Pediatric Drug Dosing and ADHD Medication Lecture PDFs Flashcards
Most common neurobehavioral disorder of childhood, who is more often diagnosed? (males or females)
ADHD, boys more than girls
Some disorders mistaken for ADHD leading to increased diagnosis prevalence over the past years (4)
- opositional defiant disorder
- autism spectrum disorder
- intellectual disability
- anxiety and depression or bipolar
ADHD etiology (4) and what is it NOT due to?
- Unknown, multiple factors
- genetics
- perinatal stress
- maternal smoking and alcohol use
-NOT due to low intelligence, poor parenting, or too much dietary sugar
ADHD 3 hallmark symptoms
-inattention
-hyperactivity
-impulsivity
(subtypes domoinant in any of these or combined)
ADHD diagnosis (3)
- Clinical/DSM5 diagnosis
- info from parents
- Neuropsychiagric EEG based assessment aid (NEBA) can assist
Why is ADHD more often diagnosed in males than females?
Males are more likely to have the hyperactivity/impulsivity while females are more often inattentive type
Untreated ADHD that continues into adulthood increases risk of…
…poor psychological development, substance abuse, unstable relationships, and accidents
ADHD treatment principles (5)
- education for patient and caretaker
- plan for long term management
- identification of target outcomes
- medication and or behavior therapy
- followup
Behavior therapy for ADHD
1st line for treatment of preschool age children with ADHD and strongly recommended in all groups, attempts to alter physical and social environment so it is easier for child to control behavior (school intervention and getting involved in sports!)
Adult 1st line treatment for ADHD therapy
Amphetamines (greater effectiveness and equal tolerability compared to other ADHD meds over the short term) followed by regular followups to determine duration of therapy and re-evaluate
Stimulant use for ADHD mech of action
- Help remove the disruptive behavior by improving attention and focus, not creating posiitive behavior but rather reducing negative
- blockage of reuptake of NE and dopamine or inhibition of MAO depending on agent (different classes use diff mechanisms so lack of response in one class does not preclude response to another class)
Stimulant use for ADHD in children 3-5 years
Not recommended as may have deleterious effects on brain development
Stimulant dosing (3)
- Started low and titrated upward to lead to optimal effects with minimal side effects
- Extended release helpful for students in school
- drug holidays required at least once a year
Stimulant ADR’s (7)
- NVD
- Insomnia
- rebound inattention
- motor or vocal tics
- effects on growth maybe
- cardiotoxicity
- psychaitricc effects including psychosis and depression
Stimulant drug interactions (2)
- MAOI’s coconcurrently can result in hypertensive crisis
- SSRI concurrent use may increase risk of serotonin syndrome
Methylphenidate (ritalin, concerta) function
Most common stimulant drug employed and best tolerated for treatment of ADHD
Concerta uses a non deformable capsule which uses an oral osmotic controlled release delivery system. Why?
Cannot be crushed and snorted because onset is delayed and duration is 10-12 hours, this prevents abuse
Transdermal methylphenidate (daytrana) function
Same as methylphenidate oral but delay 2 hours making it diadvantage in the AM particularly when kids are getting ready for school
amphetamines (adenys) function
As effective as methylphenidate at treating symptoms of ADHD, some responnd better to this,
Dextroamphetamine and amphetamine salts (adderall) function
Comparable to methylphenidate but twice as potent, longer effect can lead to greater insomnia and appetite suppression
Atomxetine (strattera) function
Unique drug approved for ADHD treatment in adults in children, only drug approved for ADHD in adults, no potential for abuse and thus not controlled substance, slower long term changes (a week or more to onset)
Methyphenidate, amphetamine, dextroamphetamine and amphetamine salts ADR’s
- N/V/D
- sexual dysfunction in adults
- priapism rarely
Clonidine and guanfacine (catapres, tenex respectively) function
Central a2 agonist traditinonally useful for hypertension but also for behavioral management, tic disorders, or insomnia (and 2nd line for ADHD) with low risk of abuse potential
Clonidine and guanfacine ADR’s
- sedation
- dizziness
Buproprion (welbutrin) function
Monocyclic antidepressant, weak dopa and norepi reuptake inhibitor, can be used off label for treatment of ADHD in adolescents and adults, can reduce behavioral symtpoms although less effective than stimulants, but may be used in patients with depression and ADHD
Buproprion (welbutrin) ADR’s (4)
- eating disorder contraindication
- exacerbation of tics
- insomnia
- electrolyte disorders
Pediatrics and elderly respond to drugs differently because of…
…more sensitive due to organ system immaturity or degeneration, drug effects are usually more intense or prolonged in both as a result
Even when accounting for weight differences, infant response to drugs differs from adult seeing much higher…
….plasma drug conc
Absorption oral in children
-variable due to irregular gastric emptying as well as low acidity 24 hours after birth
Absorption IM in children
-slow and erratic, due to low blood flow thru muscle during first days of postnatal life, by early infancy, becomes more rapid than neonates and adults
Absorption percutaneous in children
-because skin at young age is thin, it is greater in infants than older children and adults increasing toxicity
Abosrption binding protein in children
-binding to albumin and other plasma proteins is limited in infant because of relatively low endogenous compounds, increasing plasma concentration
Drugs that can pass the BBB require special precaution in ___
infants - not fully developed at birth
Hepatic excretion in children
Decreased ability to metabolize many drugs at birth resulting in slow clearance rates and prolonged elimination half lives, at one year do metabolize certain drugs (depending on the enzyme that digests it) faster than adults until age of 2 then gradually declines
Renal excretion in children
Significantly reduced at birth, renal blood flow and glomerular filtration all low during infancy, must give drugs at reduced dosage, adult levels of functions achieved by 1 year. Sensitivity over age 1 is more like that of adults,
Age related drug ADR’s (3)
- growth suppression
- discoloration of developing teeth
- kernicterus
Pediatric dosing approximation when not available on package insert
Based on age, weight, and surface area
Pediatric dose should NEVER exceed…
…adult dose
