drugs for ADHD (Martin) Flashcards
ADHD: What is It?
Triad:
Inattentiveness, Hyperactivity, Impulsiveness
Maladaptive and Pervasive – occurs in more than 2 settings
Academic and Behavioral Problems
Onset Prior to Age 12
Probable Organic Cause
Exact Etiology Unknown
DSM-5 Criteria
EITHER: 6 or more symptoms of
Inattention and/or
Hyperactivity & Impulsivity
AND
Onset before age 12 years
Impairment in at least 2 Settings (i.e., at school and at home)
Impairment in social, academic or occupational function
No other pervasive disorder
Specify whether:
- Combined presentation, i.e., both inattention and hyperactivity-impulsivity criteria are met for the past 6 months.
- Predominantly inattentive presentation
- Predominantly hyperactive/impulsive presentation
Specify if:
Partial remission
Current severity: mild, moderate, severe
Pitfalls in Diagnosis
DSM criteria also describes NORMAL kids!
No Physical or Lab Markers
Significant Overlap w/ other diagnoses
Public Awareness, Misinformation
ADHD Characteristics
ADHD is a biologic process
ADHD is not a disorder of morality
ADHD is a behavioral syndrome, not merely a result of unreasonable expectations and a fast paced society.
ADHD is a behavior disorder with multiple presentations and multiple possible causes including genetic, brain injury, abnormal brain development, and environmental factors.
ADHD involves biochemical messengers
- Dopamine, Norepinephrine, Epinephrine, others (?)
Treatment/ Management: Education:
Patient
Parent
Teachers and Caregivers
Physician
Medication Effects
decreased:
- fidgetiness
- interrupting
- physical aggressiveness
- antisocial behavior
Increased:
- compliance
- peer acceptance
- efficiency
- on-task behavior
- accuracy
- short term memory
- problem-solving
- parent-child interactions
- performance of motor tasks
Medical Therapy- Stimulants:
Methylphenidate Dexmethylphenidate Dextroamphetamine Amphetamine mixed salts Racemic Amphetamine Sulfate Lisdexamfetamine
Methylphenidate choices
Short-acting
(generic, Ritalin, Methylin ChewableTablets, Methylin Oral Solution)
Intermediate-acting
(Metadate ER, Ritalin SR)
Long-Acting
Metadate CD, Ritalin LA, Concerta, Daytrana (patch), Quillivant XR (long-acting syrup), Aptensio XR
Lisdexamfetamine
An oral prodrug that is converted to d-amphetamine and l-lysine by enzymatic hydrolysis. Longer duration than that of other amphetamine preparations, similar efficacy.
Cannot be crushed and then injected to get an amphetamine-like high.
Neurotransmitters - Psychostimulant actions:
Methylphenidate- increases DA by blocking reuptake of DA
Amphetamines block DA reuptake and increase release of DA and NE by displacing natural neurotransmitter from storage vesicles (reverse transport)
Atomoxetine
NE reuptake inhibitor
Unknown mechanism increases prefrontal cortex DA
Medications for ADHD- actions
Methylphenidate- increases DA
Amphetamines- increases NE, DA
Atomoxetine- Increases NE
Guanfacine, clonidine- decreases CNS sympathetic outflow
Stimulants- Expected benefit
Improved CONCENTRATION
evidence: better grades, etc.
All other benefits are secondary
Methylphenidate
Methylphenidate (MPH) is the active ingredient in the majority of stimulant medication in the U.S.
Effective in reducing symptoms of ADHD in both children and adults
* Acts by blocking dopamine reuptake
Most preparations are mixtures of d- & l- enantiomers; the pure d-threo –methylphenidate is sold as dexmethylphenidate (Focalin)
Amphetamines
Dextroamphetamine
d-isomer (Dexedrine, Dextrostat)
Mixed racemic forms
d- & l- isomers (Adderall, Aptensio)
Onset within 1 hour, duration up to 5 hrs
Twice daily administration required
Ascorbic acid or fruit juice ↓ absorption, sodium bicarbonate ↑ absorption
Concerns Associated with Stimulants
Diversion- Selling or giving drug to others Lisdexamfetamine dimethylate (Vyvanse) is a prodrug of dexamphetamine with rate limited metabolism and has reduced risk of abuse, diversion, and overdose.
Untreated ADHD has twice the risk for substance abuse, with earlier onset, and less likelihood to recover as an adult
25% of patients seeking substance abuse disorder treatment also have ADHD
Effective management of ADHD significantly decreases risk for substance abuse
Lisdexamfetamine dimethylate and abuse
A prodrug in which d-amphetamine is covalently bonded to L-lysine
Converted to d-amphetamine by enzymatic cleavage when given orally, but minimal active amphetamine released if taken IV
Has less potential than amphetamine itself for abuse, diversion, or overdose
Schedule II controlled substance
Medical Therapy- Non-Stimulants:
** Atomoxetine (Strattera)
A selective norepinephrine reuptake blocker
** Is neither a controlled substance nor a stimulant
Less effective than stimulants
Greatest value is for patients who have not responded to or cannot tolerate stimulants, especially those with low weight, short stature who refuse treatment with a controlled substance
Alpha-agonist Treatment
Clonidine
Stimulates alpha 2-adrenergic receptors
Decreases central sympathetic output
Clinically useful for treating tics and hypertension
** Clonidine also used in children to manage sleep problems, aggression, and self-injurious behavior
A meta-analysis of clonidine trials suggests it has moderate efficacy for treating ADHD but less than that of stimulants
Appears to treat hyperactivity and impulsivity but not distractibility
Guanfacine - modestly effective to improve hyperactivity
Centrally acting antihypertensive medication
Stimulates alpha 2-adrenergic receptors
Somnolence can be a problem, bradycardia, hypotension, and syncope can occur.
Tricyclic Antidepressant Treatment
Tricyclic Antidepressants (TCAs)
Are not first line treatments for ADHD but have proven efficacy
May be helpful for treatment of hyperactivity and impulsivity in patients that have been treatment resistant to more than 2 trials of stimulants as well as other non-stimulant medications
Less effective for treatment of distractibility than stimulant medication
Can be used in combination with stimulants to:
- Treat partially-treated ADHD
- Reduce stimulant induced insomnia and appetite suppression
*Buproprion sometimes (rarely) used but clearly less effective
