Exam 4 Flashcards
Lab findings in ADHD
- Dec total brain volume
- Dec activity in prefrontal and anterior cingulate cortex
- Lack of connectivity of ventral striatum
-Default mode network overactivity
Symptoms of ADHD
- Inattention
- Hyperactivity
- Impulsivity
- 6 or more present for more than 6 months in children, adults 5
ADHD Diagnosis pearls
- always drug test (in order to rule out alternative causes)
- evaluate every child 4-18 with behavioral or academic problems
- significant impairment in 2 or more settings
Consequences of untreated ADHD
- delay in language, motor, and social development
- inc incidence of conflicts
- inc risk of suicide attempts in early adulthood
- inc prevalence of SUD + incarceration
Preschool/school age ADHD non pharm practices
- parent/family edu
- training on behavioral mod
- behavioral class management (BCM)
Adolescents ADHD non pharm practices
- break up assignments into segments
- structure schedule
- behavioral peer intervention
Adults ADHD non pharm options
-ADHD CBT
-Metacognitive therapy ( 2h/w x 12 weeks)
Dietary supplements in ADHD
- lack of evidence but if there’s deficiencies treat it
- iron-zinc may inc stimulate effectiveness, omega 3
Predominant ADHD first line
Methylphenidate > Amphetamine
Predominant ADHD inadequate response to first line
Atomoxetine, Viloxazine, Guanfacine, Clonidine, Bupropion
Try combos or tca next
Tourette’s
DA antagonist or a2 agonist (Clonidine)
- if patient has some response add on stimulant or atomoxetine or alternative
Bipolar/severe aggression (ADHD comorbidity)
Atypical APS, Lithium, Anticonvulsant
- if pt has some response add on A LOW DOSE stimulant (AE: mania)
Anxiety/ Depression (ADHD comorbidity)
Antidepressant (SSRI)
- if pt has some response add stimulant, no response use alternative
Stimulants MOA in ADHD
Block DA & NE uptake, inc catecholamine release, in monoamine oxidase (which inc DA in prefrontal cortex)
Immediate release amphetamines
- mixed amp- IR salts (5-20)
- amp sulfate IR (5-40)
- odt (10-40)
- d-amp-IR/liquid (2.5-40)
Stimulant AEs
- psychiatric (mania/psychosis, aggression, sever anxiety) DOSE REDUCE
- small cardiac changes ( 5 bpm inc)
- dose related dec growth (drug free trial yrly)
Stimulants DDI (6)
- MAOI (avoid, 14 day washout)
- psycho-stimulants ( coffee, sildenafil, nicotine)
- anti acids, ppis, H2RAs inc absorption of IR, dec absorption of ER MPH
- Antacids dec excretion of AMP (requiring lower doses)
- CYP2D6 inhibitors can inc AMP salt exposure (paroxetine & fluoxetine) requiring lower doses
- Alcohol can cause stimulant dumping
Common stimulant SE and ways to help (6)
- reduced appetite/ weight loss= high calf meal when stimulant effect low (AM/QHS)
- stomach ache= take with food or dec dose
- insomnia = give earlier in the day, dec last dose of day or give it earlier, give sedative meds ( guanfacine, Clonidine, melatonin, cypro)
- headache = Divide dose, take with food, give analgesic
- rebound sumptuous= LA stimulant, atomoxetine, antidepressant
- irritability/jitteriness= comorbid condition, dec dose, mood stabilizer/ atypical antipsychotics
Uncommon stimulant effects (5) and what to do
- dysphoria/euphoria
- zombie like state
- tics
- HTN
- hallucinations (D/C, reassess, mood stabilizers)
- dec dose consider alternative
Immediate release advantages
low cost, less insomnia, fewer growth related ADE
Delayed release advantages
Med adherence
Delayed release AMP
- mixed AMP-XR salts (5-30mg)
- AMP sulfate ER suspension (6.3- 12.5)
- AMP XR ODT (6.3-12.5)
- D-AMP- ER (5-40 mg)
Clinical pearls about AMP ER Soln
-2.5- 5mg
- se: epistaxis(nose bleeds), upper abdominal pain, allergic rhinitis
Clinical pearls about AMP XR ODT/Suspension
- food delays time to peak
Clinical pearls about Mydayis ( Mixed AMP Salts ER)
-onset 1-2 hrs, last 16 hours
- triple time release beads within capsules to reduce medication wearing off (better control)
Amphetamines moa at high doses
Stimulate serotonin release and acts as serotonin agonist
Transdermal MPH formulation
- indication 6-17 years
- 10, 15, 20, 30
- apply 2 hrs b/f needed effect
- apply to hips only (SE: chemical run throughout body)
- max wear 9 hrs
- 1-3 hr effect after removal
- BBW site rxns: erythema/contact sensitization, chemical, leukoderma/hypopigmentation
Transdermal AMP formulation
- approved for 6 and up including adults
- 4.5, 9, 13.5, 18
- apply 2 hr prior
- multiple sites (rotation)
- max wear for 9 hrs
- effects last 3 hours after removal
- <10% of drug this present after disposal
- app site rxns: pain, itchiness
Methylphenidate clinical pearls
- Can use used in seizure patients
- Less DDIs (can use with CYP2D6 concerns)
- Used to treat tics
- Men have inc bioavail
Amphetamine CI
- history of CV disease ( mod- severe HTN, HF, recent MI )
SNRI in ADHD
- Atomoxetine
- Viloxazine
*full benefit takes 6-8 weeks, behaviors may worsen initially
SNRI AE
- upset stomach, psychiatric & cardio effects (not recommended in HD)
- Fatigue, sedation, dizziness
- liver toxicity w/ long term use
- renal dose adj
SNRI BBW
New onset sucidiality
SNRI DDI
- QT prolongation w/ TCA & APS
- Atomoxetine conct inc by paroxetine and fluoxetine
- Vuloxetine is strong CYP1A2 inhs
Which MPH products are 30/70
MPH ER
MPH ER Chew
MPH CD (beads)
Which MPH are 50/50
MPH LA
DEX-MPH-XR
Clinical pearls about MPH XR ODT (Contempla)
- do not push blister pack, peel back foil
- dissolve in tongue
Clinical pearls about Jornay PM (MPH ER)
- take in the evening (8 pm)
- drug first layer takes 10hr to dissolve, second layer dissolves through the day
-14 hr from dose to peak effect - 2 drug compartments
a2 agonist
Clonidine 0.1 QHS or BID max .4
Guanfacine 1-4 mg QD, max 7
a2 agonist ae
- sedation/dizziness/hypotension
-constipation
-heart block
-dont take w/ high fat meal
bupropion
- 50-300 mg QD
- metabolized faster in prepubertal children BID dosing
Bupropion AE
- appetite suppression
- seizures
TCA Monitoring and AE
- 4 wks to see max effects
-AE sedation, constipation, lethal overdose, rapid HR, weight gain, heart block
Lithium/ Anticonvulsants in ADHD
- treats aggression, explosive behaviors, impulsivity
-BPD & ADHD
APS in ADHD
- 1st gen: chlorpromazine & Haloperidol treats hyperactivity; EPS concerns
- 2nd gen treats severe aggression; metabolic risk
What to use in patients with SUD
- Atomoxetine, a2 agonist, bupropion
-low doses of stimulates ER only
treatment for tics
-MHP, clonidine, guanfacine, atomoxetine
What products are appropriate for 3-5 year olds
Only IR products MHP & AMP
Neuropathic pain def
pain caused by a lesion or disease of the somatosensory nervous system; nervous system damage
Nervous System Damage
- inc nerve firing
- dec inh of neuronal activity
- sensitization causing amplification and sustain sensory
presentation of neuropathic pain
- Spontaneous; continuous or intermittent
- Hyperalgesia: inc pain from painful stimuli
- Allodynia: pain from non-painful stimuli
Counseling for neuropathic pain
- Meds should not be taken on prn basis
- Take days to weeks for max effect
- Will dec pain NOT resolve it
-always initiate non pharm
Painful Diabetic Neuropathy Patho
- Damage to peripheral nerves and abnorm electric connections causes hyper excitability and activation of NMDA
PDN Treatments
-TCA, SNRI, Gabapentinoids +/- Na channel blockers
- Topical Capsaicin or Lidocaine
Post herpetic Neuralgia
- Reactivation of varicella-zoster virus (shingles)
- distribution along dermatomes
- sensory damage leads to dec neuritic density
PHN treatment
- TCA, Antiepi (gaba, pregab, divalproex), Tramadol, opioids
-lidocaine (focal!) and capsaicin
Lower back pain
- cyclical mechanism
LBP treatment
- NSAIDS
- Tramadol or Duloxetine 3. Opioids (last line)
Fibromyalgia
- enhanced sensitivity to stimuli (heat and cold) in all 4 quadrants
- fog (fatigue & sleep)
- women
- neuroendocrine abnormalities
- genetics
Fibromyalgia Treatment
Amtriptyline, Duloxetine or Milnacipran, Tramadol, Pregab, Cyclobenzapine
TCA Pearls
-Notriptyline, Despramine, Amitriptyline, Imipramine
-AE: beers list NO IN ELDERLY, delayed onset, cardiotoxic
SNRI AE and CI
- Duloxetine, Venlafaxine,
–AE: Serotonin syn;
–CI: Hepatic impairment, ESRD - Milnacipran
–AE: BID, HTN
Gabapentinoids
-Renal dose adj; crcl<15 lowest
-pregablin is a control
-both have slower onset
opioids in pain
Last line
Tramadol (lower addiction profile) and Tapentadol
Capsaicin
dont stick on sensitive areas
-ae burning
