ADHD tx Flashcards
ADHD overview
-higher rate if dx in a first-degree relative
-environmental, genetics, physiological
-1/3 of children w ADHD will have it as an adult
-inc risk of substance use and antisocial personality disorder if untreated
ADHD dx criteria
-at least 6 sx in 2 or more settings for each domain
-5 for ages >17
-several inattentive or hyperactive sx must be present prior to age 12 years and present in 2+ settings
Inattention
-6+ for 6 months inconsistent w developmental level and negatively impacting ADL:
-careless mistakes
-not listening/paying attention
-incomplete hw, chores
-difficulty organizing
-avoid tasks w mental effort
-loses things
-easily distracted
-forgetful
Hyperactivity and Impulsivity
-6+ for 6 months inconsistent w developmental level and negatively impacting ADL:
-fidgets
-leaves seat
-runs/climbs inappropriately
-not quiet
-on the go
-xs talking/blurting
-bad at waiting turn
-interupt
Stimulant dosing
-dose-response effects seen in short-period of time
-calculating dose in pediatric pt based on mg/kg not found to be helpful as variations in dosing not due to ht or wt
-IR if pt < 16kg (limited low-dose availability of ER)
-avoid giving dose too late, after school is fine
-late afternoon sx might require ER
-don’t combo stimulants
-can use 2 different dosage forms of same stimulant tho
Special considerations
-Mydaysis (mixed amphetamine salts): ages 13-17
-Daytana (methylphenidate): patch
-Vyvanse (lisdexamfetamine): prodrug converted to dextro
-Jornay PM (methylphenidate HCl): take dose in evening between 6:30 and 9:30
Stimulant adverse effects + tx
-appetite loss: high cal meal when effect is low (breakfast or din)
-sleep probs: dose earlier, lower last dose, maybe sleep med)
-dec growth
-inc BP and HR: reduce dose/ change stimulant
-rebound sx: ER form, atomoxetine, antidepressant
-hallucinations: d/c dose, reassess dx
-risk for sudden death!: if fhx concern, cardiac ECHO
Stimulant monitoring
-appetite
-behavior
-BP and HR
-growth rate
-sleep
-ECG based on CV risk
a2 agonists for ADHD drugs
-guanfacine ER
-clonidine ER
-must taper to avoid rebound HTN
Guanfacine ER
-ADHD tx
-a2 agonist
-3A4
-must taper to avoid rebound HTN
clonidine ER
-ADHD tx
-a2 agonist
-must taper to avoid rebound HTN
a2 agonist (guanfacine, clonidine) side effects
-dec HR and BP, orthostasis
-somnolence
-dizziness
-rebound HTN if abrupt dc
NE reuptake inhibitors
-atomoxetine
-viloxazine
Atomoxetine
-NE reuptake inhibitor
-ADHD tx
-2D6 substrate
-wt based dosing
-monitor LFTs
Viloxazine
-capsules (swallow whole or sprinkle on apple sauce)
-2D6/UGT substrate
-strong 1A2 inhibitor
atomoxetine/viloxazine (NERTi) side effects
-inc HR and BP
-box warning for inc in suicidal thinking
non-stimulant monitoring
-appetite
-BP and HR
-LFTs (atomoxetine)
Bupropion
-not FDA for ADHD
-2D6 inhibitor
-AVOID in sz and eating disorders
TCAs for ADHD
-less effective than methylphenidate
-cardiac concerns (sudden death in kids, lethal in OD)
mood stabilizing atypical antipsychotics for ADHD
-maybe good if bipolar, conduct, intermittent explosive disorder
-should not use atypical antipsychotics as monotherapy
Pediatric guidelines
-preschool: parent training behavior management (PTBM) +/- methylphenidate (no nonstimulants are FDA approved)
-K-8: PTBM + stimulants (2nd line: atomoxetine, guanfacine, clonidine)
-12-18: meds same as k-8, maybe PTBM
adj tx in pediatric ADHD
-only guanfacine and clonidine have evidence as effective adj to stimulants
ADHD guidelines for adults
- methylphenidate OR lisdexmfetamine
- dextroamphetamine
- atomoxetine
