Complex; has genetic and environmental factors Genetic Heritability 60% to 90% 28% of ADHD cases accounted for by genetics Environmental factors Low birth weight and prenatal complications Malnutrition

ADHD and Enuresis Flashcards by Nathan Koranda

DSM-V (Diagnostic and Statistical Manual of Mental

Disorders, 5th edition) diagnostic criteria

Persistent pattern across settings of inattention,

hyperactivity, or impulsivity

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Validated screening tools - ADHD

Children: Vanderbilt® Connor©
• Adults: World Health Organization Adult ADHD SelfReport Scale and the Diagnostic Interview for ADHD in
adults (DIVA 2.0)

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Neurobiology of ADHD

Complex; has genetic and environmental factors
Genetic
Heritability 60% to 90%
28% of ADHD cases accounted for by genetics
Environmental factors
Low birth weight and prenatal complications
Malnutrition

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Evidence-Based Treatment of ADHD

• Two sets of guidelines

American Academy of Pediatrics (AAP)

• American Association of Child and Adolescent Psychiatrists (AACAP)

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AAP Guidenlines

Behavioral therapy first line for children 5 years of age or younger
• Stimulants first-line therapy

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AACP guidelines

Stimulants first line therapy for children 6 years of age or older

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ADHD (cont.)

• Goals of Pharmacotherapy

Modulate Dopamine (DA) and Norepinephrine (NE) to improve executive function
and regulate arousal to improve performance (Dipiro p. 1145)
• *multimodal therapy most successful
• * remember ADHD often coexists with other mood and behavior disorders which
increases the challenge of prescribing pharmacotherapy\

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ADHD Options

Options
• Stimulants
• Methylphenidate
• Amphetamines
• Non-Stimulants
• SNRI
• Alpha-Agonist

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Stimulants Methylphenidate - MOA

Absorption: readily absorbed
Distribution: variable by age
Protein-Binding: variable; low
Metabolism: Liver
Elimination: Renal

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Stimulants Methylphenidate - PK/PD

Onset 1h. Peak 3-11h (depends on formulation). ½ life: 2-4h

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Stimulants Methylphenidate - + Effects

Low doses: reduce movement, impulsivity, and increase cognitive function including sustained attention and working
memory

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Stimulants Methylphenidate - Neg Effects

higher doses: impaired cognition and locomotor-activating effects.
Black Box Warning: abuse potential
LT use: growth suppression
CV risk: sudden death
Psych risk: increases Tics in comorbid tic condition
Appetite suppression, tachycardia, dizziness, headache (HA), insomnia, growth suppression

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Stimulants Methylphenidate - Monitoring

Screen for CVD: congenital, arrhythmia, other disease; MH: psychosis, bipolar, aggression; Neuro: Seizures, Vision disturbance, GI
Labs: CBC with differential, Platelets (maybe); Growth parameters

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Stimulants Methylphenidate Interactions

ncreases serum concentrations of: TCAs, SSRIs, phenylbutazone, warfarin, phenytoin, phenobarbital, and primidone
Caution: clonidine, anticonvulsants, antihypertensives. Contraindicated: MAOI
Pregnancy: risk vs. benefit: lower weight NB; old category C

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Stimulants Amphetamines - MOA

Elevates extracellular dopamine (DA) and prolongs DA receptor signaling in the striatum
Inhibits the reuptake of monoamine oxidase which acts synergistically to produce a significant increase in the
monoamine concentration
Weak dopamine reuptake inhibitor, moderate noradrenaline reuptake inhibitor and very weak serotonin reuptake
inhibitor.

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Stimulants Amphetamines - PK/PD

Absorption: Well absorbed
Distribution: high volume
Protein-binding: low
Metabolism: Liver CYP2D6
Elimination: renal

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Stimulants Amphetamines - Action

Peak 1-3h (o) 15” Inject. ½ life: varies, 9-14h

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Stimulants Amphetamines - POS Effects

Improve the core symptoms of ADHD in the short term

Gains in social and classroom behaviors

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Stimulants Amphetamines - NEG Effects

Black Box warning: abuse potential
Linked to a higher risk of experiencing adverse events such as sleep problems, decreased appetite, and stomach pain
Appetite suppression, tachycardia, dizziness, headache (HA), insomnia, growth suppression, masks exercise fatigue

Stimulants Amphetamines - Monitoring

Screen for CVD: congenital, arrhythmia, other disease; MH: psychosis, bipolar, aggression; Neuro: Seizures,
Vision disturbance, GI
Labs: CBC with differential, Platelets (maybe); Growth parameters

Stimulants Amphetamines - Interactions

MAOIs AND those listed under Methylphenidate

Long-acting stimulant medications are generally preferred for

school-age children

Start with a 1st line medication from the methylphenidate or dextroamphetamine-amphetamine class, depending
on patient’s age. - 1st, 2nd, and 3rd line examples

1
st Line: Methylphenidate (Ritalin LA, Metadate CD; dextroamphetamine/amphetamine, LA: Adderall XL
• 2
nd Line: Methylphenidate, LA: Concerta; Dexmethylphenidate, LA: Focalin XR
• 3
rd Line: Lisdexamfetamine, LA: Vyvanse

Maximize dosing of one agent before

moving to the next. If ineffective or side effects develop, switch classes,
then move to second line medication if needed.

Before considering a stimulant medication, obtain

cardiac history, including sudden cardiac death in first degree relative under age 50, history of congenital heart defect, or conduction defect.

• Maximize dosing of long-acting

stimulant before adding an immediate release formulation medication

Insufficient evidence exists for switching

methylphenidate to amphetamines. Consider switching from methylphenidate to amphetamines at half of the dose.

When switching dexmethylphenidate to methylphenidate, the methylphenidate dose should be

twice the dexmethylphenidate dose.

Concerta® (methylphenidate ER) and Vyvanse® (lisdexamfetamine) are uniquely

dosed. The table below provides an initial dose which | may require additional titration.

Non-Stimulants: Atomoxetine - MOA

Selective inhibitor of Norepinephrinereuptake; Increases the amount of norepinephrine in the brain

Non-Stimulants: Atomoxetine - Action

Plasma levels peak within 1-3h; 6 weeks before it reaches maximum effect

Non-Stimulants: Atomoxetine Pos effects

No abuse potential; not a schedule II Works around the clock Useful inpatients with comorbid anxiety

Non-Stimulants: Atomoxetine Neg Effects

2/3 as effective as stimulants Black Box Warning: May increase suicidal thoughts at initiation GI effects: decreased appetite, upset stomach, nausea or vomiting, jaundice; GEN: tiredness, problems sleeping; CV: CV events; NEURO: dizziness; Mental Health: negative.

Non-Stimulants: Atomoxetine Monitoring

CVD and health, Growth parameters, Mental health, GI status, LFTs; MH status

Non-Stimulants: Atomoxetine Interactions

Lower doses if patient on SSRIs: paroxetine or fluoxetine. Avoid: CYP2D6 inhibitors Contraindicated: MAOIs, glaucoma, Pheochromocytoma Pregnancy: Risk versus benefit

Guanfacine LA | • Used to treat

children with ADHD who have tics, sleep problems, and/or | aggression

Guanfacine LA activates

Activates presynaptic alpha2 | -adrenergic receptors in the brain

Guanfacine LA does not

Does not cause much appetite suppression

Guanfacine LA may cuase

May cause sleepiness, headaches, fatigue, stomachaches, nausea, lethargy, dizziness, irritability, decreased blood pressure, and decreased appetite

Guanfacine LA takes up to

Takes up to 3-4 weeks to see effect

Long-Acting Clonidine (Kapvay) FDA approved | • Principal side effects

Somnolence, fatigue, and hypotension

Enuresis DX

Diagnosis: voiding history/pattern, consider age, rule out physical

Enuresis Epidemiology

``` Epidemiology • 4 years:25% of children • 7 years, only 5-10% • 10 years, fewer than 5% of children • Spontaneous resolution rate = 15% per year ```

Enuresis Treatment

Nonpharm first • Lifestyle, behavioral modification, reassurance, education, wet alarm • Medication consideration • Over age 7 years • No improvement after 3 months of other therapies • Can be used intermittently for special occasions

Desmopressin Oral or disintegrating tablet

* 1 hour before bed * 0.2 mg initiall, titrate as necessary to a maximum dose of 0.6 mg * Reduces bedwetting 1.3 fewer nights/wk * Serious SE: water intoxication; counsel on fluid restriction when taking

Anticholinergic (oxybutynin 2.5-5 mg at HS, tolteridine>12 y)

• Indications: dysfunctional voiding, overactive bladder, neurogenic bladder • MOA: Reduce uninhibited detrusor contractions, increase the threshold volume at which an uninhibited detrusor contraction occurs, and enlarge the functional bladder capacity • Anticholinergic SE: dry mouth, constipation • Useful in some if daytime wetting • Can be combined with desmopressin

Imipramine (TCA)

* Dose at HS: 25 mg for patients aged 6-8 years and 50-75 mg older children * One fewer wet night per week * High relapse rate * SE profile: WHO no longer recommends