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Therapeutics P3 Fall > ADHD > Flashcards

ADHD Flashcards

1
Q

ADHD Patho

A

Reduced activity in prefrontal and anterior cingulate cortex -> stimulants

Default mode network over-activity -> methylphenidate

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2
Q

ADHD symptoms

A

Inattention
Hyperactivity
Impulsivity

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3
Q

ADHD diagnosis

A
  • sx onset before 12
  • significant impairment in at least 2 settings with documented symptoms
  • sx reduce quality of social, academic, or occupation functioning
  • sx are not due to another psychiatric/substance use disorder
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4
Q

DSM 5 inattention/hyperactivity (impulsivity)

A

children and adolescents (<17)
- 6 or more symptoms for at least 6 months

adolescents and adults (17 and up)
- at least 5 symptoms required

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5
Q

ADHD presentation (infancy)

A
  • irritability, fidgeting, crying
  • difficulty feeding
  • short periods of sleep/frequently interrupted sleep
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6
Q

ADHD presentation preschool (3-5)

A
  • excessive motor activity
  • intense temper tantrums
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7
Q

ADHD presentation school age (6-11)

A
  • difficulty academically
  • combined inattentive and hyperactive/impulsive
  • comorbid oppositional defiant disorder, conduct disorder, aggression (greater risk for SUD in adolescence)
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8
Q

ADHD presentation adolescents (12-18)

A
  • inattention and impulsivity > hyperactive
  • significant functional impairment
  • higher rates of delinquency, drug and alcohol use
  • speeding/MVA > in ADHD vs non-ADHD
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9
Q

ADHD presentation adults (>18)

A
  • inattention
  • cognitive deficits
  • impatient
  • greater risk of unemployment, unstable relationships, psychiatric hospitalization, incarceration
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10
Q

Non-pharm (preschool/school age)

A
  • parent/family education on ADHD
  • training on behavioral modification
  • behavioral classroom management (BCM)
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11
Q

Non-pharm (adolescent)

A
  • break up assignments into manageable segments
  • structured schedule
  • behavioral peer inventions (BPI)
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12
Q

Non-pharm Adolescent/Adult

A
  • ADHD specific CBT
  • Metacognitive therapy (2hr/wk x 12 weeks)
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13
Q

Use of Iron and Zinc Supplementation

A

enhances therapeutic benefit of stimulants
(only in youth with known deficiencies)

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14
Q

First line therapy for ADHD

A
  • Methylphenidate or Dexmethylphenidate
  • Dextroamphetamine or Mixed Amphetamine Salts
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15
Q

Second line ADHD treatment

A

Atomoxetine
Viloxazine
Guanfacine ER
Clonidine ER
Bupropion

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16
Q

ADHD third line treatment

A
  • combo therapy
  • TCA
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17
Q

Predominant Tourette’s + ADHD treatment

A

1st:
- dopamine antagonist
- alpha-2 agonist (guanfacine / clonidine)

(Some response)
- add stimulant, atomoxetine, or alpha-2 agonist

(Inadequate response)
- alternative dopamine antagonist or alpha-2 agonist

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18
Q

Predominant bipolar (and/or severe aggression) + ADHD treatment

A

TREAT BIPOLAR FIRST

1st: atypical antipsychotic, lithium, or anticonvulsant

(Some Response)
- add stimulant

(Inadequate response)
- alternative or additional mood stabilizer

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19
Q

Predominant depression/anxiety + ADHD treatment

A

1st: antidepressant

(Some response)
- add stimulant

(Inadequate response)
- alternative antidepressant

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20
Q

Stimulant MOA

A

Methylphenidate and Amphetamines

  • block dopamine and NE reuptake
  • amphetamines increase catecholamine release
  • inhibit monoamine oxidase
  • different stimulants work through different pathways -> lack of response to one class does not mean lack of response to another
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21
Q

Which is more potent: Methylphenidate or Amphetamines?

A

Amphetamines

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22
Q

Stimulants:
IR Formulation Pearls

A
  • Dose BID-TID (short T1/2)
  • Drug onset: 15-30 min
  • Duration: 2-6 hrs

Advantages:
- lower cost
- less insomnia
- fewer growth related ADE

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23
Q

Stimulants:
Long acting/ ER formulation pearls

A
  • once daily dosing
  • 8-12 hrs sx control

Advantages
- medication adherence

24
Q

Stimulants: ADE

A

Psychiatric
- psychosis/mania
- aggression
- severe anxiety/ anxiety attacks

Cardiac
- increased HR and BP
- increased risk for ED visits
- serious but generally negligible in patients without preexisting CVD conditions

Growth:
- 1cm/yr decrease over 1-3 yrs
- 3kg weight deficit in 1st year
- steadies out over time

25
Q

Stimulant DDIs

A

Caffeine, Modafanil, nicotine -> additive ADE
MAOI -> do not use within 14 days
TCA -> TCA concentrations inc w/ MPH
Antacids, PPI, H2RA -> increase absorption of MPH IR + decrease absorption MPH DR
Antacids -> dec excretion of AMP
PPI -> inc absorption of AMP
Acidic agents (fruit juice) -> dec absorption of AMP
CYP2D6 inhibitors -> inc exposure to AMP salts
Alcohol -> stimulant dumping

26
Q

Stimulant ADE Management: reduced appetite / weight loss

A

high calorie meals when stimulant effect is low (breakfast/bedtime)

cyproheptadine at bedtime

27
Q

Stimulant ADE Management: stomachache

A
  • take on full stomach
  • lower dose
28
Q

Stimulant ADE Management: Insomnia

A
  • give dose earlier in day
  • lower the last dose of the day
  • add sedating medication at bedtime (guanfacine, clonidine, melatonin, or cycloheptadiene)
29
Q

Stimulant ADE Management: Headache

A
  • divide dose
  • take with food
  • give an analgesic
30
Q

Stimulant ADE Management: Rebound Sx

A

long acting stimulant trial
Atomoxetine
Antidepressant

31
Q

Stimulant ADE Management: irritability/ jitters

A

assess for comorbid condition
reduce dose
consider mood stabilizer or atypical antipsychotic

32
Q

Stimulant ADE Management: dysphoria / euphoria

A
  • reduce dose
  • reassess diagnosis
  • consider alternative therapy
33
Q

Stimulant ADE Management: Zombie-like state

A
  • reduce dose
  • change stimulant medication
34
Q

Stimulant ADE Management: Tics

A
  • reduce dose
  • consider alternate med
35
Q

Stimulant ADE Management: HTN or pulse fluctuation

A
  • Reduce dose
  • Change medication
36
Q

Stimulant ADE Management: Hallucinations

A
  • DC stimulant
  • reassess diagnosis
  • mood stabilizer and / or antipsychotic
37
Q

MPH Formulation Onset : Duration

A

IR -> 20-60min : 3-6 hrs
ER -> 60-80min : 3-8 hrs
ER Chewable -> 60-120min : 10-12hrs
CD -> 20-60min : 6-8 hrs
LA -> 10-60min : 6-8 hrs
XR suspension -> 45min : 12hrs
OROS -> 30-60min : 10-12hrs
MLR -> 20-60min : 12hrs
MLR-02 -> 30-60min : 13hrs
XR-ODT -> 60min : 12hrs
PM -> >/=10hrs : 24-36hrs
Transdermal patch -> 60-120min : 11-12hrs

38
Q

Dex-MPH formulation onset : duration

A

IR -> 30min : 3-6 hrs
XR -> 30 min : 9-12hrs
Dex-MPH / Ser-Dex-MPH -> 2hrs : 10-12hrs

39
Q

Cotempla XR-ODT (MPH) pearls

A

do not push tablet through foil, peel back blister pack

dissolve on tongue; no liquid needed

40
Q

Jornay PM (MPH ER) pearls

A

Delexis drug delivery system -> multiple layer beads
- 1st layer: 10 hrs (< 5% MPH)
- 2nd layer: dissolves throughout the day: 14hrs to peak

evening dosing
not recommended to convert mg to mg from other MPH products

41
Q

MPH Pearls

A

preferred product in children/adolescents
time to peak concentration delayed by high fat meals
tics occur more often with transdermal patch
BBW for skin reaction with transdermal patch
- chemical leukoderma and/or severe allergic contact sensitization
caution in pats w/ glaucoma, tics, psychosis, and concurrent MAOI use
safe with epilepsy
Priapism reported after prolonged exposure, dose increases, or drug withdrawal

42
Q

Dyanavel XR (amphetamine ER solution)

A
  • approved >/= 6 yrs
  • dose conversion not 1:1 (re-titrate when switching)
  • ADE: epistaxis (nose bleeds), upper abdominal pain, allergic rhinitis
43
Q

Amphetamine XR-ODT / ER suspension (Adzenys)

A
  • approved >/= 6 years
  • dose conversion not 1:1
  • can be taken w/wo food
  • DO NOT CHEW ODT
44
Q

Mydayis (mixed single entity amphetamine salts ER)

A
  • > /= 13yo
  • onset: 1-2hrs
  • duration: 16 hrs
  • cannot convert mg to mg with other amphetamines
  • triple time release beads within capsule to reduce med wearing off
45
Q

AMP pearls

A
  • inc release of DA and NE into synapse
  • enhance release of NE in periphery
  • high fat meals delay time to peak
  • preferred stimulant in adults
  • IR doses should not be given < 6hrs before bed
  • IR formulation preferred <5 yo
  • CI with Hx of cardiovascular disease
46
Q

NE reuptake inhibitors: Agents

A

Atomoxetine (Strattera)
Viloxazine ER (Qulbree)

47
Q

NE reuptake inhibitors time to onset / peak

A

1-2 weeks to onset
4-8 weeks to peak
(with atomoxetine behavior may worsen initially)

48
Q

NE reuptake inhibitors ADE

A
  • Upset stomach
  • psychiatric effects
  • CV effects (QTc prolongation)
  • greater risk fatigue, sedation, and dizziness
  • liver toxicity (atomoxetine)
  • renal dose adjustment (viloxazine)
  • BBW: new-onset suicidality
49
Q

NE reuptake inhibitors DDI

A

do not use with other QTc prolonging meds (antipsychotics, TCAs)

Atomoxetine
- concentration inc with paroxetine & fluoxetine

Viloxazine
- antidepressants
- antipsychotics
- benzos
- buprenorphine, hydrocodone, methadone, oxycodone

50
Q

A- adrenergic agonists agents

A

Clonidine ER (Kapvay)
Guanfacine ER (Intuniv)

51
Q

Alpha adrenergic agonists pearls

A
  • inc blood flow to pre-frontal cortex -> enhances working memory and executive function
  • not as effective as stimulants for monotherapy
  • ADE: sedation/dizziness, hypotension, constipation, heart block
  • Clonidine commonly added as adjunct to stimulants
  • ER should not be taken with high fat meal
52
Q

Other treatment: Bupropion

A

Bupropion 50-300 mg/day
- weak DA and NE reuptake inhibitor
- found beneficial in adolescents with ADHD and depression
- ADE: appetite suppression/weight loss (less than stimulants) seizures

53
Q

Other treatment: TCAs

A

Imipramine 50-150mg/day
Desipramine 300mg/day
Nortriptyline 300 mg/day

  • up to 4 weeks to see max effects
  • ADE: sedation/dizziness, constipation, heart block, weight gain, overdose toxicity, rapid heart beat
54
Q

Other treatment: Lithium/Anticonvulsants

A

Li
Valproate
Carbamazepine

  • Effective for: aggression, explosive behavior, impulsivity
  • childhood onset bipolar disorder or combined ADHD-bipolar disorder
55
Q

Other treatments: Antipsychotics

A

Chlorpromazine & Haloperidol
- hyperactivity
- impulsivity
- negative effects on learning, cognitive function, and can cause extrapyramidal ADE

Second Gen: Risperidone, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole
- severe aggression (comorbid conduct or BPD)
- risk of metabolic syndrome

Therapeutics P3 Fall (21 decks)

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