Pharmacotherapy of ADHD Flashcards
overview of ADHD
Higher rate if diagnosed in a first-degree relative
Etiology is multifactorial (environmental, genetics, physiological)
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
ADHD diagnostic criteria
For each symptom domain, must have at least 6 symptoms present and present in two or more settings
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 and present in two or more settings
Inattention
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
Hyperactivity and impulsivity
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
Non-stimulants
Atomoxetine
Viloxazine
Clonidine ER (preferred non-stimulant agent)
Guanfacine ER (preferred non-stimulant agent)
Atypical antipsychotics
Bupropion
Imipramine
Modafinil/Armodafinil
Mood stabilizers
stimulants
Amphetamine or methylphenidate
stimulant dosing
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 stimulant
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
Mydayis (mixed amphetamine salts) special considerations
age 13-17 do not give to children under 12
Daytrana (methylphenidate) special considerations
patch
Vyvanse (lisdexamfetamine)
Prodrug,converted to dextroamphetamine
Jornay PM (methylphenidate hydrochloride)
Take dose in the evening between 6:30 pm and 9:30
Stimulant Adverse Effects
Appetite loss
Sleep disturbances
Decreased growth
Increased blood pressure
Increased heart rate
Stimulants: Common Adverse Effects and Management
Reduced appetite, weight loss:High-calorie meal when stimulant effects are low (breakfast, dinner)
Insomnia: dose earlier in day, lower last dose of day or give earlier, consider sedating med at bedtime
Rebound symptoms: Longer-acting stimulant trial, atomoxetine, antidepressant
Stimulants:
Uncommon
Adverse
Effects and
Management
↑ BP or HR: reduce dose change stimulant
Hallucinations:d/c stimulant, reassess diagnosis
Risk for sudden cardiac death:Risk no greater in clinical trials than general population assess risk of cardiac structural abnormality and family history – if concern, cardiac ECHO
stimulant monitoring
Appetite, Behavior,blood pressure Growth rate (height/weight), Heart rate Sleep
ECG may be considered based on cardiac risk
Alpha 2 agonists
good for hyperactivity sedating
guanfacine ER: 3A4 substrate
clonidine ER
Must be tapered if discontinued to avoid rebound hypertension
Norepinephrine reuptake inhibitors
Atomoxetine 2D6 substrate Weight-based dosing
Viloxazine:Capsules – swallow whole or put in applesauce 2D6/UGT substrate; strong 1A2 inhibitor
Non-stimulant AE
Atomoxetine & Viloxazine:Increased HR and BP, Increase in suicidal thinking (boxed warning)
Clonidine & Guanfacine: Decreased HR and BP, orthostasis, Somnolence, Dizziness, Rebound hypertension if abrupt discontinuation
monitoring for non stimulants
Appetite,Blood pressure Heart rate, LFTs (atomoxetine)
Bupropion
Not FDA-approved for ADHD
2D6 inhibitor
Contraindicated in seizure disorders and eating disorders
TCAs
Less effective than methylphenidate
Cardiac concerns – sudden cardiac death in children, lethal in overdose
Mood Stabilizers Atypical Antipsychotics
May be useful if there is comorbid bipolar disorder, conduct disorder,
intermittent explosive disorder,Should not use atypical antipsychotics as monotherapy
American Academy of Pediatrics (AAP) ADHD 2019 Treatment Guidelines
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 (age 12 – 18)
First-line: FDA-approved medication, may offer PTBM
AAP Medication Recommendations
Preschool age: First-line: Methylphenidate
Elementary/Middle School/Adolescents:
First-line: Stimulants
Second-line: Atomoxetine, Guanfacine ER, Clonidine ER
Adjunctive Treatment: Only guanfacine ER and clonidine ER have evidence as adjuncts to stimulants
