ADHD, anxiety, and sleep disorders Flashcards
(31 cards)
What is the preferred first line treatment for ADHD pts age 4-5 and ≥ 6 years old?
4-5 years old: first-line is training in behavioral management and/or behavioral classroom intervention
≥ 6 years old: first-line is ADHD medications AND behavioral interventions when available
What # of symptoms of inattention and hyperactivity/impulsivity are needed to diagnose ADHD? What conditions must be met?
Inattention: ≥ 6 symptoms of inattention for children up to age 16. Symptoms must have been present for at least 6 months and are inappropriate for the development level.
Hyperactivity & Impulsivity: ≥ 6 symptoms of hyperactivity-impulsivity for children up to age 16. Symptoms must have been present for at least 6 months and are inappropriate for the development level.
Conditions:
- several inattentive for hyperactive-impulsive symptoms were present before age 12
- symptoms must have been present in 2 or more settings
- symptoms interfere with functioning and are not caused by another disorder
What meds are first line for ADHD?
Stimulants are first-line
Can use non-stimulants after 2-3 medication trials of stimulants or if the side effects of stimulants are intolerable.
What are the options for stimulants if the pt cannot swallow pills?
Capsules that can be opened:
- many long-acting capsules (ex. Adderall XR, Ritalin LA) can be opened and sprinkled on a small amount of applesauce
- Vyvanse capsule can be mixed in water, orange juice, or yogurt
Chewable tablets:
- Vyvanse
Orally-disintegrating tablets
Patches:
- Daytrana
Suspensions
What is the MOA of stimulants? What are 5 safety concerns with stimulants? Do stimulants need to be tapered off?
MOA - block the reuptake of norepinephrine and dopamine
Safety concerns:
1. increased HR and BP (due to dopamine and norepinephrine)
2. other vascular problems (priapism, Raynaud’s)
3. new-onset psychosis or mania, or exacerbation of preexisting psychosis
4. loss of appetite
5. increased risk of serotonin syndrome when used in combo with other serotoneric drugs
*Do not use w/in 14 days of an MAO inhibitor due to risk of hypertensive crisis!
No, stimulants do NOT need to be tapered off, if they have not been abused.
What are the brand names for IR, ER tab with OROS delivery, ER cap, and transdermal patch methylphenidate? What is the started dose of the IR tab and ER tab w/ OROS delivery? What monitoring should be done on this drug? What is OROS delivery? How should the transdermal patch be applied?
Brand names for methylphenidate:
- IR tab -> Ritalin
- ER tab w/ OROS delivery -> Concerta
- ER cap -> Ritalin LA
- Transdermal patch -> Daytrana
Starting doses:
- IR tab: start with 5mg BID
- ER tab w/ OROS delivery: start 18-36mg qAM
Monitoring:
- consider ECG
- BP and HR
- height and weight
OROS delivery: outer coat dissolves fast, the rest is released slowly. May be a ghost tablet with this one
Transdermal patch: apply to the hip 2 hrs before desired effect (in AM). Remove after 9 hours. Alternate hips daily. Discard used patches by flushing down the toilet
What is the brand name of dexmethylphenidate? How is this related to methylphenidate?
dexmethylphenidate -> Focalin
This is an active isomer of methylphenidate, use 1/2 of the dose if converting from methylphenidate to dexmethylphenidate
What is the brand name of dextroamphetamine/amphetamine?
IR tab -> Adderall
ER cap -> Adderall XR
What is the brand name of lisdexamfetamine? What dosage form does it come in? What is a benefit of this medication?
Lisdexamfetamine -> Vyvanse
Dosage form: capsule or chewable tab
Benefit: low abuse potential. If injected or snorted, the fast effect (rush) is muted
What are 2 selective norepinephrine reuptake inhibitors that are non-stimulants used in ADHD? What is 1 boxed warning, 1 contraindication, and 6 side effects?
atomoxetine (Strattera)
- do not open the atomoxetine capsule
viloxazine (Qelbree)
Boxed warning: suicidal ideation
Contraindication: do not with w/in 14 days of an MAO inhibitor
Side effects:
- decreased appetite
- insomnia
- somnolence
- dry mouth
- increased BP
- increased HR
What are 2 centrally-acting alpha-2 receptor agonists that are non-stimulants used in ADHD? What are 2 warnings, 7 side effects, and 1 dosing note?
Clonidine ER (Kapvay)
Guanfacine ER (Intuniv)
Warnings
- dose-dependent CV effects (bradycardia, hypotension, orthostasis, syncope)
- sedation/drowsiness
Side effects
- dry mouth
- somnolence
- fatigue
- dizziness
- constipation
- decreased HR
- hypotension
Notes:
- MUST be tapered off due to risk of rebound hypertension
True or false: antipsychotics, bupropion, decongestants, steroids, and theophylline can cause anxiety
True - along with many others that are more obvious
What are some natural products that may be used for anxiety?
St John’s Wort - used for depression and anxiety
*CYP3A4 inducer
* causes photosensitivity and is serotonergic
Valerian - used for anxiety and sleep
*some products may be contaminated with liver toxins, so liver fx should be monitored
Passionflower - safe and “possibly effective”
Kava - a relaxant, but can cause severe liver damage and is NOT recommended
What drug classes are first line for anxiety? (2)
SSRIs and SNRIs
- escitalopram, fluoxetine, paroxetine, sertraline
- duloxetine, venlafaxine XR
- slowly titrate to minimize anxiousness and jitteriness
- will not provide immediate relief; takes at least 4 weeks at higher doses or a noticeable effect
When should buspirone be considered for anxiety? What is 1 contraindication? Does it have any potential for abuse?
can use in combination with antidepressants
- it’s considered more favorable of an add-on in elderly pts or if there is risk of BZD abuse
- does not provide immediate relief; takes 2-4 weeks for effect
Contraindication: do not use with MAO inhibitors for risk of serotonin syndrome
No potential for abuse, tolerance, or psychological dependence
Are TCAs (amitriptyline and nortriptyline) FDA approved for anxiety?
No, TCAs are not approved for anxiety
Are pregabalin and gabapentin FDA approved for anxiety? Have they shown benefit in any population?
No, pregabalin and gabapentin have not been approved for anxiety.
They have shown benefit in patients with anxiety and neuropathic pain
When can propranolol be considered for anx? Is it FDA approved?
propranolol (Inderal LA or XL) is not FDA approved for anxiety, but it can reduce symptoms of stage fright or performance anxiety (ex. tremor, tachycardia)
Ideally, how long should benzodiazepines be used for anx? Why are BZDs on the Beers Criteria? Which BZDs are contraindicated in severe liver disease? When is alprazolam contraindicated?
BZDs should only be used for 1-2 weeks due to the risk of dependence.
BZDs are potentially inappropriate in patients at least 65 years old. They have a high risk of confusion, dizziness, and falls in the elderly, esp if used with other CNS depressants.
- If BZDs need to be used in elderly, used LOT drugs (lorazepam, oxazepam, temazepam)
Clonazepam and diazepam are contraindicated in severe liver disease (use LOT drugs in this case)
Alprazolam is contraindicated with strong CYP3A4 inhibitors (ketoconazole, itraconazole)
If non-drug treatment has not worked for insomnia, what medications can be used to help falling asleep (4), help staying alseep (4) or both (2)?
Falling asleep:
- eszopiclone
- zolpidem
- ramelteon
- zaleplon
Staying asleep:
- eszopiclone
- zolpidem
- doxepin
- suvorexant
Both:
- eszopiclone
- zolpidem
What are 2 OTC meds that pt’s may use for insomnia? Which 4 drug should NOT be used for chronic use according to the AASM?
OTC: diphenhydramine, doxylamine
Not for chronic use:
- diphenhydramine
- melatonin
- trazodone
- valerian
What are the 3 Z-hypnotics? What is the dose of zolpidem for females/older adults and males?
Eszopiclone (Lunesta)
Zolpidem (Ambine, Edluar [SL tabs])
Zaleplon (Sonata)
Zolpidem dosing:
- female/older adults: 5mg PO/SL qHS
- male: 5-10mg PO/SL qHS
These are preferred over BZDs use to decreased abuse potential
How do the orexin receptor antagonist work? What are the 3 drugs in this class?
MOA - the orexin neuropeptide signaling system promotes wakefulness. Orexin receptor antagonists block the orexin neuropeptide signaling system, resulting in drowsiness.
- daridorextant
- lembroexant
- suvorexant
Which 2 drugs are melatonin receptor agonists? Are these controlled substances?
- ramelteon
- tasimelteon
NOT controlled substances
