Flashcards in ADHD Deck (59):
What is ADHD?
- manifests in childhood w/ sxs of hyperactivity, impulsivity, and/or inattention
- sxs affect cognitive, academic, behavioral, emotional and social fxning
Prevalence of ADHD?
- in school aged kids: 8-10%
one of the most common disorders of childhood
- male to female ratio:
4:1 for predom. hyperactive
2:1 for predom inattentive
What other psych disorders is ADHD frequently assoc with?
- oppositional defiant disorder
- conduct disorder
- anxiety disorder
- learning disabilities
Neuropathogenesis of ADHD?
- fxnl brain imaging reveals decreased activation in areas of basal ganglion and anterior frontal lobe
- major neurotransmitters involved in ADHD are dopamine and NE
Fxn of dopamine?
- most of dopamine sensitive neurons are located in the frontal lobe
- dopamine system is assoc with:
reward, attention, short term memory tasks, planning and motivation
- dopamine limits and selects sensory information arriving from the thalamus to the forebrain
Fxn of the frontal lobe?
- ability to project future consequences resulting from current actions
- choice b/t good and bad actions (or better and best)
- override and suppression of socially unacceptable responses
- the determination of similarities and differences b/t things or events
How does ADHD affect the fxn of the brain?
- decreased activation in the areas of the basal ganglion and anterior frontal lobe
- increase in dopamine transporter activity thus clearing dopamine from the synapse too quickly
- the dopamine imbalance allows an inappropriate increase in NE activity
The mechanism of ADHD tx wtih methylphenidate?
- increases extracellular dopamine in the brain
- changes the areas of fxn in the frontal lobe
- in pts w/o ADHD mehylphenidate doesn't have same effect on frontal lobe fxn
What is the DSM V criteria for ADHD?
- need 6 or more sxs of inattention or hyperactivity/impulsivity, 5 or more for age 17 and older
- sxs inappropriate for any given age
- negatively impacts social and academic or occupational activities
- sxs developed prior to age 12
- sxs present in 2 or more settings
- sxs present for at least 6 months
- sxs are not better explained by other psychiatric disorders
What are the inattentive sxs for ADHD?
- failure to give close attention to detail
- difficulty sustaining attention in task
- failure to listen when spoken to directly
- failure to follow directions
- difficulty organizing tasks and activities
- reluctance to engaage in tasks that reqr sustained mental effort
- loses things necessary for tasks or activities
- easy distractibility
- forgetfulness in daily activities
What are the impulsive-hyperactive sxs of ADHD?
- fidgetiness w/ hands and feet or squirms in seat
- difficulty remaining seated in class
- excessive running or climbing in inappropriate situations
- diff. in engaging in quiet activities
- is often on the go or acts as if driven by a motor
- often talks excessively
- excessive talking and blurting out answers b/f questions have been completed
- difficulty awaiting turns (while waiting in line)
- interrupting and intruding on others
Medical eval of pt with suspected ADHD?
- parents and teacher need to fill out a form such as the Vanderbilt form
- refer for vision and hearing tests
- complete Hx, ROS, and PE to rule out other causes and psychiatric illnesses
- if hx suggests may consider the following testing:
blood lead level
neuro consult if concern for seizures or other neuro disorder
dx and tx of ADHD in adults?
- dx should be made by mental health professional
- sxs often continue into adulthood and can have significant effects on social and occupational fxning
- same meds used for adults as for kids
What methods of tx are used in ADHD?
- stimulants (ritalin, adderall, and concerta) are the TOC
- behavioral therapy tx: hasn't been show to reduce sxs in absence of concurrent stimulant rx (in conjuction with rx - shown to be helpful)
- other alt. such as cognitive tx, dietary modification, and mutlivitamins haven't been shown to be effective in controlled studies
What is the criteria for initiation of pharm therapy for ADHD?
- complete dx assessment that confirms ADHD
- 6 or older
- parental consent
- school is cooperative (if dosing during school hours)
- no previous sensitivity to the chosen med
- normal HR and BP
- no hx of seizure disorder (if so refer to neuro to tx ADHD too)
- doesn't have tourette syndrome, autism spectrum disorder, or substance abuse among household members
Before starting stimulant therapy what should be done?
- comprehensive medical eval - no hx of seizure disorder, tourettes, autism spectrum
- EKG (rule out arrhythmia)
- document pretx ht, wt, BP, HR
- document presence of any of the following sxs prior to tx: general appetite, sleep pattern, HAs, and abdominal pain
- assess for substance use or abuse: need tx b/f starting ADHD meds
What should be included in the pt's pretx education?
- tell pt that meds are beign prescribed to help with self control and ability to focus
- benefits and potential risks:
emphasize uncertainty about causal assoc b/t serious CV risks to include sudden unexpected death and stimulants for kids with cardiac sxs or positive family hx of heart disease
- other potential risks: anorexia, insomnia, tics, priapism with methylphenidate or atomoxetine
- the f/u protocol that is expected
-pt specific tx goals
TOC in ADHD?
- depends on what pt and parents agree on
- stimulants are first line agent:
- atomoxetine (strattera) is an alt. (non-stimulant) - use if hx of substance abuse in family
What are general considerations that may affect med choice in ADHD?
- daily duration of coverage needed - completion of homework or driving after school?
- ability of child to swallow pills or capsules
- time of day when target sxs occur
- desire to avoid admin at school
- coexisting tic disorder (avoid stimulants)
- coexisting emotional or behavioral condition
- potential adverse effects
- hx of substance abuse in pt or household member (avoid stimulants)
- expense (short acting are least expensive)
What are the pros of pharm therapy for ADHD?
- stimulants have long record of safety and efficacy
- at least 80% of school age kids and adolescents will respond to stimulant med
core sxs of ADHD
parent child interactions
academic productivity and accuracy
What are the cons of pharm therapy for ADHD?
- insufficient data to judge affect on long term academic performance
- ADHD sxs tend to improve over time regardless of tx modality
- doesn't significantly affect:
reduced social skills
How do you choose b/t stimulants?
- providers preference and comfort level
- pt and parent preference: after discussion of meds
Tx preschool kids?
- this age group needs referral to behavioral health specialist
What are the drug classes used in tx of ADHD?
1. stimulants (schedule II controlled substance):
first line therapy
amphetamines: detroamphetamine and detroamphetamine-amphetamine
3. alpha-2-adrenergic agonists (refer for these)
4. Antidepressants: TCAs, bupropion
What are the short acting stimulants - methylphenidate?
ritalin and methylin are short acting formulations
- tablet, chewable tab or liquid
- time to onset of action ranges from 20-60 min
- duration of action: 3-5 hrs
- half life is 2-3 hrs
What are the long acting stimulants -methylphenidate?
single pulse: metadate ER, methylin ER and ritalin SR
onset of action 20-60 min, duration: 8 hrs
- sustained release capsules: focalin XR
(dexmethylphenidate), metadate CD, ritalin LA:
- onset of action 20-60 min, duration: 9 hrs except for focalin XR duration is 12 hrs
- contain a mix of immediate release and enteric coated delayed release beads
- approximates BID dosing of short acting
- osmotic release: concerta - immediate release on outside then uses osmotic pump to slowly release med
- approximates TID dosing of short acting formula, onset of action 20-60 min, duration of action 12 hrs
- oral suspension: quillivan XR: onset of action: 60 min, duration: 12 hrs
- transdermal: daytrana - onset of action 60 min, duration 12 hrs, effects last 3 hrs post removal of the patch
Short acting stimulants - amphetamines?
- detroamphetamine: dexedrine, dextrostat, procenta (oral) - onset: 20 min, duration 4-6 hrs
- amphetamine - dextroamphetamine: adderall, Onset: 20 min, duration: 4-6 hrs
What are long acting stimulants - amphetamines?
- lisdexamfetamine (vyvanase): prodrug of dextroamphetamine, pharm. activated after oral ingestion, designed to discourage drug misuse, onset: 1 hr, duration: 10-12 hrs
- dextroamphetamine SR (dexedrine spansule): combo of immediate and continuous release meds, onset: 20 minutes, duration: 6-8 hrs
- amphetamine-dextroamphetamine (adderall XR): combo of immediate and continuous release meds, onset: 20 min, duration: 8-10 hrs
this is most commonly rx, well tolerated
What is first line therapy in ADHD tx?
- methylphenidate, dexmethylphenidate, and amphetamines are equally effective
- have similar side effect profiles
- short acting agents: initial rx in kids younger than 6, or can be used to determine optimal dosing b/f switching to longer acting agent
- longer acting prep: may be used initially in ages over 6, starting at lowest dose and titrating up
Nonstimulant meds used fo ADHD tx?
- second line: atomoxetine (strattera)
- third line:
alpha-2-adrenergic agonists - clonidine (catapres), guanfacine (tenex)
- antidepressants: imipramine (tofranil), desipramine (norpramin)
- bupropion (wellbutrin)
How long may it take b/f effects of strattera are noted?
- 1-2 wks
* pop. in younger kids since it is a non-stimulant
- dosing by wt (older than 6)
How do you monitor the response to therapy and assess for SEs?
- assess weekly during titration stage (can last 1-3 months)
- monitored behavior through parent and teacher feedback
- after titration stage pts seen monthly to monitor wt, HR, BP until stable dose w/o new SEs
- optimal dose is where there are favorable outcomes with minimal side effects
- ?s to ask: when does side effect occur in relation to admin? Is effect related to coexisting disorder or enviro stressor?
- mild adverse effects may resolve w/ time or adjusting any of the following:
time of administration
formulation of med
What side effects should you eval for at every visit?
- decreased appetite
- poor growth
- mood lability
- diversion and misuse
How do you manage a pt with the side effect of decreased appetite?
- give med at or after meal
- encourage child to eat nutrient dense foods (no empty calories)
- offer food that child likes for noon meal
How do you manage SE: poor growth?
- drug holidays may be beneficial
How do you manage SE: dizziness?
- monitor BP and pulse (make sure you took a good hx - any arrhythmias?)
- ensure adequate fluid intake
- if assoc with peak effect, try longer acting prep
How do you manage insomnia or nightmares as SE of meds?
- establish a bedtime routine
- good sleep hygiene habits
- omit or reduce the last dose of the day
- if using long acting preparation consider short acting
How do you manage mood lability as SE of meds?
- sxs that may occur as med wears off can be averted by using longer acting formulation or increasing from BID to TID if short acting:
- sometimes mood changes can occur at peak concentration - try reducing dose or switching to longer acting
How do you manage rebound sxs from meds?
- this may improve by stepping dose down at end of the day
How do you manage tics as SE of meds?
- conduct a drug trial at different doses included no med to be sure that they are related to meds
How do you manage psychosis as SE of meds?
- Psychosis: suicidality, hallucinations, increased aggression
- verify dose is approp and med is admin as prescribed: if so d/c stimulant (can be done abruptly)
- refer to mental health specialist
Diversion and misuse of stimulants - educating pts?
- have to monitor sxs and prescribe refills - to look for evidence of misuse or diversion
- long acting stimulants have less potential for abuse
- keep track of rx dates
- open discussion with pt
What are reasons for tx failure?
- lack of adherence to med regimen
- possibility of med diversion
- are tx goals and expectations realistic?
- is there a comorbid psych dx?
- can try another stimulant med
- if fail mult stimulants or intolerable side effects then trial atomoxetine or an alpha-2 adrenergic
What are drug holidays?
- d/c of stimulant med on weekends or during summer
- decide on a case by case basis
- not an option for atomoxetine or alpha-2-adrenergic agonists becuase of extended half life
Maintenance of drug therapy?
- once on a stable dose:
follow up in office should be 3-6 months
- continue to monitor ht, wt, BP, and HR
How should you terminate ADHD meds?
- may abruptly d/c stimulants or atomoxetine
- alpha-2-adrenergic agonists and TCAs should taper off over several weeks
MOA of ritalin (methylphenidate)?
- short and long acting available
- acts on dopamine and NE to block reuptake
- 70% of pts experience significant benefit
(shortest acting: ritalin and methylin
longest acting: concerta, quillivan XR, daytrana)
SEs of ritalin?
- wt loss
- psych sxs: psychosis, aggression, hallucinations
- heart problems in at risk people
- easy bruising
- high potentiatl for addiction and abuse - schedule II drug
Use of adderral (amphetamine-dextroamphetamine) -Pros? Downside? SEs?
- high potential for abuse (II)
- may lead to drug dependence
- extremely popular
- may be slightly more effective than ritalin
anxiety, wt loss, psychosis, hallucinations, aggression
- ** heart problems in at risk people (sudden death)
Use of dexedrine? super dangerous SE?
- previously used for OTC diet pill
- among most effective tx for ADHD
- schedule II
- sudden death in people that have heart problems or cardiac defects
What SEs are concerning with dexedrine?
- heart related problems including:
sudden death in people that have heart problems or defects, sudden death, stroke and heart attack in adults.
increased BP and HR
- psych probs: new or worse behavior and thought problems, new or worse behavior
- kids and teens:
seeing things or hearing things
believing things that aren't true, new manic sxs
MOA of Lisdexamphetamine (vyvanase)?
- converted to dextroamphetamine after oral ingestion
- no generic
- less addictive but still schedule II
- amphetmaines cause release of catecholamines (primarily dopamine and NE) from their storage sites in presynaptic nerve terminals
- a less significant mechanism may include their ability to block the reuptake of catecholamines by competitive inhibition
Use of atomoxetine (strattera)? MOA? BBW? Most common SEs?
- initially only approved non stimulant tx until Intuniv
- works on NE
- initially tested for depression but didn't do much
- BBW: increased risk of suicidal behavior under 25 YOs
- may not be as effective as stimulant meds
- most common SEs: dry mouth, insomnia, nausea, decreased appetite, constipation, decreased libido, ED, urinary hesitancy, dizziness, and sweating 1-2 wks to notice effects
- other SEs: chest pain, SOB, irregular heart beat, unusual thoughts or behavior, aggression, hallucinations, nausea, abdominal pain, loss of appetite, jaundice
Why should atomoxetine (strattera) be used with some caution?
- risk of suicidal ideation in kids and adolescents
- weigh risks vs benefits
- should be monitored closely for suicidal thinking and behavior
- families and caregivers should be advised of need for close observation and communication with provider
Pros and cons of ADHD tx?
- ritalin: temporary effects - sleep not interrupted, inexpensive, effects and safety have been studied for decades, may cause jitters after snorting
- adderall XR: most popular study drug, very similar to vyvanse but comparatively more addictive, inexpensive generics available, increases dopamine levels in the brain, can impact sleep patterns
- vyvanse: expensive, no generics, some insurance plans don't cover vyvanse. Smoother absorption than adderall and less addictive, can suppress appetite drastically
- focalin XR: expensive, no generics available. SEs include loss of appetite, jitters and headache
What is extended release guanfacine (intuniv)?
- alpha-2-adrenergic agoinst (antiHTN)
- approved for tx of ADHD
fast or slow HR
pounding heartbeat, chest tightness
numbness or tingling
high rate of fainting
BP problems (low)
- caution with kidney or liver disease
Use of bupropion (wellbutrin)?
- alt tx for ADHD, other uses - Major depressive disorder cessation
- MOA: inhibits reuptake of dopamine
- mildly stimulating so good for pts with fatigue, hypersomnia, or poor concentration
- no sexual side effects or wt gain
- SEs: anxiety, insomnia, lowers seizure threshold, avoid in bulemia
When should you not use stimulants in ADHD pts?
- hx of substance abuse
- structural heart defects
- arryhthmia or increased CV risk profile