ADHD

Question 1

Patho

Answer 1

-dec total brain volume in prefrontal cortex, caudate nucleus, anterior cingulate gyrus, cerebellum
-reduced activity in prefrontal and anterior cingulate cortex (reversed w/ stimulants)
-lack of connectivity b/t the prefrontal cortex and precuneus causes lapses in attention and impulse control
-dec activation of the ventral striatum when anticipating reward
-default mode network over-activity (methylphenidate suppresses)

Question 2

Diagnosis

Answer 2

-must be before 12 yo
-significant impairment must be seen in >/= 2 setting (home, work, etc)
-evidence that symptoms interfere w/ or reduce the quality of social, academic or occupation functioning
-symptoms are not due to another psych disorder
-6 or more inattention sx or hyperactivity (impulsivity)
- >17 yo need at least 5 symptoms

Question 3

Dietary information

Answer 3

-Iron/zinc supplementation (no enough alone)
-Omega 3: may benefit some people, low SE, results not consistent
-additive free diets (useful in small numbers of children)
-sugar/artificial sweetener avoidance (proper balanced diet)

Question 4

Treatment (predominant ADHD)

Answer 4

-Methylphenidate or Amphetamine
-inadequate response: atomoxetine, viloxazine, guanfacine, clonidine, bupropion
-then combo therapy or TCA
-if patient has active sub abuse skip methylphenidate and amphetamine

Question 5

Treatment (predominant comorbidity)

Answer 5

-Bipolar always manage first bc inc risk of mania
-Tourettes: dopamine antagonist or alpha 2 agonist; then add stimulant or whatever wasn’t tried
-BPD: atypical APS, Li, or AED; then add stimulant, then add alternative mood stabilizer
-anxiety or depression: AD; then add stimulant; then alternative AD

Question 6

Stimulants

Answer 6

-Amphetamine more potent than MPH
-IR: lower cost, less insomnia, fewer growth related ADE, dose a lot during the day bc they have a shorter t1/2
ER: good for medication adherence, some pt require another dose in afternoon to make it through the end of the day
-AE: psychiatric, growth, cardiac, reduced appetite/weight, stomachache, insomnia, HA, rebound sx, irritability
-DDI: other psychostimulants, MAOIs, TCA, antacids, alcohol can cause dose dumping

Question 7

MPH ER chew

Answer 7

-good for children
-can be halved

Question 8

MPH CD

Answer 8

-30% IR and 70% ER beads
-can open and put on applesauce

Question 9

MPH LA

Answer 9

-50% IR and 50% ER beads
-can open and put on applesauce
-between for more severe morning sx compared to CD/MLR bc higher IR component so onset quicker

Question 10

MPH XR suspension

Answer 10

-requires vigorous shaking for at least 10 sec
-reconstituted by pharmacist (good for 4 months)

Question 11

MPH OROS

Answer 11

-special delivery system
-swallow whole do not crush/chew

Question 12

MPH MLR

Answer 12

better for rebound afternoon sx due to larger ER ratio

Question 13

MPH transdermal patch

Answer 13

-dose not equivalent to oral
-drug active for 3 more hrs after removal
-apply 2 hrs prior to desired onset
-may be worn up to 9 hrs
-tics occur more with patch
-BBW: chemical leukoderma and/or severe allergic contact sensitization

Question 14

Dex-MPH IR

Answer 14

-no greater benefit over MPH
-1/2 dose of MPH
-lower abuse potential

Question 15

Dex-MPH XR

Answer 15

-50% IR and 50% ER beads
-afternoon sx control not as good as OROS

Question 16

Jornay PM (MPH ER)

Answer 16

-1st layer: 10 hrs to dissolve; <5% MPH released
-2nd layer: dissolve throughout the day; 14 hrs to drug peak
-no more than 5% of total drug absorbed in first 10 hours
-administer b/t 6:30-9:30 pm
-starts working when patient wakes up
-if miss dose, skip and resume at next bedtime
-take consistently w or w/o food

Question 17

Mixed AMP-IR salts and Amphetamine sulfate-IR

Answer 17

approved in children at least 3 yo

Question 18

Mixed AMP-XR salts

Answer 18

-50% IR and 50% ER
-may be opened and sprinkled on applesauce

Question 19

AMP sulfate XR soln

Answer 19

dose conversion not 1:1 must retitrate

Question 20

Lisdexamfetamine

Answer 20

designed for less abuse potential

Question 21

Dyanavel XR (AMP soln)

Answer 21

-approved for at least 6 yo
-not 1:1 dose conversion
-SE: nose bleed, allergic rhinitis

Question 22

AMP XR-ODT/ER suspension (Adzenys)

Answer 22

-approved for at least 6 yo
-not 1:1
-food delays time to peak
-5 mg (adderall) = 3.1 mg (adzenys)

Question 23

Mydayis (mixed AMP salts XR)

Answer 23

• > /= 13 yo
  -Has XR, intermediate release, and IR (no potential for trough)

Question 24

AMP

Answer 24

-preferred stimulant in adults
-preferred for < 5 yo
-afternoon dose should not be given < 6 hrs before bedtime
-CI: CVD

Question 25

Norepinephrine reuptake inhibitors

Answer 25

-Atomoxetine, Viloxazine XR
-stimulants have greater efficacy than atomoxetine
-takes 6-8 weeks for full benefit
-behavior may worsen initially (atomoxetine)
-AE: not rec in heart problems, liver toxicity (BBW), BBW for new onset suicidality)
-DDI: APS, TCA, Paxil and Prozac inc atomox conc
-Viloxazine has a lot of DDI

Question 26

Alpha-adrenergic receptor agonists

Answer 26

-Clonidine XR, Guanfacine XR
-enhances working memory and executive functioning
-not as effective as stimulants for mono-therapy
-AE: sedation/dizziness, hypotension, constipation, heart block
-clonidine commonly added adjunct to stimulants
-XR should not be taken with high fat meal
-added on for AE management (insomnia)

Question 27

Bupropion

Answer 27

-not FDA approved
-found beneficial in adults with ADHD and depression
-AE: less appetite suppression and wt loss compared to stimulants, seizures
-should not be used to alc disorder or eating disorder

Question 28

TCA

Answer 28

-Imipramine, Dessipramine, Nortriptyline
-AE: sedation, constipation, heart block, weight gain, overdose toxicity, rapid heart beat

Question 29

Li, VPA, CBZ

Answer 29

-effective for: aggression, explosive behavior, impulsivity
-childhood onset bipolar disorder or combined ADHD-bipolar disorder

Question 30

APS

Answer 30

-chlorpromazine and haloperidol (hyperactivity, impulsivity, neg effects in learning, cog function and can cause EPS)
-SGA: risperidone, olanzapine, quetiapine, ziprasidone, abilify (severe aggression, risk of metabolic syndrome)