Psych exam 2 Flashcards
1
Q
Mania
A
essential feature, abnormally elevated, expansive, or irritable mood
2
Q
DSM-V for bipolar disorder
A
3 or more present for at least 1 wk
inflated self esteem, decreased sleep, talkative
flight of ideas, distractibility, increased goal-directed activity, involvement with high risk/pleasure activities
3
Q
What is bipolar disorder
A
cyclic disorder with periods of euthymia between episodes
4
Q
What is hypomania
A
less severe mania present for shorter time periods (4 days)
5
Q
What is rapid cycling
A
more than 4 moods w/in 12 months timeframe
6
Q
What is bipolar 1
A
manic episodes
may be psychotic/delusional and require hospitalization
may have other mood episodes (hypomania, depressive)
7
Q
What is bipolar 2
A
recurrent major depressive episodes
hypomanic episodes (NO MANIA or psychosis)
dose not affect social/work
8
Q
What are acute mania treatments
A
mood stabilizers (lithium)
anticonvulsants (VPA, carbamazepine)
second gen antipsychotics
9
Q
First and second step for acute mania
A
1: lithium, divalproex, or SGA, or 2-drug combo
2: 2 or 3 drug combo
+: BZD prn for short-term adjunctive tx of agitation or insomnia
10
Q
What is lithium the first line tx for
A
acute mania, acute bipolar depression, and maintenance tx for bipolar 1 and 2 disorders
11
Q
Acute and Maintenance therapeutic level for lithium
A
0.6-1.2 acute
0.6-1.0 maintenance
12
Q
Time to steady state for drug level
A
3-5 days
may take 1-2 wk to see full effect of drug
combo with BZD or antipsychotics may be needed
13
Q
When to get lithium levels
A
5-7 days after initiation
need 2 consecutive therapeutic serum concentrations during acute phase, then monitor q3-6months
draw 12 hours after evening dose (just before morning dose)
14
Q
Lithium side effects early in therapy (dose dependent)
A
GI upset, nausea, diarrhea
fine hand tremor
polyuria/polydipsia
15
Q
Lithium side effects long-term (dose independent)
A
cognitive effects (memory, concentration, learning)
hypothyroidism
derm
wt gain
16
Q
Lithium cause polyuria/polydipsia
A
may decrease in intensity over time as kidneys compensate for this effect
mechanism: changes in the collecting tubules decrease sensitivity to ADH, leading to decreased concentrating ability and production of dilute urine
increases thirst
17
Q
Baseline monitoring for lithium
A
CBC w/ diff
TSH, T3, T4
Electrolytes
Specific gravity
BUN, SCr
EKG
wt/glucose
pregnancy test
18
Q
Risk factors for acute lithium toxicity
A
advanced age, renal insufficiency or fatigue, dehydration or malnutrition, insufficient drug monitoring, drug interactions that decrease lithium clearance
19
Q
Mild lithium toxic effects
A
1.0-1.5 mEq/L
tremor, slurred speech, lethargy, nausea, muscle weakness, decreased concentration
20
Q
Moderate lithium toxic effects
A
1.6-2.5 mEq/L
confusion, disorientation, drowsiness, restlessness, unsteady gait, coarse tremor, vomiting, dysarthria
21
Q
Severe lithium toxic effects
A
> 2.5 mEq/L
poor consciousness, delirium, ataxia, EPS, convulsions, impaired renal function, coma, death
22
Q
Management of acute lithium toxicity
A
disc lithium
disc drugs that decrease lithium concentration
decrease intestinal absorption using activated charcoal
IV fluids
23
Q
Hemodialysis for lithium toxicity
A
goal <1 mEq/L 6-8 hours post-dialysis
li levels >2.5 mEq/L + marked sx
li levels >4
li levels btw 2.5-4, pt asymptomatic but level not expected to be <0.6 at 36 hours
24
Q
Lithium drug interactions
A
NSAIDs, diuretics, ACE-I increase lithium levels
Sodium decreases lithium levels
25
Lithium in pregnancy
1st trimester associated with ebstein's anomaly (displacement of tricuspid valve)
use in later pregnancy associated w/ fetal cardiac arrythmias, hypoglycemia, thyroid fx
26
What to do if you use lithium in pregnancy
use minimum dose, close monitoring levels, glomerular fx, renal perfusion
do not use in first trimester
27
Distribution for lithium
not protein bound
Vd=0.7 L/kg
28
Lithium kinetics
not metabolized (no CYP interactions)
~25% of creatine clearance
li follows Na
29
Factors that increase and decrease clearance of Lithium
increase: acute mania, pregnancy, Na loading
decrease: dehydration, NSAID, ACE, thiazides
30
Anticonvulsants for bipolar
may start at lower doses
ADE: GI and CNS
best when combined with li or divalproex
31
VPA ade
increase LFT
elevated ammonia levels
32
Carbamazepine ade
hyponatremia
BBW: agranulocytosis, SJS
reserved for tx failure w/ li or valproate
33
Oxcarbazepine (3rd acute mania, 4th maintenance) ade
diplopia, hyponatremia
34
Lamotrigine used for
only for maintenance
not in acute mania
35
Maintenance of bipolar disorder tx
lithium, divalproex, lamtrigine, quetiapine
2nd: carbamazepine, paliperidone, asenapine
combo w/ lithium, divalproex
36
Bipolar depression vs Unipolar depression
Bi: hypersomnia, hyperphagia
Uni: insomnia, decreased appetite
37
Tx for bipolar depression
lithium, quetiapine
lurasidone
olanzapine/fluoxetine
lamtrigine, valproate
38
No antidepressant monotherapy in bipolar depression
adj antidepressants for acute bipolar depression
permissible if h/o positive response w/ antidepressant
avoid if >2 manic sx, psychomotor agitation, rapid cycling
39
Adj therapy for bipolar maintenance
permissible if depressive relapse after stopping antidepressant
40
Antidepressant monotherapy for acute bipolar depression
avoid in bipolar 1 disorder
avoid in bipolar 1 & 2 depression if >2 manic sx
41
Lithium MOA
block hydrolysis of inositol phosphate
inhibit 5-HT1A and 5-HT1B
enhance glutamate uptake
42
What is lithium indicated for
acute and chronic tx of bipolar
only approved drug for maintenance therapy
43
Reduction in renal Na+ reaborption results in what
dehydration concentrated blood levels
44
What is the only anticonvulsant used for acute mania
valproic acid
45
valproic acid MOA
inhibitor of GABA transaminase, prevents metabolism of GABA and blocks voltage-gated Na+ and T-type Ca2+ channels
46
What three anticonvulsants block voltage-gated Na+ channels
carbamazepine, lamotrigine, topiramate
47
Chronic medical conditions associated with anxiety disorders
arrythmias, HF, diabetes, thyroid, IBS, seizures, asthma, COPD, cancer, anemia
48
Meds/substances associated with anxiety symptoms
albuterol, antipsychotics, antidepressants, bupropion, caffeine, decongestants, illicit drugs, levothyroxine, steroids, stimulants
49
GAD DSM-5
unrealistic/worry lasting for at least 6 months
3 of the follwoing:
restlessness, fatigue, difficulty concentrating, irritability, sleep disturbances, muscle tension
50
Common physical complaints of GAD
lump in throat, irritable bowel, numbness, headahce
51
Treatment goals for GAD
reduce severity and duration of anxiety sx
improve overall conditioning
long term: remission w/ minimal anxiety sx, no fx impairment, and QOL
52
First line therapy for GAD
antidepressants (start at low doses to develop anxiety)
TCAs or imipramine second line
53
Second line therapy for GAD
BZD
buspirone (partial serotonin agonist, can not be taken PRN needs 4-6 wk to work)
54
What properties does BZD have
anxiolytic, anticonvulsant, muscle relaxant, sedative/hypnotic properites
55
BZD place in therapy for GAD
rapid anxiety relief
2-4 wk as adjunct agents until antidepressants work
56
ADE of BZD
sedation
cognitive impairment
problems with balance, coordination
delayed reaction times
hostility, anger
respiratory depression
57
BZD withdrawal
anxiety, insomnia, irritability, muscle aches, tremor, nausea, depression
rare: seizures, delirium, confusion, psychosis
58
BZD who is at risk for use
pt with active or history of alcohol or substance use disorders
misuse is rare
59
How to minimize risk of BZD abuse
length of tx
contracts: duration, directions for use, follow-up, not absolute contraindication
60
Third line for GAD
hydroxyzine (sedative effects, used prn)
quetiapine, pregabalin
61
Length of tx for anxiety
12 months
risk of relapse is common if disc early
62
Which short acting BZD has a metabolite
xanax
63
Which short acting BZD do not have a metabolite
oxazepam
lorazepam* (preferred)
temazepam
64
What long acting BZD have a metabolite
diazepam
clonazepam
chlordiazepoxide
65
What is panic disorder
recurrent or unexpected panic attacks
1 attack with 1 month of 1 of the following:
concern about another attack, worry about implication of attack, significant change in behavior
66
Classification of panic disorder
4 of the following develop within minutes:
depersonalization, derealization, fear of losing control
ab distress, nausea, chest pain, tachycardia, palpitations, chills, sweating...
67
People who have panic disorder have a higher risk of what
HTN, peptic ulcer disease, depression, alcohol abuse
68
General issues with panic disorder therapy
anxiety responds after the actual panic attack
last to respond to tx is agoraphobia
long-term results poor
69
First line for panic disorder
antidepressants
start low and go slow
70
Second line for panic disorder
switch to another SSRI or to venlafaxine
71
Third line for panic disorder
imipramine, venlafaxine, or another SSRI
72
What happens if there is no relief after 3rd line panic disorder
add BZD for rapid relief (clonazepam, alprazolam)
beta blocker or atypical antipsychotic
73
Acute phase length of tx for panic disorder
1-3 months
follow up q1-2wk then q2-4wk
response is a 40% decrease in rating scale score
74
Maintenance phase length of tx for panic disorder
12-24 months
if med is disc taper over 4-6 months
75
What are the 7 dimensions of panic disorder
frequency of attack, distress during attack, anticipatory anxiety, agoraphobic, fear/avoidance, impairment of work, impairment of social
-remission s defined by a score of ≤5
76
Symptoms of social anxiety disorder
blushing is main symptom
trembling, sweating, tachycardia, diarrhea
more prevalent but least recognized
77
What is social anxiety disorder
intense, irrational, persistent fear of being negatively evaluated r scrutinized while in a social situation
exposure to the feared situation leads to panic attack
78
social anxiety disorder DSM-5
last 6 or months, interferes with normal routine
-persistent fear of one or more social situation
-exposure to the feared situation provokes anxiety
-person recognizes that fear is unreasonable
-feared situations are avoided or else endured w/ intense anxiety and distress
79
First line for social anxiety disorder
antidepressants (not fluoxetine)
80
What happens if there is no response or partial response to first line social anxiety disorder
no: different SSRI, venlafaxine
partial: augmentation w/ buspirone or clonazepam
other options: phenelzine, quetiapine, gabapentin, pregabalin
81
What to use for performance anxiety
propranolol 10-80 mg
atenolol 25-100 mg
82
Acute phase length of tx for performance anxiety
4-12 wk
reduce sx, phobic avoidance, social anxiety
adequate trial: 8-12 wks
83
Continuation phase length of tx for performance anxiety
3-6 months
improve ability to participate in social activities and QOL
dose may be increased at 6-8 wk if only partial response
84
Duration of maintenance tx for performance anxiety
12 months
85
obsessive compulsive and related disorder
OCD
hoarding
hair pulling
body dysmorphic disorder
skin picking
86
High comorbidities of obsessive compulsive and related disorders
depression, eating disorders, phobias, tourettes
87
Etiologies for obsessive compulsive and related disorder
twins
tourettes
hypoxia at birth, breech birth
encephalitis, head injury
PANDAS
88
DSM-5 for obsessive compulsive and related disorder
severe enough to cause marked distress to be time consuming or cause significant impairment in social or occupational functioning
-obsessions, compulsions, chronic illness
89
What is a good response for obsessive compulsive and related disorder
≥25% reduction in score
90
First line for OCD
antidepressants
-SSRI dose may exceed those in depression
-concurrent psychotherapy reduces risk of relapse
91
3rd line and augmentation for OCD
3: clomipramine (after failure of 2 SSRIs +/- physchotherapy)
Augmentation: low doses of risperidone or aripiprazole
92
Length of tx for OCD
adequate trial 8-12 wk
maintenance tx: 1-2 yr for first episode, 2-4 severe relapses, lifelong tx
93
What is PTSD
exposure to traumatic event one witnessed, experiences, or was confronted w/ actual or threatened death, serious injury, sexual violence, or possible harm to self or others
94
DSM-5 criteria for PTSD
re-experience: memories, dreams, flashbacks (at least 1)
avoidant behavior: people, convo, place, thought, activity, feeling (at least 1)
negative alterations: anhedonia, estrangement from others, inability to recall important aspects of trauma, negative mood, negative beliefs of oneself (at least 2)
hyperarousal: insomnia, irritability, poor concentration, outbursts, flashbacks, startled (at least 2)
95
Symptoms for PTSD category must be present for how long
at least 1 month
acute: 1-3 months
chronic: >3 months
96
PTSD TRAUMA
T: traumatic event
R: re-experience
A: avoidance
U: unable to fx
M: month (at least)
A: arousal
97
First line therapy for PTSD
antidepressants (not for combat PTSD)
FDA indication: sertraline, paroxetine
98
Second and third line for PTSD
2: TCA (imipramine, amitriptyline), mirtazapine
3: MAO-I
99
Other drugs used in PTSD
prazosin (reduce nightmares, improve sleep)
augmentation: atypical antipsychotics (risperidone, olanzapine, quetiapine)
100
What drug are ineffective in PTSD
bupropion and BZD
101
Length of tx for PTSD acute and continuation phase
acute and continuation phase: 3-4 wk after exposure to event if no improvement of symptoms
3 months response is a good long-term outcome
6-12 weeks adequate trial
102
Length of tx for PTSD maintenance phase
12-24 moths
some have chronic symptoms and qill require life-long tx
103
Non-pharm options for anxiety
CBT (1st line in mild)
Exposure therapy (exposure to triggers in safe environment)
Relaxation Techniques (deep breathing, meditation)
104
Non-pharm management strategies of anxiety
sleep
stay active, exercise
good nutrition
avoid or limit alcohol and other substances
reduce caffeine intake
105
Digital health for anxiety
mind shift (CBT)
uses management strategies based on CBT
106
Pt education for antidepressants
time to respond 6-8 wk
length 1 yr to life-long
reason for starting low doses
tx are not addicting (BZD short-term)
access to written info and instructions essential
107
BZD MOA
modulate ongoing GABA activity
increase the frequency of channel opening
hyper polarization of neuronal membranes
108
BZD CNS effects enhanced when taken with other drugs
ethanol
barbiturates
antihistamines
109
BZD detoxification
beta blockers
treatment with antidepressants
flumazenil
110
hydroxyzine MOA
antihistamine
111
Buspirone MOA
partial 5-HT1A agonist and weak D2 mixed agonist/antagonist
112
What is insomnia
trouble falling and/or staying asleep
113
What is sleep apnea
partial or complete closure of upper airway during inspiration
signs: gasping, snoring, daytime sleepiness
114
Management and risk factors for sleep apnea
management: wt loss, surgery, CPAP
risk factors: obesity, FH, HTN
115
Type 1 vs Type 2 narcolepsy
1: with cataplexy
2: without cataplexy
116
Narcolepsy and treatment
excessive daytime sleepiness, cataplexy, hallucinations, sleep paralysis
tx: modafinil, armodafinil, stimulants, SSRI/SNRI, sodium oxybate
117
Risk factors for insomnia
increasing age, female, comorbid conditions, shift work
possibly unemployment, lower socioeconomic status
118
What causes insomnia
crossing time zones
blue light
stress
alcohol, smoking, or caffeine
heavy food
medicines
environmental factors
uncomfortable bed or pillow
119
Assessment for insomnia
primary complaint
pre sleep conditions
sleep wake patterns
120
Supporting information for insomnia
detailed psychiatric and med history
rating scales, questionnaires, sleep diaries
actigraphy and polysomnography
121
Insomnia classifications
primary (unidentifiable cause) vs comorbid (secondary to a condition)
episodic (<3 months) vs persistent (≥3 months)
recurrent (≥2 episodes within 1 year)
122
Digital Health for insomnia
Nox A1 PSG system
-fully wireless and portable polysomnography system that can be used in-lab and in ambulatory
easy hookup for pt comfort
123
What is the epworth sleepiness scale
assesses likelihood of falling asleep in a given situation
used in clinical practice and in clinical trials
124
DSM-5 criteria for insomnia
at least 1: difficulty initiating sleep, difficulty maintaining sleep, waking in the early morning and not being able to return to sleep
sx occur ≥3 nights per week and are present for ≥3 months
125
Cognitive behavioral therapy (CBT) for insomnia
1st line tx option
-combines behavioral and cognitive therapy components
goal: change faulty beliefs and unrealistic expectations about sleep
126
Sleep restriction therapy for insomnia
time someone spends in bed leads to negative beliefs
do not lay down, take a nap until next bedtime
goal: decrease time spent in bed; induces mild, temp sleep deprivation
if in bed for 20 minutes get up and move around
127
Sleep hygiene for insomnia
sleep in dark, quite place, avoid heavy meals before sleep, limit electronic devices at night, avoid caffeine
goal: change in lifestyle and environmental factors to improve sleep
128
Relaxation Training for insomnia
meditation, progressive muscle relaxation, imagery training
goal: reduce somatic tension, control thought patterns impairing sleep
129
Digital Health for insomnia
Breethe: sleep and meditation app
start your day, take a break, and go to sleep
130
NTs in sleep disorders
ACh, Histamine, Adenosine, NE, Serotonin, Melatonin
131
Falling asleep and the non-REM state: decrease in firing of many brainstem neurons, __________ firing in some cholinergic neurons
increased
132
What drug reverses BZD toxicity
flumazenil (its an antagonist at BZD binding sites)
-no direct effect on Cl- influx
133
ADE of BZD and other GABAA receptor modulators
anterograde amnesia
rebound insomnia/anxiety
interaction with ethanol
134
Zolpidem MOA
non-BZD that binds to BZD site on GABA receptors
-decreases REM sleep
135
Zaleplon, Eszopiclone MOA
non-BZD that binds to BZD site on GABA receptors
136
Ramelteon MOA
melatonin receptor agonists (suprachiasmatic nucleus)
-elevates prolactin levels
137
Barbiturates therapeutic uses
sedation, anesthesia, anti-seizure
138
What does chloral hydrate do to ethanol metabolism
enhances effects of ethanol
rapidly and effectively promotes sleep
139
What does orexins A and B do
elevate histamine levels
increase REM sleep
(aka hypocretin 1 and 2)
140
What do orexin antagonists do
increase sleep in rodents
abandoned
survorexant is a dual orexin receptor antagonist
141
What are the 4 different pharm categories for insomnia
orexin (promotes wakefulness) use suvorexant
melatonin (regulates circadian rhythm) use ramelteon
histamine (promotes wakefulness) use doxepin
GABA (promotes sleepiness) use BZD, or BZD-like agents
142
Hypersensitivity reactions for hypnotics
anaphylaxis and angioedema
143
Neuropsychiatric effects for hypnotics
worsening depression/suicidality
abnormal or bizarre behavior, hallucinations, decreased inhibition
144
Complex sleep related behaviors for hypnotics
occur when not fully awake
sleep driving, eating, intimacy, walking, phone calls
more common with short-acting agents, alcohol, high doses
145
What effects do BZDs have
hypnotic, amnestic, anxiolytic, myorelaxant, anticonvulsant effects
increase sleep time, reduce sleep latency and wakefulness after sleep onset
146
ADE of BZD
next-day sedation, anterograde amnesia, incoordination, falls
147
Caution for BZD
pt with substance use disorders or sleep apnea
148
Short intermediate acting BZD
triazolam (anterograde amnesia, paradoxical rxn)
estazolam (intermediate-acting)
temazepam (intermediate-acting)
149
Long acting BZD
quazepam
flurazepam
(both cause next day sedation)
150
Non-BZD receptor agonist MOA
bind to GABAa receptor, selective for alpha-1 subunit, results in amnestic and hypno-sedative effects
151
ADE of Non-BZD receptor agonist
next day sedation, anterograde amnesia, incoordination, falls
*less potential for rebound insomnia, tolerance, dependence than BZD
152
Caution for Non-BZD receptor agonists
pt with substance use disorder or sleep apnea
153
What Z-drug has sleep-onset and shortest acting agent
Zaleplon
154
What Z-drugs has onset and maintenance therapy
Zolpidem (ambien and ambien CR)
155
What Z-drug has middle-of-the-night therapy
zolpidem (intermezzo)
156
What Z-drug has onset and maintenance and longest acting agent
eszopiclone (lunesta)
157
Zolpidem FDA warning about dose
women should be on 5 mg
susceptible to effects, slower metabolism
cautions all patients taking CR product against driving next day
158
Eszopiclone FDA warning about dose
1 mg starting for all pts
all pts caution takine 3 mg against driving next day
159
Ramelteon FDA approved for and contraindication
sleep onset insomnia
CI: fluvoxamine
(MT1>MT2)
1: induces sleepiness, 2: regulates circadian rhythm
160
Ramelteon ADE
dizziness, fatigue, depression, neuroendocrine effects
161
Ramelteon onset of action
may take up to 3 wks of nightly use to start working
take 30 min before bed
162
Suvorexant MOA
blocks orexin A and B neuropeptides from binding to OX1R and OXR2 receptors
163
Suvorexant FDA approved for
sleep-onset and sleep-maintenance insomnia
164
Suvorexant onset of action
within 30 min
peak concentrations at 2 hours
165
Suvorexant CI
narcolepsy: avoid with strong CYP3A4 inhibitors
166
Suvorexant ADE
sleep paralysis, hallucinations, cataplexy
167
Doxepin FDA approved for
H1 TCA receptor antagonist
for sleep maintenance insomnia
168
Amitriptyline for insomnia should not be used in what patients
not for only insomnia due to side effects
-can benefit pts with chronic neuropathic pain
169
Trazodone for insomnia
beneficial for short-term use to reduce number of nighttime awakenings and improve quality of sleep
170
Trazodone ADE
sedation, orthostatic hypotension, next-day sedation, priapism
171
Mirtazapine for insomnia
alpha-2 receptor antaonist, also H1
ADE: sedation, appetiti stimulation, wt gain
lower doses = more sedating
172
Quetiapine for insomnia
consider only in pts with primary antipsychotic effect
cause wt gain, EPS, diabetes, QT prolongation
173
OTC for insomnia
Benadryl: avoid in elderly secondary to high anticholinergic activity, tolerance w/in 1-2 wks of use
Doxylamine: mainly seen in pregnancy
Melatonin
174
Herbal Meds for insomnia
Valerian root: cause severe hepatic effects
Kava Kava: cause hepatoxicity
175
Patient Education for insomnia drug
take if going to sleep 7-8 hours
avoid alcohol
food delay onset of action
176
Duration of therapy for insomnia drugs
6-12 months
should be disc after 4-5 wks
177
What are the "LOT" drugs used for
Lorazepam, oxazepam, temazepam for elderly
178
Drugs that treat ADHD/ADD work by _____________ the concentrations of __________
increasing
dopamine
179
Psychostimulants increase the availability of ______________ in the synaptic cleft
catecholamines
180
Amphetamine MOA
competitive reuptake inhibition w/ dopamine
helps movement of DA out of vesicles
help DAT of DA into the synaptic cleft
181
Methylphenidate MOA
dopamine reuptake inhibitor (DAT blocker)
182
Risk factors for ADHD
genetics, structural brain differences, pregnancy, environmental factors, psychosocial factors
183
American Peds Guidelines for ADHD
4-18 yo w/ any academic or behavioral problems or symptoms of inattention, hyperactivity, impulsivity should be screened
diagnosis can be made at 4-5 yo
must come from more than 1 major setting
184
DSM-V for ADHD
children: 6 sx present for 6 months
≥17: only 5 sx
sx present before 12 yo
significant impairment must be seen in 2 or more settings (social, academic, occupational)
185
What age of people are most cases of ADHD diagnosed
6-11
186
Features of 12-18 yo ADHD
moody, easily overwhelmed, decision making impaired, drug and alcohol use, speeding and motor accidents
187
Features of adults ADHD
inattentive symptoms most common
higher risk for unstable relationships, unemployment
188
Comorbid conditions of ADHD
ODD, depression, conduct disorder, learning disabilities, autism, mood disorders, anxiety, tics
189
Sleep disturbances associated with ADHD
insomnia, sleep apnea, restless leg syndrome
190
Secondary complications of ADHD
poor academic performance, socially unpopular, low self-esteem, resentment, injury, substance use
191
Therapeutic Objetives for ADHD
improve relationships, decrease disruptive behaviors, improve academic performance, increase independence in self-care, improve self-esteem, enhance safety, minimize risks of tx
192
Non-pharm for ADHD
feingold diet, refined sugar restriction, diet deficiencies
(not proven to work)
193
Behavioral therapy for ADHD
does not work better than drugs
194
Guidelines for ADHD tx based on age
4-5 yo: behavioral therapy
≥6 FDA approved meds for ADHD
195
Stimulants use in ADHD
DOC
try up to 3 stimulants
failure: consider coexisting disorder, re-eval diagnosis
196
Parental concerns to use of stimulants
stigma of use
decrease intelligence and spontaneity
slow growth
fear of substance use
legal restrictions
197
What do stimulants improve
attention and ability to learn, academics, peer interactions, normalize behavior, self-esteem, self-control
198
Stimulant dosing guidelines
not wt based
IR after meals, ER on empty stomach
give last dose before 4 pm
199
Monitoring for stimulants
wk or biwk phone call follow up
face-to-face at one month
monthly until response, then q3months in first yr
once stable, twice a year
200
Methylphenidate and d-amphetamine MOA
stimulate release of dopamine from presynapic dopamine terminals
block DA transporter
block NE transporter
201
I-amphetamine MOA
stimulate release of dopamine and NE
202
Ritalin, Methyline duration
tablets, 3-5 hours
203
Metadate ER and Methyline ER duration
6-8 hours, tablets
204
Ritalin LA and Metadate CD duration
capsules, 8-10 hours
205
Concerta duration
OROS: oral release osmotic system, immediate and sustained release
12 hours
206
What product of methylphenidate can you take at night
jornay
207
What product of methylphenidate is a suspension or powder for reconstitution
quillivant (ER methylphenidate suspension)
208
What product of methylphenidate is transdermal
daytrana (worn for 9 hours)
209
Duration of action for focalin and focalin XR (dexmethylphenidate)
normal: tablet 4-5 hours
XR: 8-12 hours
210
Duration of actions for dextrostat and dexedrine spansules (dexmethylphenidate)
dextrostat: solution, 4-5 hours
dexedrin espansules: capsules, 6-8 hours
211
Adderall and Adderall XR duration
normal: 4-6 hours
XR: 10-12 hours
212
Vyvanse duration of action
10-12 hours (may be 14)
has to get metabolized in gut (can't snort)
213
Safety issues with stimulants
high abuse potential
increased CV events
214
Disease related concerns with stimulants
uncontrolled HTN, CV disease, hyperthroidism, agitation, glaucoma, h/o drug abuse
must have 14 d wash out with MAOIs
215
Stimulant ADE
appetite loss/anorexia
insomnia
nervousness/anxiety
GI sx
216
Stimulant monitoring parameters
wt, ht, sleep, tics, BP, pulse, CBC, platelets, CNS, EKG, vision, liver function
217
Drug interactions with stimulants
MAOI, vasopressors (increase BP)
methylphenidate mat inhibit metabolism of phenobarbital, TCA, SSRIs
218
Atomoxetine for ADHD
inhibit presynaptic NE inhibitor
duration 10-12 hours
take 4 wks for effect
219
ADE of atomoxetine
vomiting (take w/ food or bid)
insomnia (give AM)
dizziness (give PM or split dose)
suicide risk
220
Violxazine (qelbree) for ADHD
less potent inhibitor of NE transporter, increase 5-HT
improvement at 1 wk therapy
goos for depression and anxiety
221
ADE of Violxazine (qelbree)
somnolence, decreased appetite, nausea/vomiting, insomnia, irritability, suicide risk
222
Clonidine place in therapy for ADHD
monotherapy or adjunct tx for children with tics or who respond poorly to stimulants
223
Clonidine ADE
sedation, dizziness, orthostasis, headache, constipation
224
Guanfacine MOA
decrease transmission of NE across synapse via pre and post synaptic alpha 2 activity
225
Guanfacine place in therapy for ADHD
monotherapy or adjunctive therapy to stimulants
226
Guanfacine ADE
sedation, dizziness, hypotension
