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Flashcards in ADHD Management Deck (51):
1

What are the requirements for an ADHD diagnosis?

Hyperactivity/ impulsivity or inattention:
1. Occur often
2. Present more than one setting
3. Present before age 12
4. Impair function
5. Be excessive

2

What are examples of ADHD that require attention of a specialist to treat ADHD?

1. Intellectual disability
2. History of abuse
3. Developmental disorder
4. Visual or hearing impairment
5. Severe aggression
6. Children unresponsive to treatment

3

Who is to be involved and what target goals are to be set?

-Include pt, family, and school personnel
-3-6 targetable outcomes at 1 time that are realistic, achieveable, and measureable

4

What type of therapy is 1st line for kids diagnosed at 4-5 (preschool age)?

-Behavioral therapy (administered by parents or teachers)
-Add medications if target goals not met (Methylphenidate)

5

What is the recommended 1st line tx for school age kids (>6) for ADHD?

Stimulant plus behavioral therapy

6

What is monitoring schedule for ADHD drugs?

Weekly to once every 3-6 months based on stage of pharmacology treatment

7

What are important considerations of initiating pharmacotherapy in children with ADHD?

-Child is 6 or older
-School will cooperate in administration and monitoring
-Child has normal heart rate and normal blood pressure
-Child is seizure free
-Substance abuse among household members is not a concern (IR stimulants)

8

If there are risk factors to ADHD pharm treatment what should be done?

-Comprehensive CV focused pt history, family Hx, and physical exam

9

Before starting adolescents on ADHD pharm treatment what should be done?

Assess them for substance use/abuse

10

What considerations must be taken when deciding on drug agents to assist in pharm tx of ADHD?

-Time of day target sx
-Duration of desired coverage
-Coexisting tic D/O (avoid stimulant)
-Substance abuse in family member at residence
-Expense

11

What three stages exist for pharm treatment in ADHD?

-Titration
-Maintenance
-Termination

12

What is the most common practice for a pt to start pharm therapy for ADHD?

On the weekend

13

What is good good practice for prescription writing for ADHD kids?

Writing multiple prescriptions so pharmacy supplies multiple bottles for administration at school

14

What is the general titration period for ADHD med and monitoring of patients on these drugs?

- 1 to 3 months
-Close follow-up usually every week

15

What is the recommended way to titrate with ADHD drugs?

Start lowest dose and titrate every 3-7 days until core sxs improve to 4-50% or until ADRs unacceptable

16

What is the thought on drug holidays with stimulant medication?

Not routinely recommended; Case by case basis

17

What are the ADRs associated w/ stimulant use?

-Decreased appetite
-Poor growth
-Dizziness
-Insomnia/nightmare
-Mood lability
-Rebound sx
-Tics
-Psychosis

18

How should ADHD pts take their medication to avoid decreased appetite?

-Administer at or after a meal
-Nutrient dense meals; high fat meals delay onset and increase peak concentrations of some formulations

19

How is poor growth controlled w/ stimulant use?

Drug holidays IF growth trajectory crosses 2 major percentiles for growth

20

How is dizziness managed with stimulant use?

Ensure adequate hydration/ fluid intake and try long-acting formulations if associated only at peak concentrations

21

How is insomnia/nightmares managed when using stimulants?

Change in dosing schedule (change to short acting, take earlier in the day, or omit)

22

How is mood lability managed in ADHD stimulant use?

Switch to long acting formulation; If still present referral for mood disorder evaluation

23

How is rebound managed in stimulant use?

Sx/ ADRs occur as medication wears off; Step down to lower dose late in day

24

How are tics managed w/ stimulant use?

Try different dose or stop medication to see if drug-related

25

How is psychosis managed w/ stimulant use?

Verify appropriate dose and adherence; if correct stop drug and send to mental health for evaluation

26

How is diversion/misuse managed w/ stimulant use?

-Monitor prescription refills
-Try long- acting preparations

27

How is termination of therapy monitored?

Similar to starting, every few days/weeks to check for sx return

28

What is important to know about stimulants as a drug class?

Controlled substance (II)

29

What are severe ADRs associated w/ stimulant use?

Cardiac arrhythmia (especially during 1st few days)
BP/Hr elevation

30

If an ADHD pt has a CV risk, how should they be managed?

work-up and/or referral should occur

31

What are contraindications of stimulant use?

-Symptomatic CV disease
-Moderate/severe HTN
-Seizure disorders
-Hyperthyroidism
-Motor tics or tourettes syndrome
-Glaucoma
-Agitated states
-Anxiety
-Drug abuse hx
-Concurrent use/ use w/in 14 days of MOAI

32

What are the type of stimulants?

-Methylphenidate -dexmethylphenidate
-Amphetamines

33

What is the MOA of the stimulants to treat ADHD?

Block reuptake of NE and DA into presynaptic neurons

34

What is the PK information for short acting methylphenidate?

-Initial effect 20-60 minutes
-Duration of action 3-5 hours

35

What is the PK information for long acting methylphenidate?

Onset and duration very by formulation

36

What are types of methylphenidate long acting drugs?

Metadate, Concerta, Quilivant, Ritalin

37

What are types of methylphenidate short acting drugs?

Methylin, Ritalin

38

What type of drug is available of dexmethylphenidate?

Focalin

39

What drugs are amphetamines?

Adenzys, Dexedrine, Procentra & Adderall

40

What amphetamine drug is useful in use to discourage misuse? How does it work?

Lisdexamfetamine, prodrug activated after oral ingestion

41

What non-stimulant drug is used to treat ADHD?

Atomoxetine

42

When would Atomoxetine be preferred over stimulants?

Those w/ or family w/ substance abuse, tics, significant ADRs w/ stimulants

43

What is important PK/management information about Atomoxetine?

-Requires 1-2 weeks for initial response and up to 4 weeks for maximal effect
-Dose every day and do not use drug holidays

44

What ADRs are associated with Atomoxetine?

-Weight loss
-Suicidal thinking (BBW)
-Abd pain/N/V
-Decreased appetite
-Rare sudden death
-CV issues

45

What are contraindication of Atomoxetine?

-Concurrent use/ use w/in 14 days of MAOI
-Glaucoma
-Current/ past pheochromocytoma
-Severe CV disorder

46

When would alpha-2-adrenergic agonists be used to treat ADHD?

When stimulants or Atomoxetine can not be used or are not effective

47

What are the alpha-2-adrenergic agonists used to treat ADHD?

-ER Clonidine
-ER Guanfacine

48

What is useful about ER Clonidine/ Guanifacine?

They can be used as adjuncts to stimulants

49

When would antidepressants be used to treat ADHD?

Nothing else works use TCAs or Bupropion

50

What is important to know about stimulant use in adults w/ ADHD?

-Are not as effective and have greater potential for ADR CV risk than in children

51

How are adults managed with ADHD?

-Normally stimulants unless substance abuse and tx w/ Atomoxetine or Bupropion