STIMULANTS

Question 1

treatment failure for ADHD is the result of what?

Answer 1

inappropriate drug management rather than inactivity of the drug

Question 2

do the serum drug levels correlate with the adequacy of response?

Answer 2

NO

Question 3

what are the four phases of management in treating ADHD?

Answer 3

1. counseling
2. titration
3. maintenance
4. Potential termination

Question 4

describe the counseling phase of adhd therapy?

Answer 4

1. explaining why pt needs meds and outlining the pros and cons
2. tell parents about behaviors to monitor, potential side effects and how to deal with them
3. advise that both dose and timing will change as treatment progresses; with adequate activity a move is made from short-acting to sustained release preparations

Question 5

how do you usually figure out which stimulant to use?

Answer 5

trial and error b/c there’s no real difference b/w the initial response of drugs

Question 6

what are the most common side effects of stimulants?

Answer 6

appetite suppresion
delayed sleep onset
wearing off phenomenon
tics
depression
social withdrawal

Question 7

what do you do if pt has intractable tics with stimulant therapy?

Answer 7

stop stimulant and consider adding or substituting another agent (like centrally acting alpha-agonist) with consult

Question 8

describe the maintenance phase of stimulant therapy

Answer 8

less doc visits
still need to see doc every so often for refills
monitor med effects and progress

Question 9

amphetamines MOA

Answer 9

releases DA & NE

Question 10

atomoxetine MOA

Answer 10

Selective NE reuptake inhibitor centrally & peripherally

Question 11

methylphenidate MOA

Answer 11

block reuptake of DA & NE

Question 12

guanfacine MOA (as a stimulant)

Answer 12

believed due to regulation of NE release from locus ceruleus

Question 13

clonidine MOA

Answer 13

shows improved prefrontal cortical function through post-synaptic alpha-2-receptor agonist effects in the PFC

Question 14

haloperidol MOA

Answer 14

blocks post-synaptic D2 receptors (typical high potency anti-psychotic)

Question 15

what is the clinical utility of short-acting amphetamines?

Answer 15

used as initial treatment in small kids

Question 16

what is the clinical utility for longer acting amphetamines?

Answer 16

more convenient
confidential
greater adherence
more problems with appetite and sleep

Question 17

describe the outcome of using drugs that alkalinize the urine (acetazolamide, NaBicarb) with amphetamine/dextroamphetamine

Answer 17

alkalinizing the urine favors reuptake of drug in renal tubules; increases the drug levels

Question 18

using ammonium chloride can have what outcome with amphetamine thereapy?

Answer 18

acidifies the urine favoring renal elimination; decreases the serum drug levels

Question 19

what is the outcome of using chlorpromazine/haloperidol with amphetamines?

Answer 19

dopamine receptor blockers diminish effects of amphetamines

Question 20

what is the outcome of using dextromethorphan with amphetamine?

Answer 20

increasingly impaired judgmement, erratic euphoria

Question 21

what is the outcome of using digoxin with amphetamines?

Answer 21

increasingly pro-arrhythmogenic

Question 22

what is the outcome of using MAOIs with amphetamines?

Answer 22

increases serum drug levels and toxicity

Question 23

which CYP enzyme can have an effect on amphetamines serum drug levels?

Answer 23

CYP2D6

Question 24

what are the more common adverse effects of amphetamine therapy?

Answer 24

abdominal pain
headache
insomnia
loss of appetite

Question 25

what is the effect of using albuterol with atomoxetine?

Answer 25

accentuates CV adverse effects

Question 26

what is the outcome of using epinephrine with atomoxetine?

Answer 26

further increases in BP

Question 27

what is the effect of using MAOIs with atomoxetine/methylphenidate?

Answer 27

increases toxicity; allow 2 week interval b/w drugs

Question 28

what is the effect of using alcohol with methylphenidate?

Answer 28

increase production of toxic metabolites--> functional inability to concentrate (drive)

Question 29

what is the outcome of using phenytoin with methylphenidate?

Answer 29

increases blood levels of phenytoin in some pts

Question 30

what is the outcome of using ergotamine/pseudoephedrine with atomoxetine/methylphenidate?

Answer 30

exacerbates pressor agent effect on BP

Question 31

which CYP enzyme can affect the serum drug levels of atomoxetine/methylphenidate?

Answer 31

CYP2D6

Question 32

what are some of the adverse effects of atomoxetine?

Answer 32

``` dry mouth headache abd. pain decrease appetite cough somnolence vomiting insomnia ```

Question 33

what are some of the adverse effects of methylphenidate?

Answer 33

``` headahce insomnia decreased appetite N/V abd. pain ```

Question 34

what are some of the absolute contraindications to stimulant use?

Answer 34

``` MAOIs psychosis glaucoma underlying cardiac conditions (mild increases in pulse and BP) existing liver disorders a hx of stimulant drug dependence ```

Question 35

what is the most common co-morbid condition encountered in people with tics and tourette syndrome?

Answer 35

ADHD

Question 36

what is the 1st choice therapy for pts with tics and ADHD?

Answer 36

alpha-2 agonists

Question 37

what is 2nd choice for pts with ADHD and tics/tourett'es?

Answer 37

stimulants have rapid activity against ADHD but no activity against tics

Question 38

what is 3rd choice for pts with ADHD and tics/tourette's?

Answer 38

methylphenidate + alpha-2 agonist combo

Question 39

which class of drugs has the greatest demonstrated effect of reducing tics in clinical trials?

Answer 39

antipsychotic agents (must base decision for treatment on risk/benefit analysis b/c of lost of adverse effects with antipsychotics)

Question 40

which class of drugs demonstrated similar or slightly larger benefit in reducing tics, but only among subjects with comorbid ADHD?

Answer 40

alpha-2 agonists

Question 41

what is the effect of using clonidine/guanfacine together with cyclosporine?

Answer 41

increased serum levels of interactant

Question 42

what is the outcome of using clonidine/guanfacine with buproprion?

Answer 42

grand mal seizures

Question 43

what cardiac adverse effect will you see if one of the metabolic pathways (CYP2D6/3A4, glucuronidation) for haloperidol metabolism is blocked and there are increased haloperidol concentrations?

Answer 43

QT prolongation

Question 44

what are some of the adverse effects of clonidine/guanfacine?

Answer 44

``` skin rxns (patch) dry mouth somnolence headache fatigue drowsiness dizziness anxiety abd. pain ```

Question 45

what are some of the clinical signs of amphetamine/methylphenidate toxicity?

Answer 45

``` mydriasis tremor agitation hyperreflexia combative behavior confusion hallucinations ```

Question 46

describe the management of amphetamine/methylphenidate toxicity?

Answer 46

supportive, w/ judicious use of BNZs

Question 47

describe the management of atomoxetine toxicity?

Answer 47

supportive, w/ focus on sedation and control of dyskinesias and seizures