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701 > Exam 4: ADHD > Flashcards

Exam 4: ADHD Flashcards

1
Q

physiolgoic risk factors of developing ADHD

A
  1. Male
  2. First degree relative diagnosed
  3. Minor physical abnormalities (hypertelorism, highly arched palate, low set ears)
  4. Motor delays, neurological soft signs
  5. VLBW 2-3x risk for ADHD!
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2
Q

Environmental risk factors of developing ADHD

A
  1. fetal alcohol syndrome
  2. Lead poisoning
  3. meningitis
  4. obstetric adversity
  5. maternal smoking
  6. adverse parent child relationship
  7. PTSD
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3
Q

Describe pathophysiology of ADHD

A

Decrease brain volume/reduced activty = attention deficit
* Decreased activation of ventral striatum
* Default mode network overactivity (active attention supression)

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4
Q

How do stimulants work?

A
  1. block DA and NE reuptake (MPH)
  2. increase catecholamine release (AMP)
  3. inhibit MAO

MPH
* Selective inhibits presynaptic reuptake of DA & NE
* more action on DA > NE
* Supresses default mode network overactivity!!!!

AMP
* Increase release of DA and NE into synapse from the presynaptic nerve terminal (enhance NE release in periphery)
* At high doses, stimulates 5HT release too (agonist)
* high fat meal delay time to [peak]

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5
Q

Treatment for primary ADHD diagnosis

A

1) Stimulants (FDA)
* MPH, d-MPH, ser-dex-MPH
* AMP, d-AMP, lis-dex-AMP

2) Non-stimulants
* NE reuptake inhibitorsm (FDA)
* alpha adrenergic receptor agonists (FDA)
* Other (Bupropion, TCAs, Lithium, APS)

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6
Q

AMP FDA approved for ≥3 y.o

A

IR forms ONLY
2. Dexedrine (d-AMP)
2. Evekeo, Adderal (AMP)

FDA approval

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7
Q

MPH approved for ≥3 y.o?

A

IR forms only of MPH
not fda approved
but recommended by guidelines for 4+

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8
Q

AMP FDA approved for ≥6 y.o

FDA approved

A
  1. Vyvanse (lis-d-AMP)
  2. Dynavel XR (AMP ER)
  3. Adxenys XR (AMP ER)
  4. Adderal XR (AMP ER)
  5. Xelstrym TD (d-AMP)
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9
Q

MPH FDA approved for ≥6 y.o

A
  1. Ritalin IR/SR/LA (MPH IR/SR/ER)
  2. Methylin ER (MPH ER)
  3. Focalin IR/XR (d-MPH IR/ER)
  4. Metadate CD (MPH modified release)
  5. Cotempla XR (MPH ODT)
  6. Jornay PM (MPH ER cap)
  7. Quillivent/Quillichew (susp/chew)
  8. Adhansia XR (MPH layer)
  9. Daytrana TD (MPH TD)
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10
Q

AMP FDA approved for ≥13 y.o

A

Mydayis (mixed AMP/d-AMP XR)

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11
Q

AMP products are preferred in which age group?

A

Adults

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12
Q

MPH products are preferred in which age group?

A

Children

however only AMP IR FDA approved <5

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13
Q

Which MPH products are 30% IR/70% ER?

A

MPH ER, MPHCD
* ritalin, methylin
* metadate ER/CD
* Quillivant XR/Quillichew

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14
Q

Which AMP products are 50% IR/50% ER?

A

Mixed AMP-XR salts (ex: Adderal XR)

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14
Q

Which MPH products are 50% IR/50% ER?

A

MPH LA
* ritalin LA
Dex-MPH XR
* Focalin XR

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15
Q

AMP products that require re-titration

A

AMP sulfate XR solution (Dynavel)
AMP XR ODT/ER suspension (Adzenys)
mixed AMP ER (Mydayis)

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16
Q

MPH products that require re-titration

A

Jornay PM
Cotempla XR ODT (?)
Azstarys (?) (ser-dex-MPH)

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17
Q

prior to diagnosis, rule out alternative causes

A
  • learning disability
  • situation stressors
  • oppositional defiant disorder
  • conduct disorders
  • Tics/tourettes
  • sleep disorder
  • mood disorder
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18
Q

DSM5 ADHD

A
  1. Sx before 12 y/o
  2. impairment ≥2 places, sx documented
  3. sx interfere w/ functioning
  4. sx not d/t other idsorder
  5. sx: hyperactivity/inattention + impulsivity
    > 6 or more present at least 6 months
    > if ≥17 y/o, at least 5 sx required
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19
Q

School age ADHD presentation (6-11)

A
  1. difficulty at school
  2. combined: inattentive + hyperactive/impulse
  3. Comorbid: ODD, conduct disorder, aggression –> risk for delinquincy and SUD
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20
Q

Adolescent ADHD presentation (12-18)

A

Inattention/impulsive > hyperactive
sig. functional impairment
higher rate delinquincy/drug/etoh use
speeding/mva

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21
Q

Pre-School ADHD presentation (3-5)

A

excessive motor activity
intense tamper tantrum

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22
Q

preschool/school nonpharm

A

fam education on adhd
train behavior modification
behavioral classroom management (BCM)

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23
Q

Adolescent nonpharm

A

Break up assignments
structure schedule
behavioral peer interventions (BPI)

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24
Q

Adolscent/adult nonpharm

A

ADHD CBT
Metacognitive therapy (2hr/week x 12 wks)

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25
Q

Predominant comorbidity?

A
  1. Tourettes
  2. BP/severe aggression
  3. Anxiety/depression
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26
Q

Tourretes dx

A
  1. DA antagonist/A2 agonist
    • dash of stimulant/atomoxetine/a2 agonist
    • alt DA antagonist or a2 agonist
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27
Q

BP/severe agression dx

A
  1. atypical APS/lithium/anticonvulsant
  2. +dash of stimulant (careful of mania)
    • alt or add mood stabilizer
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28
Q

Anxiety/depression dx

A
  1. antidepressant
    • stimulant
    • Alt. antidepressant
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29
Q

Characteristics of IR stimulants

A
  1. lower cost
  2. less insomnia, faster onset
  3. fewer growth related ADR
  4. short half life, frequent dosing
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30
Q

Characteristics of ER stimulants

A
  1. more insomnia, slower onset
  2. more growth related ADR
  3. long half life, Qday dosing, better adherence
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31
Q

General stimulants ADR

A
  1. Psych: mania, agression, anxiety
  2. Cardiac: slight increase HR/BP, avoid if cardiac (SEVERE HTN, arrythmia, HF, recent MI) – prefer MPH over AMP if cardiac
  3. Growth (barely, a couple cm, use IR to avoid)
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32
Q

General stimulant DDIs

A

antacid/ppi/h2ra
* Increase MPH IR absorption
* decrease MPH ER absorption
* Increase AMP absorption (PPI only)
* decrease AMP excretion (antacids only)

Acid (fruit juice)
* decrease AMP absorption

Food effect
* delay time to onset
*Additive if coffee/smoke/other psycho stim
* alcohol = stimulant dump

CYP 2D6 inhibitors (bup/fluox)
* increase mixed AMP exposure

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33
Q

Which forms of stimulants can be opened into applesauce?

A

Metadate CD (MPH CD)
Ritalin LA (MPH LA)
Adderal XR (mixed AMP XR)

34
Q

Ritalin LA pearls

A
  • applesauce
  • better for severe morning sx than CD/MLR
35
Q

Most MPH doses are 60mg MDD except:

A

Aptensio XR (MLR)
* 10 QD
Adhansia XR (MLR)
* 25 QD
Cotempia XR ODT
* 17.3 QD
Daytrana TD
* 10-30
Dex-MPH IR/ER
* MDD 20 (IR =bid dosing)
* 1/2 dose of MPH
Ser-Dex-MPH
* 52.3mg
MPH PM
* 20-100 QD

36
Q

MPH XR suspension pearls

A
  • shake virogrously ≥10sec
  • when reconstituted, good for 4 months
37
Q

MPH OROS pearls

A

Swallow whole - see shell in toilet
afternoon sx control better than d-MPH XR

38
Q

MPH MLR pearls

A

has larger ER ratio
Better for rebound afternoon sx

Aptensio XR

39
Q

Dex-MPH IR pearls

A

not better than MPH
1/2 dose of MPH
MDD 20 mg
5-10mg BID

40
Q

Dex-MPH XR pearls

A

50/50
2 peak: 1.5hr post, 6.5 hr post
afternoon sx control not as good as OROS

41
Q

d-MPH/ser-d-MPH

A

Ser-d-MPH is prodrug
RISK OF SUICIDAL IDEATION

42
Q

MPH PM pearls

Jornay PM (MPH ER)

A

give between 6:30-9:30 PM
DO NOT GIVE IN AM
LONG DURATION 24-36 hrs
20 mg QHS –> MDD 100mg
DELEXIS DDS: multilayer DR/ER/CORE
* DR layer: 10 hours: ≤5% drug absorbed (≥10 hr onset)
* ER layer: dissolve throughout day, 14 hr to peak

43
Q

Cotempla XR ODT pearls

A

Don’t push tab through foil
ORAL dissolve
start 17.3 QAM, increase weekly in 8.6-17.3 increments to MDD 51.8 mg

44
Q

MPH TD pearls

Daytrana TD

A

6-17 years
10mg-30 mg / 9 hr
hip only
effect 1hr after removal (up to 3)
>50% drug left in patch
BBW: leukoderma hypopigmentaiotn

45
Q

dAMP TD pearls

Xelstrym

A

≥6 y.o + adults
4.5 - 18 mg/9hrs

hip, upper arm/back, chest, flank
drug effect 3 hrs after removal
< 10% dAMP remains in patch
pain, itchiness, better tolerated

46
Q

What stimulant has BBW for leukoderma/hypopigmentation

A

MPH TD (Daytrana)

47
Q

Most AMP doses are 40 MDD except:

A

AMP sulf
* XR solution: MDD 20 mg
* XR ODT/ER susp: 6.3-12.5 mg QD

Mixed AMP XR salts: MDD 30mg (?6-11)
dAMP TD: MDD 18mg/9hr
lis-dAMP: MDD 70mg

48
Q

AMP ER solution pearls

Dyanavel XR

A

≥ 6 y/o
2.5-5mg QDay (max 20)
RETITRATE
ADR
- nosebleed
- allergic rhinitis….
- upper GI pain

49
Q

AMP ER susp/XR ODT pearls

A

use ≥6 y/o
Dose conversion NOT 1:1
food delays time to serum peak

50
Q

Conversion: AMP XR > ODT/SUSP

A

5>3.1
10>6.3
15>9.4
20>12.5
25>15.7
30>18.8

51
Q

mixed AMP salt ER pearls

Mydayis

A

≥13 y/o
12.5mg QAM
MDD adult: 50mg
MDD adoles: 25mg
Can’t convert 1:1 with other AMP
TRIPLE TIME release beads - reduce wear off
* IR bead + DR bead 1+ DR bead 2
Compared to ER/IR combo, does not have dip mid-day

52
Q

AMP IR pearls

A

AT LEAST BID
preferred for < 5 y/o
Afternoon dose not to be given <6 hrs before bedtime

53
Q

norepinephrine reuptake inhibitors MOA

A

inhibit pre-synaptic reuptake of norepinephrine (like MPH but no DA)

54
Q

NE reuptake inhibitor DDI

A

avoid duplicate therapy
avoid additive QTc prolongation (APS/TCAs)
* Atomoxetine elevation w/ paroxetine/fluoxetine/bupropion
* Viloxazine (strong CYP1A2 inhibit, weak CYP2D6/3A4)

54
Q

Norepinephrine reuptake inhibitor efficacy

A

not as good as stimulants
safe /effective in children/teenager/adult
onset takes 1-2 weeks
full benefit: not seen for 6-8 weeeks
behavior could worsen initially

55
Q

Norepinephrine reuptake inhibitor ADR

A

Upset stomach
Psych
Cardiovascular QTC (more so than stimulants)
Avoid TCA, APS
Fatigue, sedation ,dizziness
* liver tox w/ long term atomoxetine
* renal dosing for viloxazine

56
Q

What non-stimulant has BBW for new-onset suicidality?

A

Norepinephrine Reuptake Inhibitors
* Atomoxetine (Strattera)
* Viloxazine ER (Qelbree)

57
Q

Viloxazine DDIs

A

ADs
*SSRI: dulox,fluox,parox
* SNRI: venlafaxine
* TCAs
APS
* ariprazole
* asenapine
* risperidone
* chlorpromaz,cloza, olanza
* perphenazine, thoridazine
Benzos
Opiates
* buprenorphine, hydrocodone, methadone, oxycodone
(strong CYP1A2 inhibit, weak CYP2D5/3A4)

58
Q

alpha adrenergic receptor agonist MOA

A

Increase blood flow to prefrontal cortex
Enhance working memory/executive functioning
Inhibits NE release

59
Q

alpha adrenergic receptor agonist efficacy

A

Not as effective as stimulants for monotherapy
onset of effect 1-2 weeks

60
Q

alpha adrenergic receptor agonist ADR

A

sedation/dizziness
hypotension
constipation
heart block

61
Q

which medications time to peak is delayed by high fat meals?

A

MPH
AMP
ER alpha adrenergic RA

62
Q

non stimulant FDA approved dosing

A

QD-BID
* Atomoxetine MDD 40mg (5-20 BID)
* Clonidine ER MDD 0.4mg (0.1 QHS or BID)
QD only
* Vioxazine ER MDD 400-600 (≤17/adult; 100-600 QD)
* Guanfacine ER MDD 7 mg (1-4 QD)

63
Q

Bupropion for ADHD

A

off label: 50-300mg/day
weak DA/NE reuptake inhibitor (like MPH)
benefit: adolescent w/ ADHD + depression; also adult..

64
Q

bupropion ADR

A

less appetite supression/weight loss compared to stimulants
causes seizures (MPH better for seizures)
avoid in AUD/eating disorders

65
Q

TCAs for ADHD

A

imipra: 50-150/day
Desipra: MDD 300
Nortriptyline: MDD 300
up to 4 weeks to see max effect

66
Q

TCA ADR

A

sedation/dizzy
constipation
heart block
rapid heart beat
weight gain
overdose toxicity - suicide risk bad

67
Q

Lithium/AEDs in ADHD

A

for aggression, explosive behavior, impulsivity
childhood onset BP or combined ADHD BP disorder

68
Q

APS for ADHD

A

FGA: chlorpromazine/haloperidol
* hyper/impulse
* >cause EPS (BAD- permanent tardive dyskinesia!!)
SGA: risper/olanz/quet/zipras/aripip
* severe agression, comorbid conduct/bp disorder
* >metabolic syndrome risks

69
Q

Preferred agents for ADHD in active SUD

A

atomoxetine
alpha agonist
bupropion

70
Q

T/F: ADHD is a risk factor for development of SUD, and stimulant use does not affect risk of subsequent SUD

A

True
treating ADHD can reduce development of SUD

71
Q

Starting treatment early for ODD/conduct disorder w/ ADHD with stimulants is indicated

A

helps avoid APS use later
reduce need for use of higher doses

72
Q

Bupropion dosing in prepubertal children

A

BID dosing optimal, even in SR forms
metabolized faster

73
Q

Atomoxetine dosing in children

A

BID preferred for tolerability

74
Q

Which stimulant is less likely to have drug interactions?

A

MPH forms

75
Q

Gender difference in bioavailability of MPH

A

males have increased F

76
Q

Evaluating ADHD treatment

A

baseline sx/complaints
height/weight/eat/sleep baseline / Q3month

77
Q

6 weeks at max tolerated dose is considered an adequate trial for which drugs?

A

Atomoxetine
Viloxazine
Bupropion

78
Q

1-2 months is considered an adequate trial for which drugs?

A

Guanfacine
Clonidine
+monitor BP and pulse!
EKG not mandatory but often done

79
Q

Managing reduced appetite d/t stimulant

A

eat high calorie meal when med is low (breakfast/HS)
Cyproheptadine at bedtime

80
Q

Managing insomnia d/t stimulant

A

Give earlier in day /sleep hygiene
Lower last dose of day
Add sedating agent
* Clonidine&raquo_space; guanfacine
* Melatonin (avoid if pre-puberty)
* Cyproheptadine
Try patch (effect wear off 1-3 hr)
IF RECENT ONSET: wait and watch, stimulants can help improve sleep cycle

81
Q

Managing rebound symptoms d/t stimulants

A

trial long acting stimualnt
or
* Atomoxetine
* Antidepressant

82
Q

Managing jitteriness/irritability d/t stimulants

A

Assess comorbid condition
Reduce dose
+/- mood stabilizer/atypical APS

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