Chapter 66: ADHD Flashcards
The primary treatment for ADHD is stimulant medications because they raise ____ and ____ levels
Dopamine and NE
First-line treatment for pre-school aged children (age 4-5 years)
Parent training in behavior management and/or behavioral classroom intervention
ADHD medications are considered first-line in patients ≥ __ years old
6
DSM-5 diagnostic criteria for inattention
≥6 symptoms of inattention for children up to age 16, OR 5+ symptoms for ages 17 and older. Symptoms must have been present for at least 6 months
Fails to pay attention, trouble holding attention, does not pay attention when someone is talking, does not follow through on instructions, fails to finish schoolwork, has difficulty organizing tasks, avoids or dislikes tasks which require mental effort, loses things, is easily distracted, is forgetful
DSM-5 diagnostic criteria for hyperactivity and impulsivity
6+ symptoms of hyperactivity-impulsivity for children up to age 16, OR 5+ symptoms for ages 17 and older. Symptoms must have been present for at least 6 months
Often fidgets or 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 and interrupts or intrudes on others
Which conditions must be met in order to be diagnosed with ADHD
- several inattentive or hyperactive-impulsive symptoms were present before the age of 12
- symptoms must have been present in 2 or more settings (e.g., at home, school, work, with friends or relatives, babysitters)
- symptoms interfere with functioning, and are not caused by another disorder
Which natural product is used for a variety of psych conditions and have shown to modestly improve cognitive function and behavior in children with ADHD
Fish oils
What natural product can be taken to help with sleep onset in individuals taking stimulants
Melatonin
What formulation of stimulants are preferred for children who would otherwise need a dose during the day at school
Long-acting
A child or person who cannot swallow capsules or tablets can use these long-acting stimulant formuations:
Capsules - to sprinkle Chewable tablet ODT Patch Suspension
Which stimulant capsules can be opened and sprinkled on a small amount of applesauce
Adderall XR, Ritalin LA
Which stimulant medication can be opened and mixed in water, orange juice or yogurt
Vyvanse capsule
T/F: you can warm the food when sprinkling capsule contents, but you must take it right away
False - do NOT warm the food
Which medication can be used first line when prescribers are concerned about the possibility of abuse by the patient or family
Atomoxetine (Strattera)
Which non-stimulant medication can be tried when stimulants do not work well enough after a trial of 2-3 medications
Atomoxetine (Strattera)
Which medications can be taken to help sleep while taking stimulants
Clonidine IR (Catapres), diphenhydramine (OTC, 25-50 mg), melatonin (OTC, 2-5 mg)
non-stimulants that can be used alone or added onto stimulants
guanfacine ER (intuniv), clonidine ER (Kapvay)
Which symptoms of abuse should be assessed prior to and monitored during stimulant use
dilated pupils, increased HR and BP, sweating, tremor, anxiety
CI: Do not use stimulants within ___ days of ____
14 days of MAOi
What causes the increased HR and BP in patients taking stimulants
Increased levels of DA and NE. Assess for cardiac disease at baseline
What other vascular problems can occur when taking stimulants
Priapism and Raynaud’s disease
T/F: stimulants do not typically lower seizure threshold
False - they can lower the seizure threshold which increases the risk of seizures
T/F: stimulants can cause serotonin syndrome when used with other serotonergic drugs
True
T/F: loss of appetite is common with stimulants and can contribute to a decrease in growth trajectory of the child
True
MOA of stimulants
Block the reuptake of NE and DA
Stimulant doses can be titrated up every ___ days to reduce adverse events
every 7 days, prn
T/F: stimulants do not need to be tapered off when used as directed
True
Brand name for methylphenidate IR tablet
Ritalin
Dose for methylphenidate IR tablet
5 mg BID 30 min before breakfast and lunch
Brand name for methylphenidate ER tablet
Concerta (OROS delivery)
Dose for methylphenidate ER tablet
18-36 mg QAM
Brand name for methylphenidate ER capsule
Ritalin LA, Jornay PM (given qPM)
Brand name for methylphenidate TD patch
Daytrana
Side effects of stimulants
Insomnia, decreased appetite/weight loss, HA, irritability, N/V, blurry vision, dry mouth
Monitoring for stimulants
Consider ECG prior to treatment; BP and HR, height and weight (in children)
Counseling points for Concerta OROS delivery
the outer coat dissolves fast to give immediate action, and the rest is released slowly. Can see a ghost tablet in the stool; harder to crush which decreases abuse potential
concerta = methylphenidate ER tablet
When should Daytrana be applied for desired effect & when should it be removed
2 hours before desired effect and remove 9 hours after
Where should Daytrana patch be placed?
Hips; alternate daily
____ is the active isomer of methylphenidate
dexmethylphenidate
Brand name for dextroamphetamine/amphetamine IR tablet
Adderall
Brand name for dextroamphetamine/amphetamine ER capsules
Adderall XR
What formulations does lisdexamfetamine come in
capsule and chewable tablet
Brand name for lisdexamfetamine
Vyvanse
T/F: lisdexamfetamine has a similar abuse potential to other stimulants
False - low abuse potential
if injected or snorted, fast effect is muted
Boxed warning for amphetamines
misuse can cause sudden death and serious CV events
Drug class of atomoxetine
SNRI
Brand name of atomoxetine
Strattera
Atomoxetine boxed warning
risk of suicide ideation
Atomoxetine contraindication
MAOi use within the past 14 days
Atomoxetine side effects
decreased appetite, insomnia, somnolence, dry mouth, HTN, tachycardia
T/F: you can open the capsule for atomoxetine
False - capsules contain an occular irritant
Brand name for clonidine ER tablet
Kapvay
Brand name for clonidine IR tablet (used for hypertension)
Catapres
Brand name for guanfacine ER tablet
Intuniv
When is clonidine dosed for ADHD
QHS
How is guanfacine dosed
daily then increased slowly weekly
Why should central alpha-2A Adrenergic agonists like guanfacine and clonidine not be d/c abruptly
can cause rebound hypertension
decrease dose every 3-7 days
Warnings for central alpha-2A Adrenergic agonists like guanfacine and clonidine
dose-dependent CV effects, sedation and drowsiness
do NOT abruptly d/c due to rebound HTN
What should be done to guanfacine dose if used with strong CYP3A4 inducers?
how about inhibitors?
Double the dose
decrease dose by 50% if inhibitor
