaptic uptake of DA and NE by specifically blocking transport proteins
Leads to increased sympathomimetic activity in CNS - limited peripheral activity
The MOA of amphetamines are to…
Increase release of DA and NE into synapses from presynaptic nerve terminal
Enhance release of NE in periphery from adrenergic nerve terminals
May stimulate release of serotonin and act as serotonin agonist at higher doses
Inhibit reuptake of monoamines in extraneuronal space
The MOA of atomoxetine is to…
Inhibit presynaptic uptake of only NE in the CNS
The MOA of guanfacine and clonidine is…
Why are they not the best?
Alpha-2 adrenergic receptor agonists
Binding to postsynaptic alpha2A receptors in PFC improves delay related firing of PC neurons, which may lead to improvement in underlying working memory + behavioural functions
Guanfacine more selective for alpha2A receptor than clonidine
Peripherally block sympathetic nerve impulses = decreased vasomotor tone (blood pressure) and heart rate (bad)
1st line pharmacotherapy for ADHD is…
Long-acting stimulants
Long-acting stimulants includes…
Methylphenidate + Amphetamines - Adderall XR, Vyvanse, Biphentin, Concerta, Foquest, Quillivant
Long-acting stimulants have shown to reduce core ADHD symptoms by…
30-40% in 70%+ of treated patients
Onset of action for long-acting stimulants may be seen in ____, but an adequate trial is usually…
1st week - adequate trial is 3-4 weeks
Between methylphenidate and amphetamines, efficacy is…
Equal - no method to predict which stimulant class patients will respond to
If treatment failure occurs with one long-acting stimulant class, this should be tried…
Other class (methylphenidate or amphetamines), before moving to non-stimulant
Benefits of long-acting stimulants over immediate release includes…
Maintaining privacy in context of school, work, and social situations
Diminish diversion and rebound
Associated with better tolerability
2nd line pharmacotherapy includes…
Non-stimulants (atomoxetine, guanfacine XR)
Short/intermediate acting psychostimulants
With non-stimulants, they have been shown to reduce core ADHD symptoms by…
25-30% in 60-70% (treated with atomoxetine)
Onset of effect for non-stimulants is ____, and an adequate trial (maximum effect) is…
2 weeks; max effect seen at 6-8 weeks
SLOWER than stimulants
Non-stimulants are used first line if…
Stimulants are CI
Intolerable AE’s develop (anxiety, mania, psychosis)
Comorbid active substance use
Severe anxiety/tic disorder
Hesistancy to use a stimulant
If a patient experiences a partial response with a non-stimulant, it could be combined with…
Behavioural therapy
Stimulant (off-label)
Short/intermediate acting psychostimulants include…
Dextroamphetamine, dextroamphetamine spansules
Methylphenidate, methylphenidate SR
Short/immediate stimulants are usually used to…
Augment long-acting formulations early/late in the day, or early evening
Examples of 3rd line agents include…
Bupropion
Clonidine
Imipramine
Modafinil
Exceeding maximum dose is also a 3rd line option
3rd line agents are usually reserved for treatment resistant cases because…
Higher risk, more AE’s, lower efficacy profile
Off-label
Atypical antipsychotics may be considered in the presence of…
Co-morbidities - sometimes used for aggression or occupational disorder
Concerta is specifically made with an osmotic-controlled release system, so when it is switched to a generic formulation…
A clinical difference may be observed, since the duration of effect may be shorter and the peak may be reached sooner (earlier TMax)
The formulations would still be considered bioequivalent due to similar Cmax and AUC
Precautions to watch for with ALL ADHD medications include…
Cardiac disease
Bipolar/psychosis
Pregnancy and lactation
CI’s with psychostimulants and atomoxetine include…
Glaucoma
Pheochromocytoma
Untreated hyperthyroidism
Moderate/severe HTN, symptomatic CV disease
Hx of mania or psychosis
Treatment with MAOI, up to 14 days after discontinuation
Some precautions specific with stimulants include…
Hx of substance abuse
Anxiety
Renal impairment
Tic disorders
Epilepsy
Some precautions specific with atomoxetine include…
Asthma
CYP2D6 poor metabolizers
An important counselling point regarding alpha-2 agonists is…
Ensure regular daily dosage, due to risk of rebound hypertension when stopped abrutly
Some precautions specific to the alpha-2 agonists include…
Hepatic and kidney impairment
Some notable DI’s with stimulants include…
3 notable classes, and then 1 for both AMP and MPH
AMP = amphetamine, MPH = methylphenidate
Antidepressants (risk of HTN crisis with MAOI, increased AE’s with SSRI/SNRI and TCA)
Antihypertensives (lower hypotensive effect)
AP’s with AMP (lowered effect of AMP), anticonvulsants with MPH (increased conc. of anticonvulsant)
Decongestants (increased BP, HR)
Common AE’s with stimulants include…
Atomoxetine AE’s are very similar
CV - BP + HR increase, dizziness
GI - appetite suppression, N/V/D/C, dry mouth, GI upset
Psych - anxiety, insomnia, headaches, irritability
Weight decrease, skin reactions
Atomoxetine differs by less dizziness, can be sedating, rebound effect not present
Rebound effect of ADHD symptoms can occur with stimulant usage - this can be avoided by…
NOT using immediate release formulations
Common AE’s with alpha-2 agonists include…
CV - BP and HR decrease, rebound when stopped abruptly
GI - N/V/D/C, dry mouth
Psych - Headache, sedation
Dosing of ADHD medications should be done…
With a titration schedule - start low and go slow
Dose increases should continue until…
Desired goals of treatment are reached
AE’s occur
Max dose reached
Optimal dose = dose above where there is no further improvement
