Ott Pharmacotherapy of ADHD Flashcards
Who has a higher risk of developing ADHD?
If parent has ADHD, then child will likely have ADHD
Etiology of ADHD
Multifactorial (environmental, genetics, physiology)
Clinical course of ADHD
-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
Diagnostic criteria for ADHD
-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
-Several inattentive or hyperactive-impulse symptoms are present in two or more settings
How do you define inattention?
Six or more of the following symptoms persisting for at least 6 months; inconsistent with developmental level and negatively impacting daily function:
-Fails to give close attention to details, makes careless mistakes
-Difficulty sustaining attention in tasks or play activities
-Does not seem to listen when spoken to directly
-Does not follow through on instructions, fails to finish homework, chores, duties in the workplace
-Difficulties 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
How do you define hyperactivity and impulsivity?
Six or more of the following symptoms persisting for at least 6 months; inconsistent with developmental level and negatively impacting daily function:
-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
Non-pharmacologic treatment options for ADHD
-Behavioral therapy and psychosocial treatment
-Training interventions
What stimulants are used to treat ADHD?
-Amphetamine based
-Methylphenidate based
What non-stimulants are used to treat ADHD?
-Atomoxetine
-Viloxazine
-Clonidine ER (preferred)
-Guanfacine ER (preferred)
-Atypical antipsychotics
-Bupropion
-Imipramine
-Modafinil/armodafinil
-Mood stabilizers
How to dose stimulants
-Dose-response effects seen in a short period of time
-Calculating a dose for pediatric patients using mg/kg not found to be helpful
-IR preferred for patients weighing less than 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
-Do not use two different stimulants but can use two different dosage forms of the same stimulant
What is the age range for the use of Mydayis?
13-17
What is unique about Daytrana?
It is a methylphenidate patch
What is unique about Vyvanse?
It is a prodrug that is converted to dextroamphetamine
What is unique about Jornay PM?
Dose should be taken in the evening between 6:30 and 9:30 pm
Adverse effects associated with stimulants
-Appetite loss
-Abdominal pain
-Headaches
-Sleep disturbances
-Decreased growth
-Hallucinations or other psychotic symptoms
-Increased blood pressure (1 to 4 mmHg)
-Increased heart rate (1 to 2 bpm)
-Sudden cardiac death (rare)
-Priapism (prolonged erection that leads to necrosis)
-Peripheral vasculopathy (Raynaud’s)
How do you manage reduced appetite or weight loss when taking a stimulant?
High-calorie meal when stimulant effects are low (breakfast, dinner)
How do you manage stomach ache when taking a stimulant?
Give on full stomach, lower dose if possible
How do you manage insomnia when taking a stimulant?
Give dose earlier in the day, lower last dose of day or give earlier, consider sedating med at bedtime
How do you manage headache when taking a stimulant?
Divide dose, give with food, give analgesic
How do you manage rebound symptoms when taking a stimulant?
Longer-acting stimulant trial, atomoxetine, antidepressant
How do you manage irritability or jitteriness when taking a stimulant?
Assess for co-morbid condition, reduce dose, consider mood stabilizer or atypical antipsychotic
How do you manage hallucinations when taking a stimulant?
D/c stimulant, reassess diagnosis
How do you prevent sudden cardiac death when taking a stimulant?
Assess risk of cardiac structural abnormality and family history - if concern, cardiac ECHO
What to monitor in someone who is taking a stimulant?
-Appetite
-Behavior
-Blood pressure
-Growth rate
-Heart rate
-Sleep
-ECG may be considered based on cardiac risk
What alpha 2 agonists are used for ADHD?
-Guanfacine ER
-Clonidine ER
Guanfacine ER clinical pearls
3A4 substrate
What norepinephrine reuptake inhibitors are used for ADHD?
-Atomoxetine
-Viloxazine
Atomoxetine clinical pearls
-2D6 substrate
-Weight based dosing
Viloxazine clinical pearls
-Capsules - swallow whole or put in applesauce
-2D6/UGT substrate; strong 1A2 inhibitor
Adverse effects of norepinephrine reuptake inhibitors
-Increased HR and BP
-Increase in suicidal thinking (boxed warning)
Adverse effects of alpha 2 agonists
-Decreased HR and BP, orthostasis
-Somnolence
-Dizziness
-Rebound hypertension if abrupt discontinuation
Monitoring for non-stimulants
-Appetite
-Behavior
-Blood pressure
-Growth rate (atomoxetine)
-Heart rate
-LFTs (atomoxetine)
-Sleep
Bupropion clinical pearls
-Not FDA-approved for ADHD
-2D6 inhibitor
-Contraindicated in seizure disorders and eating disorders
Tricyclic antidepressant clinical pearls
-Less effective than methylphenidate
-Cardiac concerns - sudden cardiac death in children, lethal in overdose
Atypical antipsychotic clinical pearls
-May be useful if there is comorbid bipolar disorder, conduct disorder, intermittent explosive disorder
-Should not be used as monotherapy
AAP ADHD treatment guidelines for preschool aged patients
-First-line: parent training in behavior management
-Second-line: PTBM plus FDA-approved medication
AAP ADHD treatment guidelines for elementary and middle school aged patients
First-line: FDA-approved medication plus PTBM
AAP ADHD treatment guidelines for adolescents
First-line: FDA-approved medication, may offer PTBM
AAP ADHD medication recommendation for preschool age
First-line: methylphenidate
AAP ADHD medication recommendation for elementary/middle school/adolescents
-First-line: stimulants
-Second-line: atomoxetine, guanfacine ER, clonidine ER
AAP ADHD medication recommendation for adjunctive treatment
Only guanfacine ER and clonidine ER have evidence as adjuncts to stimulants
NICE: ADHD guidelines for adults
-Methylphenidate OR lisdexamfetamine (if no response to one, switch to the other)
-Dextroamphetamine (if unable to tolerate lisdexamfetamine half-life)
-Atomoxetine (if no symptom response to above agents)
