Stimulants Flashcards
amphetamine
Adzenys XR – ODT; Dyanavel XR; Eveko
Indication: ADHD (>6yo; Evekeo >3yo); narcolepsy (Evekeo); obesity (Evekeo)
Dose: Evekeo (ADHD): Start 5mg QAM, increase by 5mg/d in weekly increments (half this for children 3-6yo); MAX 40mg/d)
(Narcolepsy): Start 10mg QAM (5mg in <12yo); increase by 10mg in weekly increments, MAX=60mg/d
Adzenys: Start 6.3mg daily; increase by 3.1mg or 6.3mg in weekly increments; MAX=18.8mg (>12yo) and 12.5mg (6-12yo)
Dyanavel (suspension): Start 2.5-5mg QAM; increase in 2.5-10mg weekly increments; MAX=20mg/d
Monitoring: EKG; height/weight; Vitamin C use (Vitamin C acidifies urine and increased excretion of amphetamines – stop vitamin C instead of increasing dose!)
Mechanism: inhibits reuptake of dopamine and norepinephrine; racemic mixture
Advantages: racemic mixture has more potent forms
Disadvantages: more CV and tic effects; high price tag
ADEs: abdominal pain; decreased appetite; weight loss; insomnia; nervousness; EKG changes
atomoxetine (Strattera)
Indication: ADHD (>6yo)
Dose: Start 40mg QAM for 3d, then increase to 80mg QAM; may increase to 100mg after four weeks; <70kg: Start 0.5mg/kg for 3d, then increase to 1.2mg/kg may increase to 1.4mg/kg after four weeks (MAX=100mg or 1.4mg/kg, whichever is LESS)
Monitoring: LFTs
Mechanism: selective norepinephrine reuptake inhibitor
Advantages: non-controlled; less anxiety and tic development than stimulants; more effective with attention than hyperactivity
Disadvantages: less effective on average
ADEs: headaches; nausea; abdominal pain; decreased appetite; fatigue; dry mouth; constipation; erectile dysfunction; dizziness; urinary hesitation; SERIOUS: class warning for increased suicidal ideation in teens; increased hepatic enzymes (40x normal) and jaundice (12x upper limit of bilirubin); increased BP (15-20mmHg); increased HR (20bbm)
Off-Label: treatment-resistant depression
clonidine (Catapres; Kapvay)
Indication: hypertension; ADHD (6-17yo – not adults) as monotherapy or adjunctive
Dose: IR: Start at 0.1mg BID, increase by 0.1mg at weekly intervals; MAX = 2mg/d
ER (Kapvay): Start at 0.1mg QHS, increase by 0.1mg at weekly intervals; MAX = 0.4mg/d
Monitoring: BP monitoring (hold at <90/60)
Mechanism: centrally acting selective alpha-2 adrenergic agonist
Advantages: not controlled
Disadvantages: rebound hypertension if missed doses
ADEs: dry mouth; somnolence; dizziness; constipation; fatigue; headache; postural hypotension; syncope; hypotension
Off-Label: conduct disorder; Tourette’s; motor tics; developmental disorders; migraine prophylaxis; opioid withdrawal
Fun Facts: patches abused in prisons by inmates eating them to produce euphoria
ethylphenidate (Focalin; Focalin XR)
Indication: ADHD (>6yo; adult indication is for the XR form only)
Dose: IR: Start 5mg QAM, increase by 5mg/d in weekly increments; MAX 20mg/d
ER: Start 10mg QAM, increase by 10mg/d in weekly increments (half the dose for children); MAX 40mg/d (30mg/d in children)
Monitoring: EKG; height/weight
Mechanism: inhibits reuptake of dopamine and norepinephrine; d-isomer of methylphenidate which is why is it prescribed at half the dose
Advantages: potent form of methylphenidate
ADEs: decreased appetite; insomnia; anxiety; GI distress; irritability; tics; tachycardia; hypertension; dry mouth; EKG changes
Off-Label: narcolepsy; obesity; treatment-resistant depression
Fun Facts: a) beads cannot be split in half, but can be sprinkled over good; b) half the beads are immediate release beads and half are enteric coated; c) a single dose of XR is the same dosage as (2) IR tablets given (4) hours apart; d) XR 20mg~Ritalin LA 40mg
dextroamphetamine (Dexedrine)
Indication: ADHD (>3yo); narcolepsy (>6yo)
Dose: ADHD: Start 5mg QAM, increase by 5mg/d in weekly increments (half this for children 3-6yo); MAX 60mg/d (though doses >40mg rarely effective)
Narcolepsy: Start 10mg QAM (5mg in <12yo); increase by 10mg in weekly increments, MAX=60mg/d
Monitoring: EKG; height/weight; Vitamin C use (Vitamin C acidifies urine and increased excretion of amphetamines – stop vitamin C instead of increasing dose!)
Mechanism: inhibits reuptake of dopamine and norepinephrine
Advantages: potent isomer of amphetamine; age-limited as low as 3yo
ADEs: abdominal pain; anorexia; nausea; tics; insomnia; tachycardia; headache; EKG changes
Off-Label: obesity; treatment-resistant depression
Fun Facts: new form: Zenzedi; Dexys Midnight Runners’ (“Come on Eileen”) name is based on Dexedrine and the energy it provides
guanfacine (Intuniv; Tenex)
Indication: ADHD (6-17yo – not adults) as monotherapy or adjunctive
Dose: 27-40.5kg: Start at 0.5mg QHS; increase by 0.5mg/d in weekly intervals up to 1.5mg/d; may go up to 2mg/d after two weeks; MAX=2mg/d (or 3mg if up to 45kg
>45kg: Start at 1mg QHS; increase by 0.5mg/d in weekly intervals up to 3mg/d; may go up to 4mg/d after two weeks; MAX=4mg/d
ER: Start at 1mg QHS; increase by 1mg/d in weekly intervals up to 4mg/d; some adolescents have tolerated up to 7mg/d – DO NOT take with high-fat meal (increases medication exposure)
Monitoring: BP
Mechanism: centrally acting selective alpha-2 adrenergic agonist
Advantages: not controlled; less sedating than clonidine
Disadvantages: significantly delayed onset of action (4 weeks or more); rebound nervousness and hypertension
ADEs: dry mouth; somnolence; dizziness; constipation; fatigue; headache; postural hypotension; syncope; hypotension
Off-Label: conduct disorder; Tourette’s; motor tics; developmental disorders; migraine prophylaxis; opioid withdrawal; treatment of nightmares and dissociative events in PTSD
lisdexamfetamine (Vyvanse)
Indication: ADHD (>6yo); binge-eating disorder
Dose: Start 30mg QAM; increase by 10mg/d weekly to lowest effective dose (50mg usual in BED); MAX=70mg/d; TAKE ON EMPTY STOMACH; 70mg=30mg of Adderall
Monitoring: EKG; height/weight; Vitamin C use (Vitamin C acidifies urine and increased excretion of amphetamines – stop vitamin C instead of increasing dose!)
Mechanism: inhibits reuptake of dopamine and norepinephrine; is simply dextroamphetamine with lysine attached to make it inactive until cleaved in the duodenum
Advantages: lower risk of diversion
ADEs: headache; insomnia; anorexia; abdominal pain; irritability; agitation; tics; decreased appetite; increased heart rate; jitteriness; anxiety; EKG changes
Off-Label: narcolepsy; obesity; treatment-resistant depression (through trials for depression indication were very disappointing and indication abandoned)
methamphetamine (Desoxyn)
Indication: ADHD (>6yo); obesity (>12yo)
Dose: Start 5mg QD or BID; increase by 5mg/d weekly; MAX=20mg/d in divided doses
Monitoring: EKG; height/weight
Mechanism: inhibits reuptake of dopamine and norepinephrine
Disadvantages: pharmaceutical-grade meth (only 16k rx in 2012, mostly short-term for caloric restriction for obesity)
ADEs: anorexia; tachycardia; dizziness; insomnia; tremor; tics; restlessness; headache; decreased GI motility/constipation; dental complications (esp. with abuse: bruxism, caries); EKG changes
Fun Facts: methamphetamine is actually found naturally in acacia trees (in West Texas)
methylphenidate (Ritalin, Methylin)
Indication: ADHD (>6yo); narcolepsy
Dose: Start 5mg BID, increase by 10mg/d weekly; MAX = 60mg/d
(Child): Start at 0.3mg/kg BID, increase by 0.1mg/kg/dose Weekly;
MAX = 2mg/kg/d
Monitoring: EKG; height/weight
Mechanism: inhibits reuptake of dopamine and norepinephrine
ADEs: abdominal distress; anorexia; nausea; nervousness; tics (low incidence); insomnia; tachycardia; headache; affective lability; EKG changes
Off-Label: obesity; treatment-resistant depression
methylphenidate ER (Concerta)
Indication: ADHD (>6yo); narcolepsy
Dose: Start 18mg daily; increase by 18mg/d at weekly intervals; MAX=72mg/d
Monitoring: EKG; height/weight
Mechanism: inhibits reuptake of dopamine and norepinephrine; uses the OROS osmotic delivery system – 22% of the dose is IR (with onset in 1-2 hours) and the remainder is delayed release
ADEs: abdominal distress; anorexia; nausea; nervousness; tics (low incidence); insomnia; tachycardia; headache; affective lability; EKG changes
Off-Label: obesity; treatment-resistant depression
Dosing Equivalents: 18mg: 10-15mg/d; 36mg: 20-30mg/d; 54mg: 30-45mg/d; 72mg: 40-60mg/d (27mg dose for in-betweens)
methylphenidate ER
Ritalin LA; Metadate CD; Quillivant XR
Indication: ADHD (>6yo); narcolepsy
Dose: Start 20mg daily; increase by 20mg/d at weekly intervals; MAX=60mg/d
Monitoring: EKG; height/weight
Mechanism: inhibits reuptake of dopamine and norepinephrine; Ritalin LA is a combination of 50% IR & 50% DR beads, which mimics BID dosing of IR
ADEs: abdominal distress; anorexia; nausea; nervousness; tics (low incidence); insomnia; tachycardia; headache; affective lability; EKG changes
Off-Label: obesity; treatment-resistant depression
methylphenidate ER (Journay PM)
Indication: ADHD (>6yo); narcolepsy
Dose: Start 20mg in the evening; increase by 20mg/d; adjust time between 1830-2130; MAX=100mg/d
Monitoring: EKG; height/weight
Mechanism: inhibits reuptake of dopamine and norepinephrine
ADEs: abdominal distress; anorexia; nausea; nervousness; tics (low incidence); insomnia; tachycardia; headache; affective lability; EKG changes
Off-Label: obesity; treatment-resistant depression
methylphenidate transdermal (Daytrana)
Indication: ADHD (>6yo)
Dose: Start 10mg/patch, applied 2hrs before effect is needed and remove 9hrs after application; MAX=30mg/dose
Monitoring: EKG; height/weight
Mechanism: inhibits reuptake of dopamine and norepinephrine
ADEs: headache; insomnia; irritability; decreased appetite; anorexia; nausea; tics; application site reaction (10-40% incidence) to contact dermatitis; EKG changes
amphetamine salts (Adderall)
Indication: ADHD (>3yo for IR; >6yo for XR); narcolepsy
Dose: IR: Start 5mg BID; increase by 10mg/d in weekly increments (half for C&A); MAX=40mg/d
XR: Start 20mg QAM, increase by 10mg/d weekly (half in C&A); MAX=60mg/d (if converting from IR XR, use same daily dose)
Rule of Thumb: Start at 0.5mg/kg/d, target dose of 1.0-1.2 mg/mg/d
Monitoring: EKG; height/weight; Vitamin C use (Vitamin C acidifies urine and increased excretion of amphetamines – stop vitamin C instead of increasing dose!)
Mechanism: inhibits reuptake of dopamine and norepinephrine; dose contains mixture of dextro and levo isomers (75:25 ratio)
ADEs: insomnia; headache; decreased appetite; abdominal distress; anorexia; weight loss; agitation; EKG changes
Off-Label: obesity; treatment-resistant depression
