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Flashcards in ADHD and Tics Deck (57):
1

Pathophysiology of ADHD

reduced activity of dopamine and norepinephrine in the prefrontal cortex, alterations in the default mode attention network, less cortical mass has been detected in patients

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Symptoms of inattention

inattentive to details or activities, difficulty sustaining attention, does not appear to listen when spoken to, lack follow through, difficulty w/ organization, avoidance of task requiring mental effort, frequently losing things, forgetfulness

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Symptoms of hyperactivity

frequent fidgeting and squirming, inappropriately leaves seat in class, inappropriately runs or climbs, difficulty playing or performing activities quietly, often on the go, talks excessively

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Symptoms of impulsivity

blurts out, difficulty waiting turn, often interrupts or intrudes on others

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ADHD diagnosis

dec attention and inc levels of impulsivity, DSM-V diagnostic criteria, at least 5-6 symptoms of inattention or hyperactivity, impulsiveity present for >6 months, some 2 settings, observed by parents and clinician

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Differential diagnoses of ADHD

Biomedical problems (metabolic, neurologic, chronic illness), speech/lang probs, academic/learning probs, emotional/psychiatric probs (anxiety, bipolar), family probs (abuse)

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Consequences of ADHD

social difficulties, behavioral issues, impaired academic performances, strained familial relationships, inc risk for development of conduct disorders, abuse, psych disorders

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Treatment goals of ADHD

alleviate target sx, imp relationships, imp academia, imp rule following, imp QOL, minimize ADRs

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Non pharm interventions of ADHD

maintain daily schedule, minimize distractions, set reachable goals, limit choices, encourage hobbies, use calm disciplines, use check lists

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Stimulants MOA

all serve to inc [NT], block reuptake, act as agonists

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Stimulants PEARLS

first line, onset several weeks, imp behavior in all children, 70-80% response rate, trial w/ alternative stimulant warranted if lack of effectiveness, intolerable ADRs

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Stimulants imporve

over activity, attention span, impulsivity and self-control, physical/verbal aggression, social interactions, academic productivity

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Stimulants may not improve

academic performance, learning problems, social skills, oppositional behavior, emotional probs, long-term cog, academic, behavioral, emotional and social functions

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Stimulant ADRs

loss of appetitie, insomnia, wt loss, possible tachy, HTN, anxiety, irritability, HA, tics, stunted growth, generally mild or short duration, often reversible

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Stimulant abuse potential

risk of misuse/diversion by pts, family, prevent by open discussion w/ pts and family, utilize long-acting preparations, monitor refill dates

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Stimulant IR

immediate release, duration 4 hrs, up to 3x/day, adderal may be BID, beneficial when first titrating dose, can see wearing off during the day

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Methylphenidate IR

Ritalin, methylin; duration 3-4 hrs, adjust every 1-2 weeks as needed, schedule II, contraindications tics, marked agitation

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Methylphenidate IR dosage

children 5-15 mg PO BID before breakfast and lunch, adults 10-20 mg PO BID-TID 30-45 mins before meals

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Dexmethylphenidate (Focalin)

Duration 4-5 hrs, conversion from methylphenidate: initiate at 1/2 the total daily does of methylphenidate, BID>4-5 hrs apart w/out regard to meals, children >6 y/o and adults

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Dextroamhetamine (Dexedrine, Dextrostat)

typically half the methylphenidate dose, rarely used

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Stimulants er

extended, controlled, sustained release, long acting formulation, once daily dosing, 8-12 hr duration, preferred dosage form due to diminished rebound ADR and wearing off, convert when stable on IR dose, adolescents and adults may require dose of IR for evening coverage

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Methylphenidate ER (Ritalin LA, SR)

schedule II, dosed 1-2x daily w/ breakfast, lunch, 1/2 IR, 1/2 ER, duration 6-10 hrs, switching from IR: usually same daily dose

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Daytrana patch

10-30 mg/ 9hrs, apply patch 2 hrs before desired effect, leave on for 9 hrs, dose may be increased weekly, duration 12 hrs, must ensure the pt will leave patch alone, apply to hip, do not cut

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Metadate CD

10-60 mg, dose 1 x daily, formulations=30% IR coating, 70% ER center, duration 8-9, may sprinkle over apple sauce

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Concerta

18, 27, 54, 72(adolescents) mg dosed daily, duration 12 hrs,

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Dexmethylphenidate ER (Focalin XR)

duration 12 hrs, may take whole or sprinkle over applesauce, schedule II

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Dextroamphetamine SR

Dexedrine Apansule (5,10,15 mg) dosse 1-2x daily, formulation IR and ER beads, duration 6-10 hrs schedule II

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Adderall

Dose 10-20 mg PO BID, as dose inc doa inc, duration 6-8 hrs, schedule 2

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Adderall XR

dose 10-60 mg PO Daily, duration 10-12 hrs, may sprinkle over applesauce, schedule 2

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Lisdexamfetamine (Vyvanse)

Schedule II, dose 1x daily, duration 13-14 hrs, potentially less abuse potential

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Non-stimulants

alternative therapy to stimulants and can be used when comorbid conditions/diseases (anxiety, drug abuse issue, HTN, CVD), intolerable ADRs, therapeutic failure of first line agents, current substance abuse issue

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Atomoxetine (Strattera) MOA

NE reuptake inhibitor, selectively inhibits presynaptic NE transporter, not a stimulant, not a controlled medication

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Atomoxetine (Strattera) uses and ADRs

approved for pediatric and adults, decreased abuse potential, good option if ADRs w/ stimulants, ADRs- N/V/C, dizziness, irritability, sleep disturbances, dec appetitie, upset stomach, abdominal pain

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Atomoxetine (Strattera) dosage

given 20-40 mg PO BID, may take 2-4 weeks to see full benefit

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Atomoxetine (Strattera) advantages

shown to improve inattention and hyperactivity impulsive sx, not controlled substances, no abuse potential

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Atomoxetine (Strattera) disadvantages

black box warning- inc suicidal thinking in children adolescents and young adults, poor metabolizers of Cyp2D6 which inc cardiac ADR and must dec in liver function impairment, prolonged doa

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Antidepressants

Buproprion (Wellbutrin), TCAs, 2nd line agents to stimulant and atomoxetine, option if substance abuse a problem

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Buproprion (Wellbutrin)

ne/DA reuptake inhibitor, dec hyperactivity and aggressive behavior, reserved for adults if stimulant or atomoxetine fails, ADRs- insomnia, HA, restlessness, tics, seizures

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Buproprion (Wellbutrin) advantages

safer CV profile compared to stimulants, atoxetine and TCAs, less toxicity in overdose compared to TCAs, less appetitie suppression, useful if comorbid depression, IR- 150 mg PO BID, XL- 300 mg PO daily

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Buproprion (Wellbutrin) disadvantages

less effective for distractibility compared to stimulants, inc time to show therapetic benefit, can worsen tics, dose dependent risk seizures

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TCAs

NE/serotonin reuptake inhibitor, reserved for older children who do not respond to stimulants, use limited, baseline EcG required, may be used to manage stimulant induced insomnia

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TCA options

Impiramine (Tofranil), Desipramine (Norpramine)

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TCA advantages

usefel in coexisting depression/anxiety, no anorexia, no rebound symptoms, studies indicate a dec in impulsivity&hyperactivity

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TCA disadvantages

inc sedation which may impair function at school, CV side effects, anticholinergic side effects, toxic if overdose, inc time to show therapeutic benefit (4 weeks)

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TCA toxicity

risk adverse CV events, screen for fam hx of heart disease, baseline ECG and monitoring, do not use or d/c if resting HR> 130 BPM, ECG abnormalities, ADRs- anticholinergic

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Alpha-2 agonists

mediate effects of NE in frontal cortex, used for mono-therapy or add-on, dec efficacy compared to stimulants, beneficial in over-aroused, easily-frustrated, highly-active or aggressive individuals, don't stop abruptly 6-8 weeks for max benefit, not controlled substance

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Guanfacine (Intuniv, Tenex)

longer t1/2 and fewer ADRs compared to clonidine, use peds 6-17 y/o, may be beneficial in those w/ tics, intolerance to stimulants, or as add-on therapy, absorption inc w/ high fat meal

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Clonidine (Catapres, Kapvay)

.2 mg PO BID, catapres available as patch

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Types of tics simple

motor: eye blinking, neck jerking, shoulder shrugging, facial grimacing, vocal: coughing, throat clearing, grunting, sniffling, snorting, barking

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Types of tics complex

grooming behaviors, smelling, jumping, touching vocal: repeating words

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Types of tic disorders

tourette's disorder, chronic motor or vocal tic disorder last>year, transient tic disorder (goes away by themselves), tic disorder not otherwise specified

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Tourette's disorder

multiple motor tics and > 1 vocal tic, tics occur many times per day, occur nearly every day or intermittently for >1year, onset before age 18, not due to substance abuse or stimulant use, prevalence

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Treatment of tics

Evaluate overall ability of function, mild tics may not require treatment, mod to severe tics often interfere w/ social and academic functioning, behavioral interventions, pharm interventions, comb treatment

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Pharm treatment of tics

dopamine antagonist (typical and atypical), alpha-2 agonist

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Typical antipsychotics for tics

haloperidol, fluphenazine, risk of extrapyramidal effects, risk of inc QT interval, monitor

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Atypical antipsychotics for tics

Risperidone (Risperdal), Olanzapine (Zyprexa), may be preferred due to dec risk of EPS, ADR- wt gain, metabolic abnormalities, sedation, FPS

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Alpha-2 agonist for tics

clinidine, guanfacine, in pt w/ concurrent ADHD reevaluation use of stimulants