Dr. Campbell: ADHD

Question 1

DSM-5 Criteria

Answer 1

1) Age < 17 = 6 or more symptoms of hyperactivity OR inattention
2) Age > 17 = 5 or more symptoms of hyperactivity OR inattention
- Symptoms must persist for at least 6 months

Question 2

Diagnostic Caveats

Answer 2

• Symptoms are NOT due to defiance or lack of comprehension
• Several symptoms must be present before age 12
• Symptoms may be minimal or absent in certain settings
• Delays in development are common but NOT required for diagnosis

Question 3

Amphetamines MoA

Answer 3

• Increase DA/NE release
• Decrease in DA/NE reuptake
  ex. Adderall, Lisdexamfetamine (Vyvanse)

Question 4

Methylphenidate MoA

Answer 4

• Inhibits reuptake of DA
• Increases DA only when DA is actively being released
• Slower uptake and clearance (decreased abuse potential)
  ex. Ritalin/Methylin, OROS (Concerta)

Question 5

Formulation Considerations

Answer 5

• Desired duration of effect
• Abuse potential
• Ease of administration
• Cost/Coverage
• Patient preference

Question 6

Atomoxetine MoA

Answer 6

• Non stimulant approved for ADHD
• Increases NE/DA release
• Slower onset (lower abuse potential)
• Ages > 6 only

Question 7

Guanfacine (Intuniv) or Clonidine (Kapvay)

Answer 7

• Alpha 2 agonists
• Decrease NE mediated arousal
• Increase blood flow
• Used in conjunction with stimulants OR as monotherapy

Question 8

Clonidine vs Guanfacine

Answer 8

1) Clonidine
- Less selective
- More sedating
- Shorter half life
- Greater risk of rebound
2) Guanfacine > Clonidine

Question 9

Bupropion MoA

Answer 9

• Inhibits the reuptake of NE/DA
• Faster onset than Atomoxetine or alpha 2 agonists
• Start at 150mg/day dose titrate up to 300mg/day

Question 10

TCA MoA (Desipramine)

Answer 10

• Inhibit NE and 5HT reuptake
• No effect on DA
• Third line treatment option after stimulants and atomoxetine
• Potentially beneficial with concomitant tic disorder/ Tourette’s
• Sudden cardia death in pts < 12

Question 11

Polyunsaturated Fatty Acids (PUFA)

Answer 11

-Dosing 300 to 1000mg EPA/DHA + 60mg omega 6

Question 12

Role of Antipsychotics

Answer 12

• Presecribed for treatment of resistant aggression in ADHD
• Significant risk for long term adverse effects (weight gain, diabetes, etc.)
• Reserve for last line therapy

Question 13

Adverse effects commonly seen in treatment of ADHD

Answer 13

• Insomnia
• GI upset/ weight loss
• Agitation/ irritability
• Delayed growth
• Hypertension/tachycardia

Question 14

First line therapy for children age 4 to 5

Answer 14

• Behavioral therapy

- Methylphenidate if medication is necessary

Question 15

First line therapy for children age 6 to 11

Answer 15

• Medication/ behavioral therapy

- Evidence for stimulant is strongest

Question 16

First line therapy for children age 12 to 18

Answer 16

• Use medication first line

- Assess for comorbid substance use

Question 17

Texas C-MAP Algorithm

Answer 17

Stage 0- non medication options
Stage 1- MPH or AMP
Stage 2- agent not used in stage 1 
Stage 3- Atomoxetine
Stage 4- Bupropion/ TCA
Stage 5- Agent not used in step 4 
Stage 6- Alpha 2 agonist

Question 18

Why use long acting formulations

Answer 18

• Ease of administration
• Increased compliance
• Lower abuse potential