Lecture IDK - ADHD Flashcards
DSM-5 ADHD Diagnostic criteria
Persistent pattern of inattention, or hyperactivity that clearly interferes with or reduces academic, social or occupational functioning
Must occur for > 6 months
Symptoms present before age 12 and in more than 1 setting
Must have > 6 symptoms of inattention or hyperactivity-impulsivity
Symptoms not manifestation of mood/anxiety disorder, personality disorder, substance into/withdrawal, etc
What changes for ADHD criteria at age 17?
> 5 criteria for inattention if develop after age 17
Inattention vs Hyperactivity
Inattention = fail to focus, hard to maintain attention, cant listen, follow instruction, finish schoolwork, etc
Hyperactivity = cant stop talking, sitting still, always on the go, interrupt, fidget
ADHD risk factors
Family HX of ADHD
perinatal stress
low birth weight
mom smoking during preg
TBI
severe early ox deprivation
adverse partent/child relationship
Genetics
DA/NE transporter gene
Twins 90% concordance n siblings too
Clinical Course + Comorbidities
onset during preschool years
diagnosis during school age
progress into adolescence
sleep & learning disorders, substance use disorder, psychiatric conditions, oppositional defiant disorder = dont listen to rules
pathophysiology ADHD
focused in Dopamine, dec dopamine in space
dysfunction with dopamine transporter
txm for ADHD
1st line = methylphenidate or amphetamine
2nd = atomoxetine
3rd = bupropion or TCA
Duration of ADHD treatment
if symptom free for 1 yr, need for med should be assessed
frequent attempt drug holidays when appropriate
Non-pharm ADHD therapy
family focused = 10-20 sessions, teach how to respond to actions
School focused = smaller classrooms other stuff
child focused = how to remove distractions n how to improve concentration
Methylphenidate MOA
CNS stimulant, inhibits reuptake of DA and NE
Methylphenidate PK
time to peak can be delayed by high-fat breakfast
Methylphenidate dosing
dont give within 6hrs of bed time
can use IR for breakthrough or wear off dosing along with LA dosages
concerta info
IR release Outer coat
semipermeable membrane that will control release of drug
Low conc released first then mid-day high conc drug is expelled
allows longer duration and limits abuse potential
Aptensio XR
combo of IR and ER
40% = IR, 60% = ER later in day
Methylphenidate CD Caveats
2 peaks in lvls
Ritalin LA Caveats
2 peaks in lvls
Quillivant XR Caveats
recon, shake before giving, store at room temp
** contains Benoni acid which is metabolite of benzyl alc; potential for allergic reaction**
Concerta Caveats
2 peaks, most likely find capsule in stool
Avoid w/ GI obstruction or narrowing
Daytrana Caveats
** apply to hip, leave for 9hrs, inflamed skin/heat inc absorption**
** caution switching oral to patch, patch higher bioavailability, lower 1st pass**
may cause severe allergic reaction n spread past patch site
recent warning patch labeling perm loss of skin color at app site
Focalin XR Caveats
2 peaks in lvls
Amphetamine MOA
stim release of DA n NE
Block DA/NE reuptake
Amphetamine PK
time to peak maybe delayed by his-fat breakfast
Lisdexamfetamine prodrug -> Dextroamphetamine
Amphetamine dosing
dont give within 6hrs of bed time
can use IR for breakthrough or wear off dosing along with LA dosages
All stimulant CI and Boxed warnings
Warnings = abuse potential + sudden cardiac death w/ pre-existing conditions
CI = Cardiovascular instability, hyperthyroidism, Glaucoma, Agitated States, H/x drug abuse, within 14 days of MAOI
All stimulant precautions
HTN/Tachycardia
Psychiatric ADE
Long term growth suppression = controverial
Seizures, stim lower threshold
Visual disturbances such as blurred vision
Tics, both motor n phonic
Stimulant ADE
Appetite suppression
Insomnia
GI distress
Irritability
Headache
How to manage Appetite suppression in stimulant patients
eat high calories breakfast n dinner
switch to non-stim
How to manage insomnia in stimulant patients
dec afternoon dose or switch to earlier timing
try melatonin or trazodone
change to non-stim
How to manage GI distress in stimulant patient
take med with food
switch to diff med
How to manage irritability in stimulant patient
reduce dose
switch to non-stim
How to manage Headache in stimulant patient
divide doses, lower dose, or give with food
NSAID or Tylenol
Switch to non-stim
Stimulant DDI
Psychostimulants = additive effects
Anti-HTN = less effected when used with stim
MAOI = inc BP n HTNsive crisis
TCAs = MPHA can inc TCA concentration = lethal
Antacid/PPI/H2RAs = can inc absorption and delay excretion MPHA/AMP
Opioids/Sympathomimetics = inc AMP conc
Stimulant Monitoring
BL+ each follow up = appetite, BP, HR, Weight
BL + annual for kids = height
Atomoxetine (Strattera) MOA
inhibit reupatke of NE
Atomoxetine PK
CYP2D6 poor metabolizers have inc 1/2 life from normal 5hrs up to 24hrs
Atomoxetine CI
within 14 days of MAOI, glaucoma, pheochromocytoma, CV disease
Atomoxetine Warnings
Black box for inc suicidality, bolded warning for potential liver injury
Atomoxetine Dosing
initial = 40mg
max dose = 100mg
frequency = QD, Q3 days if poor metaolizer
Duration = 24hrs
Common adverse effects Atomoxetine
GI discomfort, HA, insomnia, irritability, loss of appetite, nausea, small inc in BP
Give w/ food to avoid GI discomfort/nausea
take in morning to avoid insomnia
Atomoxetine DI
CYP2D6 inhib inc drug, so dec dose req
Clonidine XR (Kapvay) + Guanfacine Xr (Intuniv) MOA
postsynaptic alpha2 receptor agonist
promotes NE firing
Clonidine XR (Kapvay) + Guanfacine Xr (Intuniv) Onset
may see in 1st week, up to 2-4wks
Clonidine XR (Kapvay) + Guanfacine Xr (Intuniv) warnings
Hypotension, bradycardia, heart block, syncope, combo other CNS depressants or meds that lower HR
Clonidine XR (Kapvay) + Guanfacine Xr (Intuniv) ADE
sedation, hypotension, dizziness all at first dose
Clonidine XR (Kapvay) + Guanfacine Xr (Intuniv) DDI
Mirtazapine = inhibit antihypertensive effects
CYP3A4 = req dose reduction guanfacine
Clonidine XR (Kapvay) dosing
initial = 0.1
max = 0.4
BID
Guanfacine Xr (Intuniv) dosing
initial = 1mg
max = 4mg
QD
Stim in pregnancy
inc risk of premature death and low birth weight
stim should be avoided in pregnancy
newborn can have withdrawal
Stim in laktation
refrain from breastfeeding because excreted in milk
Stim in geriatrics
not widely studied so not recommended
