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Pharmaco > Class 9-Ped > Flashcards

Class 9-Ped Flashcards

1
Q

Gastrointestinal absorption

A
  • Different gastric pH
  • Unpredictable gastric emptying
  • Irregular intestinal transit
  • Undiversified intestinal flora
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2
Q

Other routes of administration

A
  • Low muscle mass àIM more painful / irregular absorption
  • Good absorption under the skin
  • Erratic rectal absorption (as in adults)
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3
Q

Distribution

A
  • Age-variable plasma proteins (e.g. less albumin affinity in newborns)
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4
Q

Metabolism

A
  • Immature metabolic pathways (e.g. cytochromes)
  • Examples : CYP1A2 in the first months of life, CYP2D6 in the first days of life
  • Once the maturity of metabolic pathways : ↑ liver activity
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5
Q

Renal elimination

A
  • ClCr formula not applicable for children, variation in creatinine
    production by age
  • ↑ kidney activity
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6
Q

CAN CHILDREN SWALLOW TABLETS?

Alternatives

A
  • Liquid formulations (solutions, suspensions)
  • Preparations at the pharmacy
  • Powder, capsules
  • Some drugs taste really bad… if possible mix in small amounts of puree or liquid
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7
Q

ETIOLOGY ADHD

A

GENETIC
• Significant contribution (40-90%)
• If patient affected: risk increased by 2 to 8 times

  • Environmental factors, e.g.:
  • Low birth weight or preterm birth
  • Exposure to cigarettes or alcohol during pregnancy

NEURONAL CIRCUITS
Dysfunction of several systems involving neurotransmitters, especially NA and DA

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8
Q

COMORBIDITIES ADHD

A 
Nearly 70% of children with the condition are reported to have another psychiatric disorder
Examples :
• Behavioural disorders
• Anxiety
• Depressive disorder
• Tourette’s syndrome
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9
Q

NON-PHARMACOLOGICAL TREATMENT

A 
§ Interventions at school
• Environnement, organisation, routine, educational help
§ Psychosocial interventions
• Individual psychotherapy
• Behavioural psychotherapy
• Sports activities
• Family therapy
• Respite measures
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10
Q

THERAPEUTIC ARSENAL ADHD

A

PSYCHOSTIMULANTS
q Methylphenidate
q Amphetamines-based

NON PSYCHOSTIMULANTS
q Atomoxetine
q Alpha2-adrenergic agonists
q Bupropion
q Tricyclic antidepressants
q Antipsychotics
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11
Q

NON PSYCHOSTIMULANTS onset

A

Slower onset of action than psychostimulants (2 weeks)

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12
Q

METHYLPHENIDATE types

A

RitalinTM Short: BID-TID
ConcertaTM Long
BiphentinTM Long
FoquestTM Very long

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13
Q

METHYLPHENIDATE MECHANISM OF ACTION

A

Inhibition of DA and NA recapture

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14
Q

Why treat hyperactivity with a stimulant?

A
  • Inattention is often the main problem

* Treating inattention (FOCUS) indirectly treats other symptoms

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15
Q

CONCERTATM release system

A

OROS RELEASE SYSTEM
• Part of the active ingredient (22%) is released for rapid action < 1 hour
• The rest of the drug (78%) frees itself through an orifice for about 12 hours

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16
Q

BIPHENTINTM release system

A

BIPHASIC RELEASE

• The capsule contains short- and long-acting granule

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17
Q

FOQUEST release system

A

MLRTM TECHNOLOGY (IN GRANULES)
• Multi-layered release
• Capsule made up of multi-layered release
• 1st layer : immediate-release methylphenidate
• Other layers: act by delaying the release of the drug

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18
Q

ADVERSE EFFECTS METHYLPHENIDATE

A 
o ↓ appetite and weight loss
o Gastrointestinal pain
o Irritability
o Sleep disorders
o Headache
o Worsening tics
o ↑ heart rate and blood pressure
o Long-term growth delay
o Risk of abuse : risk with longacting formulations
• Dose-dependent
• Especially at the beginning of treatment
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19
Q

AMPHETAMINES types

A 
Dextroamphetamine short
Amphetamine salts (Adderall) XR long 
Lisdexamfetamine Vyvanse long
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20
Q

ADDERALL XR release system

A

CAPSULE CONTAINING 2 TYPES OF GRANULES IN EQUAL PARTS
• Immediate release granules (effect lasts 4 to 6 hours)
• Controlled-release granules (effect lasts 12 hours)

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21
Q

VYVANSETM pharmacokinetic

A

INACTIVE PRO-DRUG

• Enzymatic reaction releases dextroamphetamine (active molecule)

22
Q

ADVERSE EFFECTS stimulants

A 
o Decreased appetite (+) and weight loss
o Gastrointestinal pain
o Irritability
o Sleep disorders (+)
o Headache
o Worsening tics
o ↑ heart rate and blood pressure
o Long-term growth delay
o Risk of abuse : (+) vs methyphenidate
• Dose-dependent
• Especially at the beginning of treatment
23
Q

ATOMOXETINE duration

A

long straterra

24
Q

MECHANISM OF ACTION ATOMOXETINE

A

Inhibition of NA recapture

25
Q

ADVERSE EFFECTS ATOMOXETINE

A
  • Céphalées
  • Douleurs abdominales
  • Vomissements
  • Augmentation de la tension artérielle
  • Augmentation de la fréquence cardiaque
  • Très faible potentiel d’abus
  • Ne cause pas d’aggravation des tics
  • Peu d’insomnie
26
Q

ALPHA2-ADRENERGIC AGONISTS

A

Clonidine CatapresTM intermediate adjuvant only
Extended-release
Guanfacine Intuniv XRTM long

27
Q

MECHANISM OF ACTION Guanfacine

A

selective alpha2A receptor agonist

28
Q

MECHANISM OF ACTION Clonidine

A

non-selective alpha2 receptor agonist

29
Q

Guanfacine used for

A

Used as an adjuvant with psychostimulants in complex cases or for tics or aggression comorbidities

30
Q

SIDE EFFECTS ALPHA2-ADRENERGIC AGONISTS

A 
• Headache
• Hypotension
• Drowsiness
• Xerostomy
• Bradycardia (rare)
Gradually taper to avoid the rebound hypertensive effect
31
Q

TRICYCLIC ANTIDEPRESSANTS ADHD

A

Inhibition of NA recapture
• Sometimes used in patients with other comorbidities, including anxiety disorders, tics and depression
• Imipramine, desipramine, nortriptyline
• Lower doses than in depression
• Profile of adverse events limits their use

32
Q

ANTIPSYCHOTICS ADHD

A
  • Limited evidence
  • Risperidone may decrease symptoms of hyperactivity and impulsivity
  • Little effect on symptoms of inattention
  • Negative impact on learning and cognition
33
Q

Short-acting pros and cons

A 
PROS: • PRN Use
• Supplemental doses
• Little anorexia and insomnia
Cons:  • Administration BID
• Loss of effect in the
evening
• Dependence
34
Q

Intermédiaire pros and cons

A 
PROS: • Administration DIE
• Less anorexia and insomnia than
long-acting
• Less dependency than short-acting 
CONS: • Loss of effect in the
evening
35
Q

Long-acting pros and cons

A 
PROS • Administration DIE
• Evening effect
• Little dependency
CONS • Morning action time
• Insomnia, anorexia at
dinner
36
Q

Atomoxetine

Bupropion pros and cons

A 
Pros
• Administration DIE
• Duration of 24 hours and + if missed
dose
• Possible association with
psychostimulants
• No dependency
• No tics 
Cons 
• Delay of action : 2 weeks
• Less effective than
stimulants
• Drug interactions (CYP2D6)
37
Q

Guanfacine pros and cons

A 
Pros: • Administration DIE
• Duration of 24 hours and if dose
missed
• Possible association with
psychostimulants
• Little dependency
• Decrease in insomnia and tics
associated with psychostimulants 
Cons: • Delay of action : 2 weeks
• Less effective than stimulants
38
Q

At least ??? of patients respond to psychostimulants

A

60- and 70%

39
Q

CHOOSING A DRUG ADHD

A

① Long-acting psychostimulants based on methylphénidate or amphetamines
Preschool-age :
- Methylphenidate if failure to non-pharmacological measures
School-aged children and teenagers :
- Non-pharmacological measures + psychostimulant
② Short/intermediate-acting psychostimulants, atomoxetine (StratteraTM) or extended-release guanfacine (Intuniv XRTM)
③ Others
• Bupropion, clonidine, imipramine, modafinil, atypical
antipsychotics

40
Q

COMBINAISON? ADHD

A

Same molecule
• Combine a long action time (e.g. ConcertaTM) with a short action time (e.g. Ritalin SRTM) to cover certain moments of the day

Different molecules
• Only guanfacin XR is approved by Health Canada in adjuvant treatment for psychostimulants (not for adults)
• Other combinations sometimes used in practice: atomoxetine and psychostimulants
• Attention to additive effects (e.g. increase in BP/HR)

41
Q

BIPOLAR DISORDER and ADHD

A
  • Manic Phase: mood Stabilizers

* If ADHD treatment is added: bupropion, atomoxetine, guanfacine

42
Q

TOURETTE’S DISORDER and ADHD

A
  • Psychostimulants or atomoxetine

* If tics worsen: add clonidine or change to a non-psychostimulant

43
Q

FOLLOW UP PSYCHOSTIMULANTS

A

1 week

44
Q

FOLLOW UP NON-PSYCHOSTIMULANTS

A
  • Longer onset of action

* Wait at least 2 weeks

45
Q

KEY PARAMETERS FOLLOW UP

A
  • Weight
  • Size
  • Heart rate
  • Blood pressure
  • Appetite
  • Sleep
46
Q

WILL MY CHILD BE DEPENDANT TO DRUGS IF HE TAKES

PSYCHOSTIMULANTS?

A
  • ADHD (not exposure to psychostimulants) increases the risk of substance abuse and addiction
  • A well-treated ADHD could reduce the risk of other substance use
  • If there is a risk of substance abuse, choose a non-psychostimulant
47
Q

BIPOLAR DISORDER – MANIC EPISODE

A

abilify

48
Q

BIPOLAR DISORDER – DEP EPISODE

A

latuda

49
Q

DEPRESSION

A
  • Support, psychoeducation, implication of school/family
  • If no response after a 2 – 3 months : psychotherapy or pharmacotherapy
  • Fluoxetine is often a first-line choice
  • Other SSRI : citalopram, escitalopram, sertraline, fluvoxamine
  • More side effects with paroxetine
50
Q

MOOD STABILIZERS

A
  • No anticonvulsivant indicated in the treatment of BP in pediatrics
  • Studies with : carbamazepine, oxcarbazepine, valproate, lamotrigine, topiramate
  • Valproate and lamotrigine are often used
  • Lithium recommended by CANMAT in first-line treatment
51
Q

INSOMNIA

A
  • Priorise non pharmacological interventions
  • Antihistaminics
  • Melatonine

Pharmaco (11 decks)

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