Chapter 66 - Attention Deficit Hyperactivity Disorder (ADHD) Flashcards
ADHD Sx:
- Inattention
- Hyperactivity (dec with age)
- Impulsivity
Patients usually have
- Difficulty focusing
- Are easily distracted
- Have trouble staying still
- Are frequently unable to control impulsive behavior
ADHD is caused by defect in:
Primary focus of ADHD research is on:
- Defects in the dopamine pathways that regulate reward anticipation and emotional self-regulation
- Primary focus of ADHD research is on the catecholamine system (dopamine is metabolized to epinephrine and norepinephrine).
- They have very low dopamine levels
Treatment algorithm
- 1st line treatment based on age:
- 1st line medications
- 2nd line meds…
Pre-school aged children (age 4 - 5 years):
- Parent training in behavior management and/or behavioral classroom intervention.
- Methylphenidate can be considered if moderate-severe symptoms persist despite behavioral interventions.
> = 6 years old:
- 1st line: ADHD medications + behavioral interventions
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1st line:
- Stimulant medications (e.g., methylphenidate and amphetamine) because they raise dopamine and norepinephrine levels.
- Long-acting formulations are preferred for children
- Atomoxetine (Strattera), a non-stimulant medication, can be tried when stimulants do not work well enough (after trials of 2 - 3 medications).
Strattera can be used first line when prescribers are concerned about the possibility of abuse by the patient or family. - Guanfacine ER (Intuniv) and clonidine ER (Kapvay) are non-stimulant medications that can be used alone or in combination with stimulants.
Diagnosis: Inattention
<=16 yo: >= 6 symptoms
>= 17 yo: >= 5 symptoms
- For at least 6 months (1/2 a year) and are inappropriate for the developmental level.
Sx of inattention:
1- Fails to pay attention
2- Has trouble holding attention
3- Does not pay attention when someone is talking
4- Does not follow through on instructions
5- Fails to finish schoolwork
6- Has difficulty organizing tasks
7- Avoids/dislikes tasks which require mental effort
8- Loses things
9- Easily distracted and is forgetful
Diagnosis: Hyperactivity & Impulsivity
<= 16 yo: >= 6 symptoms
>= 17 yo: >= 5 symptoms
- Symptoms must have been present for at least 6 months and are inappropriate for the developmental level.
Sx of Hyperactivity and impulsivity:
1- Often fidgets or squirms
2- Leaves seat unexpectedly
3- Runs about when not appropriate
4- Unable to play quietly
5- Is “on the go” as if “driven by a motor,”
6- Talks excessively
7- Blurts out answers
8- Has trouble waiting his/her turn
9- Interrupts or intrudes on others
THE FOLLOWING CONDITIONS MUST BE MET
for diagnosis:
1■ Several inattentive or hyperactive-impulsive symptoms were present before age 12.
2■ Symptoms must have been present in 2 or more settings (e.g.,at home, school, work, with friends or relatives, babysitters).
3■ Symptoms interfere with functioning and are not caused by another disorder.
We need either inattention or hyperactivity/impulsivity to diagnose
Natural Products:
- Fish Oil modestly improve cognitive function
- Melatonin is used to help with sleep onset in individuals taking stimulants.
Young children (and others) who cannot swallow capsules or tablets can use these long-acting formulations:
■ Capsule
- Some capsule contents can be sprinkled on a small amount of applesauce (Adderall XR, Ritalin LA)
- Vyvanse capsule contents can be mixed in water, orange juice or yogurt
■ Chewable tablet
■ Orally-disintegrating tablet
■ Patch
■ Suspension
- When putting capsule contents in food, use a small amount of food and do not chew the beads.
- Do not warm the food, and take it right away.
Stimulants
- Are they first line or second line?
- When should you take them?
- List the different stimulants available.
- 1st line
- Take in AM
1- Methylphenidate (e.g., Concerta, Daytrana, Ritalin)
(meth fen? date - contert - date rana - rita lin)
2- Lisdexamfetamine (Vyvanse)
3- Dextroamphetamine/Amphetamine (Adderall, Adderall XR)
Non-stimulants
- Are they first line or second line?
- List the non-stimulant drugs
- Second line (if 2-3 stimulants are used)
- Take if risk of abuse (1st line)
- Atomoxetine (Strattera)
Add-on medications (or used alone)
Name them + their brand names
- Guanfacine ER (Intuniv) (guana is in-tounis)
- Clonidine ER (Kapvay)
To help sleep at night
- Clonidine IR (Catapres) (note: not the ER!)
- Diphenhydramine (OTC 25-50 mg) (Antihistamine H1 antagonist)
- Melatonin (OTC 2-5 mg)
Methylphenidate
IR Tablet brand
Dose
Max dose
Ritalin
Start 5 mg BID, 30 min before breakfast and lunch
Max: 60 mg/day
Methylphenidate
IR oral solution
Methylin
Start 5 mg BID, 30 min before breakfast and lunch
Max: 60 mg/day
Methylphenidate
- ER Tablet
- Dose + Max dose
- In what conditions should you not use it?
- How does OROS work?
- Does it have a high abuse potential?
Concerta OROS (or2os bl concert)
Dose: Start 18-36 mg QAM (Max: 72 mg/day)
Warning:
Do not use with GI narrowing conditions (e.g., motility issues, small bowel disease) (Mafiyun yruho aal concert)
- The outer coat dissolves fast to give immediate action, and the rest is released slowly;
- Can see a ghost tablet in stool; (Marra b tiz l zamen mn ruh aa concert)
- Harder to crush which decreases abuse potential
Methylphenidate
ER Capsule
Ritalin LA:
Dose: start 10-20 mg QAM
Jornay PM:
- Dose: start 20 mg QPM (the journey starts at night)
- Max dose: 100 mg/day
- Outer coating delays initial drug release 10 hours to allow for evening dosing
- Inner coating controls the slow release of the drug during the day
Methylphenidate
Transdermal patch
How do you apply it?
Warnings?
Daytrana (date rana cz hiye laz2a)
Dose: Start 10 mg/9 hr patch QAM
Max: 30 mg/9 hr
- Apply 2 hrs before desired effect (or as soon as the child awakens so it starts to deliver prior to school);
- Remove after 9 hrs;
- Alternate hips daily
Warning:
- Loss of skin pigmentation at application site and areas distant from the application site (can resemble vitiligo);
- Allergic contact dermatitis with local reactions (e.g.,edema, papules)
Methylphenidate
ER chewable tablet:
QuilliChew ER
Chewable tablets: contain phenylalanine (avoid with PKU)
SE of methylphenidate
- Insomnia
- Dec appetite/weight loss
- Nausea/ Vomiting
- Blurry vision
- Dry mouth
- Headache
- Irritability
Monitoring with methylphenidate
- Consider ECG prior to treatment
- Monitor BP and HR
- Cardiac symptoms
- CNS effects
- Abuse potential
- Height and weight (children)
Dexmethylphenidate
- Brands
- How can u convert from methylphenidate to dexmethylphenidate?
- Focalin (IR tablet)
- Focalin XR (ER Capsule)
(dexter took meth phen? date so foc Aline) - Active isomer of methylphenidate;
- To convert from methylphenidate to dexmethylphenidate use one-half of the total daily dose of methylphenidate (dexmeth is stronger so we need half dose) (dexter needs half dose cz foc aline)
Serdexmethylphenidate
- Prodrug to dexmethylphenidate
- Provides extended duration of action following faster-acting dexmethylphenidate
(la ser de dexter hiye prodrug w aanda loger DOA)
Dextroamphetamine/Amphetamine
IR tablet: Adderall
ER capsules: Adderall XR, Mydayis (mid days like adderall)
