Lecture 64 - Pharmacotherapy of ADHD Flashcards

1
Q

Overview of ADHD

A

higher rate is diagnosed in a first -degree relative
etiology is multifactorial (environmental, genetics, physiological)

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2
Q

Clinical Course

A

one-third of children with ADHD will have the diagnosis in adulthood
increased risk of substance use and antisocial personality disorder if ADHD is left untreated

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3
Q

Potential impact of ADHD

A

Poor academic performance
Low self-esteem
Poor interpersonal relationships
Employment difficulties

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4
Q

ADHD Diagnostic Criteria

A

For each symptom domain, must have at least 6 symptoms present
For older adolescents and adults (17 years and older), at least 5 symptoms are required for either of the two specifiers
Several inattentive or hyperactive symptoms must be present prior to age 12 years
Several inattentive or hyperactive-impulsive symptoms are present in two or more settings

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5
Q

ADHD Types

A

Combined: criteria met for both inattention and hyperactivity
Predominantly inattentive presentation: criteria met for inattention, but not hyperactivity
Predominantly hyperactive/impulsive presentation: criteria met for hyperactivity/impulsivity but not inattention

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6
Q

Inattention

A

Six or more of the following symptoms persisting for at least 6 months; inconsistent with developmental level and negatively impacting daily functioning: Fails to give close attention to details, makes careless mistakes; Difficulty sustaining attention in tasks or play activities; Doesn’t seem to listen when spoken to directly; Doesn’t follow through on instructions, fails to finish homework, chores, duties in the workplace; Difficulty organizing tasks and activities; Avoids, dislikes, reluctant to engage in tasks that require sustained mental effort; Loses things necessary for tasks/activities; Easily distracted by extraneous stimuli; Forgetful in daily activities

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7
Q

Hyperactivity and Impulsivity

A

Six or more of the following symptoms persisting for at least 6 months inconsistent with developmental level and negatively impacts functioning: Fidgets with or taps hands/feet, squirms in seat; Leaves seat in situations when remaining seated is expected; Runs about or climbs in inappropriate situations; Unable to play or engage in leisure activities quietly; “On the go”, acting as if “driven by a motor”; Talks excessively; Blurts out an answer before a question is completed; Difficulty waiting their turn; Interrupts or intrudes on others

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8
Q

Non-Pharmacologic Treatment Options

A

Behavioral therapy and psychosocial treatment; training interventions

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9
Q

Pharmacologic Treatment Options

A

stimulants (amphetamine or methylphenidate-based)
non-stimulants

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10
Q

Stimulant Dosing

A

Dose-response effects seen in a short period of time
Calculating a dose in pediatric patients based
on mg/kg not found to be helpful as variations in dosing not found to be due to height or weight
IR preferred for patients weighing < 16 kg due to limited low-dose availability of long- acting stimulants
Avoid giving dose too late in the day, may give an after-school dose
Late afternoon symptoms may require longer-
acting formulation
Don’t use two different stimulants, Can use two different dosage forms of the same stimulant

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11
Q

Special Considerations - Mydayis

A

mixed amphetamine salts
only for ages 13-17

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12
Q

Special Considerations - Daytrana

A

methylphenidate
only patch formulation

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13
Q

Special Considerations - Vyvanse

A

lisdexamfetamine
prodrug covalently linked to l-lysine; converted to dextroamphetamine via first-pass metabolism/hepatic metabolism
NOT useful if no response to dextroamphetamine

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14
Q

Special Considerations - Jornay PM

A

methylphenidate hydrochloride
take dose in evening between 6:30 and 9:30 pm

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15
Q

Stimulant adverse effects

A

Appetite loss
Abdominal pain
Headaches
Sleep disturbances
Decreased growth (1 to 2 cm, diminished after 3rd year of treatment)
Hallucinations or other psychotic symptoms (rare)
Increased blood pressure (1 to 4 mmHg) Increased heart rate (1 to 2 bpm)
Sudden cardiac death (rare)
Priapism
Peripheral vasculopathy (Raynaud’s)

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16
Q

Stimulants: Common Adverse Effects and Management - reduced appetite, weight loss

A

High-calorie meal when stimulant effects are low (breakfast, dinner)

17
Q

Stimulants: Common Adverse Effects and Management - stomach ache

A

Give on full stomach, lower dose if possible

18
Q

Stimulants: Common Adverse Effects and Management - insomnia

A

dose earlier in day, lower last dose of day or give earlier, consider sedating med at bedtime

19
Q

Stimulants: Common Adverse Effects and Management - headache

A

Divide dose, give with food, give analgesic

20
Q

Stimulants: Common Adverse Effects and Management - rebound symptoms

A

Longer-acting stimulant trial, atomoxetine, antidepressant

21
Q

Stimulants: Common Adverse Effects and Management - Irritability, jitteriness

A

Assess for co-morbid condition, reduce dose, consider mood stabilizer or atypical antipsychotic

22
Q

Stimulants: Uncommon Adverse Effects and Management - hallucinations

A

d/c stimulant, reassess diagnosis

23
Q

Stimulants: Uncommon Adverse Effects and Management - risk for suddent cardiac death

A

Risk no greater in clinical trials than general population – assess risk of cardiac structural abnormality and family history – if concern, cardiac ECHO

24
Q

Stimulant Monitoring

A

appetite, behavior, blood pressure, growth rate (height/weight), heart rate, sleep, ECG may be considered based on cardiac risk

25
Q

Alpha 2 Agonists

A

Guanfacine ER: 3A4 substrate
Clonidine ER
must be tapered if discontinued to avoid rebound HTN

26
Q

Norepinephrine Reuptake Inhibitors

A

Atomoxetine: 2D6 substrate; weight-based dosing for those less than 70 kg
Viloxazine: capsules - swallow whole or put in applesauce; 2D6/UGT substrate, strong 1A2 inhibitor

27
Q

Non-Stimulant Adverse Effects - atomoxetine and viloxazine

A

increased HR and BP, increase in suicidal thinking (boxed warning)

28
Q

Non-Stimulant Adverse Effects - clonidine and guanfacine

A
  • Decreased HR and BP, orthostasis
  • Somnolence
  • Dizziness
  • Rebound hypertension if abrupt discontinuation
29
Q

Monitoring for Non-Stimulants

A

Appetite
Behavior
Blood pressure
Growth rate (height and weight) (atomoxetine) Heart rate
LFTs (atomoxetine)
Sleep

30
Q

Bupropion

A

Not FDA-approved for ADHD
2D6 inhibitor
Contraindicated in seizure disorders and eating disorders

31
Q

Tricyclic Antidepressants

A

Less effective than methylphenidate
Cardiac concerns – sudden cardiac death in children, lethal in overdose

32
Q

Mood Stabilizers: Atypical Antipsychotics

A

May be useful if there is comorbid bipolar disorder, conduct disorder, intermittent explosive disorder
Should not use atypical antipsychotics as monotherapy!!!

33
Q

American Academy of Pediatrics (AAP) ADHD 2019 Treatment Guidelines

A

preschool age:
* First-line: parent training in behavior management (PTBM)
* Second-line: PTBM plus FDA-approved medication
elementary and middle-school age:
* First-line: FDA-approved medication plus PTBM
adolescents (age12-18):
* First-line: FDA-approved medication, may offer PTBM

34
Q

AAP Medication Recommendations - preschool age

A
  • First-line: Methylphenidate
35
Q

AAP Medication Recommendations - Elementary/Middle School/Adolescents

A
  • First-line: Stimulants
  • Second-line: Atomoxetine, Guanfacine ER, Clonidine ER
36
Q

AAP Medication Recommendations - Adjunctive Treatment

A
  • Only guanfacine ER and clonidine ER have evidence as adjuncts to stimulants
37
Q

NICE: ADHD Guidelines 2018 for Adults

A

Methylphenidate (short- or long-acting) OR Lisdexamfetamine (if no response to one, switch to the other)
Dextroamphetamine (If unable to tolerate lisdexamfetamine long half-life)
Atomoxetine (if no symptom response to above agents)