EXAM 4 Pharmacotherapy ADHD Dr. Thomason Flashcards
What is the recommended ADHD treatment for children younger than 6 years?
6 months of behavioral classroom treatment and parental training before starting meds
based on the Guidelines
What are the risk factors for developing ADHD?
-Genes -> also contribute to other disorders:
schizophrenia, mood disorder, autism
-Mother:
often young, without a father, smoking during pregnancy, preeclampsia (HTN during pregnancy), early delivery
Which test is done to assess ADHD?
MRI test while the child is doing tasks
-prefrontal, frontal, parietal, and cerebellum can be involved
When does a child need to be evaluated?
!!!
-age 4-18y
-academic or behavioral problems
-> Inattention, hyperactivity, impulsivity: it has to occur before 12y !!!
-6 or more symptoms have to be present for 6 !!! months in 2 settings (often school and at home)
-5 symptoms if 17y or older
What is the first-line therapy for ADHD?
Stimulants
-meds work best in combo with behavioral treatment
-pharmacologic treatment is protective
less unintended injury; less risk for SUD, obesity, car accidents, criminality
Which drug is preferred in adult and young (<5y) patients with diagnosed ADHD?
!!!
adults: start with Lisdexamfetamine or dexamfetamine (Lisdex is a prodrug is safer for abuse) -> may switch to MPH or DMPH
children: start with Methylphenidate or dexmethylphenidate -> may switch to LDX or DEX
Which drug may be used if LDX or MPH doesn’t work?
Atomoxetine or bupropion
Why do we start behavioral treatment first in young children?
in less than 6y:
they may develop mood lability and dysphoria when started on a stimulant
What are the side effects of stimulants?
Know it well
-decreased appetite, stomach pain
-sleep disturbance
-headache
less common:
-hallucination (too much dopamine can cause it)
-growth supression
-labile mood
-cardiac risk -> risk for sudden death in kids!!!!
-BP goes up -> monitor
-priapism in males
-skin discoloration in methylphenidate patch
How to manage insomnia?
-give the first earlier, and the last dose earlier
-lower the last dose
-use melatonin or guanfacine or clonidine
How to manage irritability or jitteriness?
assess for bipolar disorder
-reduce the dose
-add a mood stabilizer
-add 2nd gen antipsychotic (not preferred)
How to manage Dysphoria, Zombie-like state, and hallucinations?
-reduce the dose
-change the drug
for hallucinations: STOP the stimulant and reassess the diagnosis (they may have bipolar disorder, schizophrenia)
-> Patients with psychotic illness should not be on a stimulant -> it causes hallucinations
Warning about stimulants
avoid in children with structural cardiac abnormalities or other heart problems
-adults: hx of structural cardiac abnormalities, cardiomyopathy, coronary artery disease or other heart disease
->it can cause sudden cardiac death
->use atomoxetine
How much do stimulants increase BP in children?
-3-10 beats/min
-BP goes up by 2 to 14 mmHg
What is the impact of stimulants on growth and weight in children?
1 cm per year of treatment
10 lbs weight deficitif over 2 years (decreased appetitive)
-not significant height deficit, probably they catch up with eating while their off the stimulant (weekend, summer break)
What causes Raynaud’s syndrome?
peripheral release of catecholamines -> causing Vasoconstriction in response to cold or stress
->dose-dependent: decrease the dose or change the drug
-cold fingers and toes
-color change in fingers and toes
What should be monitored for patients on stimulants?
-BP and HR
-weight (look for weight loss)
-appetite
-sleep (insomnia)
-headache
-GI distress
Drug interactions of Methylphenidate
CYP2D6
-don’t use with MAOi -> would cause hypertensive crisis
Drug interactions of Amphetamines
-TCA
-phenytoin
-phenobarbital
-warfarin
-don’t use with MAOi -> would cause hypertensive crisis
How do start Methylphenidate
-drug of choice in younger and smaller children
-start with IR and find the effective dose -> switch to long-acting form so that they only need to take it once a day
-IR can be combined with long-acting to prolong the duration
-high-fat meals delay the absorption
Which stimulant is designed to be given at bedtime?
Jornay PM (methylphenidate)
-for patients with early morning functional impairment
-give it between 6:30 and 9:30 pm
-when switching stop the other product and follow titration schedule
How do Ritalin LA and Focalin XR provide long-acting levels?
Two peaks mimicking the twice-daily administration
-50% is released immediately (IR)
-50% 4h later
When is bupropion contraindicated?
-eating disorder
-seizure disorder
max dose: 300 mg/day (higher may cause anxiety)
MOA of bupropion
NET and DAT inhibitor
How long does bupropion take to work?
about 2 weeks
MOA of atomoxetine
potent NE reuptake inhibitor
-doesnt affect DAT -> no euphoria
-it takes 2-4 weeks (even longer for peak) -> tell patients and parents
When to consider atomoxetine?
-cant tolerant or respond to stimulants
-patients with anxiety or SUD
-oppositional defiant disorder
-patients with tics
-less growth and insomnia compared to stimulants
What are the drug interactions of atomoxetine?
CYP2D6:
-fluoxetine, paroxetine, bupropion, risperidone
->increases atomoxetine levels
ADE:
-GI -> take with food
-rare hepatitis: screen LFT
-suicidal ideation
-treatment-induced mania (reassess if they have bipolar disorder)
MOA of Viloxazine
-selective NE reuptake inhibitor (less than atomoxetine)
-5-HT2B antagonist
-5-HT2C agonist
How long does Viloxazine take to work?
within 1 week (faster than atomoxetine)
-but more expensive (400$/month)
-similar side effects
Drug interactions of Viloxazine
!!!
-CYP1A2 inhibitor -> increases levels of caffeine (6x), theophylline (contraindicated)
->can cause anxiety
-similar side effects as with Atomoxetine
MOA of Clonidine
α2agonist on postsynaptic receptors
-> Release of NE
What is the role of Clonidine in therapy?
adjunctive to a stimulant
-trials show better outcomes when both are on board
-but patients are often started when they have trouble with sleep or tics or other side effects (reduce stimulant and add clonidine)
-sedating -> give it at bedtime
-taper: to prevent rebound hypertension
MOA of Guanfacine
-selective α2 agonist
-not as effective as clonidine, but less dizziness and sedation
-need taper
MOA Modafinil
not fully understood
-take a few days to work
-even though it is not a stimulant it is stimulating: may cause agitation, anxiety, insomnia, decreased appetite
Role of antipsychotics
-patients with impulse aggression together with ADHD
-Autism spectrum disorder
-metabolic side effects: long-term use
hyperlipidemia
hyperglycemia
weight gain
increased prolactin or gynecomastia (ex with risperidone)
Which antipsychotic increases prolactin?
NAPLEX
Risperidone
Which drug may be added for insomnia with ADHD?
-clonidine
-guanfacine
-may try melatonin
also, work on sleep hygiene
-go to bed and wake up at the same time
-avoid phone before bedtime
-no caffeine before bedtime
-dark room
How to treat ADHD with bipolar disorder?
-start with a mood stabilizer then a stimulant
-in children, an atypical antipsychotic is used
-in adults atypical antipsychotic or lithium, valproate, Tegretol, lamotrigine
-hard to differntiate:
we see impulsivity, inattention, hyperactivity, and aggression in both
How to treat ADHD with autism spectrum disorder?
-start with a low dose of stimulants -> monitor closely
-clonidine and guanfacine (both α2 agonists) have some evidence
How to treat ADHD with SUD?
screen for SUD: nicotine, vaping (even at a young age), other illicit drugs
-avoid the stimulant (EXAM!!!)
-atomoxetine
-bupropion
-α2 agonists: clonidine, guanfacine
How to treat ADHD with an eating disorder?
inattention increases the risk of aberrant eating behavior or obesity, binge eating, bulimia
-Lisdexamfetamine is approved for ADHD and binge eating disorder
How to treat ADHD with oppositional defiant disorder?
stimulants seem to work (patients may require a higher dose of stimulants to treat both)
How to treat ADHD with aggression?
-hitting, and biting other kids
-start with behavioral therapy (parents teaching)
-second-gen antipsychotic (they are anti-aggressive and it calms them down) -> Risperidone
-> Watch for prolactin stimulation, extrapyramidal symptoms (Parkinson-like, rigid joints), weight gain, and metabolic effects
-lithium and depakote can be used
How to treat ADHD with Tics and Tourette disorder?
-combination therapy: stimulants and clonidine or guanfacine
-if it still doesn’t improve add an atypical antipsychotic -> Apriparzole is FDA-approved for Tourette
How to treat ADHD with anxiety?
-behavioral therapy
-atomoxetine (helps with anxiety and ADHD)
-if it doesn’t improve -> add an SSRI
How to treat ADHD with depression?
-treat the one that causes the most impairment first!
-increased suicide risk when treated with antidepression -> close monitoring for 3 months
In which comorbidities are clonidine and guanfacine considered?
-insomnia
-autism
-SUD
-Tics and Tourette
When would Vyvanse (Lisdexamfetamine) be preferred over Methylphenidate in ADHD treatment?
in adults
