ADHD Therapeutics

Question 1

TRUE OR FALSE

it is very common for people with ADHD to have comorbid mental illness

Answer 1

true

Question 2

decreased _____ drives the disease of ADHD

Answer 2

decreased dopamine

Question 3

ADHD is characterized by inattentiveness, with or without….

Answer 3

hyperactivity and impulsivity

Question 4

ADHD = ___ +____

Answer 4

inattentive + hyperactive

Question 5

name some things that can be misdiagnosed as ADHD

Answer 5

autism, tourette’s, conduct disorders

depression, bipolar disorder

anxiety disorder

Question 6

stimulants will make _____ disorders worse

Answer 6

anxiety

Question 7

name some risks of not treating ADHD

Answer 7

difficulty socializing, poor work/school performance, unstable relatioships, substance use disorders, accidents

Question 8

____ can be the sole intervention for mild-moderate ADHD

what about for moderate-severe cases

Answer 8

psychotherapy

for moderate-severe ADHD, psychotherapy should be used alongside medications

Question 9

first line options for treating ADHD

Answer 9

stimulants

Question 10

as far as stimulants for ADHD, _____ may have a higher incidence of adverse events than _____ preparations

Answer 10

amphetamines have a higher risk of AE than methylphenidate

Question 11

which are more affordable - IR or ER stimulant dosage forms

Answer 11

IR more affordable

Question 12

which formulations are more likely to be misused - IR or ER

Answer 12

IR more likely to be abused

use ER/XR if this is a concern

Question 13

true or false

when stimulants are used for ADHD, there will be an IMMEDIATE RESPONSE

Answer 13

true

Question 14

in children, which dosage formulations are preferred

Answer 14

ER/XR

more convenient dosing strategies

Question 15

the 2 stimulant treatment choices are all variations of ___ or ____

Answer 15

methylphenidate or amphetamine

Question 16

which dopamine firing is preferred and why - tonic or pulsatile

Answer 16

tonic is preferred

pulsatile release increases the risk of compulsive use and dependence, and also leads to higher dopamine levels which can cause a stress-like state

Question 17

BBW of stimulants

Answer 17

drug misuse and dependence!

Question 18

5 warnings for stimulants (not the BBW of dependence and misuse)

Answer 18

-ocular effects - can increase IOP or worsen glaucoma

-pts with cardiac conditions - can raise HR and BP! (minimal risk in young pts w no cardiac issues)

-can exacerbate tics in tourette’s

-risk of mania/psychosis in bipolar or schizophrenia

-growth suppression in peds bc decreased appetitie

Question 19

2 stimulant CONTRAINDICATIONS

Answer 19

hypersensitivity

when used during or within 14 days of MAO inhibitors

Question 20

3 “relative” stimulant contraindications that depend on the patient

Answer 20

active psychosis ( can worsen)

active substance use disorder

significant anxiety disorder/sensitivity to stimulants

Question 21

methylphenidate brand and dexmethylphenidate brand

Answer 21

methylphenidate - ritalin

dexmethylphenidate - focalin

Question 22

MOA of ritalin and focalin

Answer 22

noncompetitive dopamine and NE reuptake inhibitor (like buproprion)

Question 23

which is the more potent enantiomer and what is the dose conversion - methylphenidate or dexmethylphenidate

Answer 23

dexmethylphenidate (focalin) is more potent

1mg focalin = 2mg ritalin

Question 24

which has a LONGER half life - amphetamines or focalin/ritalin

Answer 24

amphetamine has longer

Question 25

true or false ritalin and focalin have MINIMAL CYP drug interactions

Answer 25

true

Question 26

is buproprion used in ADHD

Answer 26

can be used off label for MILD ADHD not really effective in severe

Question 27

true or false methylphenidate can cause weight gain

Answer 27

FALSE - weight loss bc it decreases appetite

Question 28

what are the only 3 trade names of dexmethylphenidate

Answer 28

azstarys focalin focalin XR

Question 29

true or false jornay and quillivant are brand for methylphenidate

Answer 29

true

Question 30

true or false concerta is brand for dexmethylphenidate

Answer 30

FALSE - methylphenidate

Question 31

what is unique about jornay

Answer 31

the drug doesn't actually start working until around 10 hours after taken. taken at night and then starts to take effect in the morning hours - and lasts until evening

Question 32

which has higher potential for abuse - ritalin/focalin or amphetamine

Answer 32

amphetamine

Question 33

MOA amphetamines

Answer 33

COMPETITIVE dopamine and NE reuptake inhibitor. amphetamine can actually get in the synaptic terminal and at high doses it can displace dopamine from the vesicles causing MORE dopamine release so higher potential for abuse and misuse!

Question 34

which amphetamine is the most psychoactive enantiomer

Answer 34

dextroamphetamine so mixed salts are used

Question 35

amphetamine is more prone to DDI than ritalin/focalin which enzyme

Answer 35

CYP2D6

Question 36

what decreases the absorption of amephetamine? does this apply to lisdexamfetamine?

Answer 36

acidic food and drinks (bc basic structure) DOES NOT apply to lisdexamfetamine

Question 37

what INCREASES the absorption of amphetamines

Answer 37

antacids

Question 38

both methyl/dexmethylphenidate and amphetamines have similar adverse effects. however.....

Answer 38

amphetamine AE's happen more often

Question 39

what's the only stimulant indicated for moderate/severe binge-eating disorder

Answer 39

lisdexamfetamine

Question 40

structurally, what is lesdexamfetamine

Answer 40

a prodrug of dextroamphetamine. has a lysine attached therefore, can't be injected! must be ingested. less abuse potential

Question 41

is methamphetamine indicated for ADHD

Answer 41

yes - actually is but not really used in practice bc of misuse

Question 42

most often, what formulations of amphetamine are used

Answer 42

mixed amphetamine salts

Question 43

long active mixed amphetamine salts capsule

Answer 43

mydayis

Question 44

true or false adderall is mixed amphetamine salts

Answer 44

true

Question 45

can ER mixed-amphetamine capsules be opened

Answer 45

yes - but do not crush or chew

Question 46

what are considered 2nd line for ADHD

Answer 46

"NRIs" --- selective norepinephrine reuptake inhibitors (note - NOT SNRI's!!!) can be used as monotherapy OR as an adjunct to stimulants

Question 47

explain when NRIs would be used as an adjunct to stimulants when would they be considered FIRST LINE as monotherapy?

Answer 47

adjunct -- if the pt had some response from a stimulant but can't tolerate a higher dose NRI's are first line monotherapy for patients with substance use disorders or have a CI to a stimulant (or just prefer a non-stimulant)

Question 48

true or false NRIs are stimulants

Answer 48

FALSE - they are not

Question 49

name the 2 NRI's

Answer 49

atomoxetine viloxazine

Question 50

are NRI's effective at treating depression

Answer 50

no

Question 51

can strattera capsules be opened what about viloxazine

Answer 51

NO - must be swallowed whole viloxazine can be opened

Question 52

name 2 alpha 2 agonists that can potentially be used for ADHD

Answer 52

guanfacine and clonidine

Question 53

which alpha 2 agonist is generally preferred over the other and why

Answer 53

guanfacine preferred over clonidine bc less AE

Question 54

for ADHD, alpha 2 agonists tend to improve _____ symptoms more than ______ symptoms

Answer 54

improve behavioral, impulse symptoms more than the inattentive

Question 55

true or false alpha 2 agonists are considered 2nd line for ADHD

Answer 55

true

Question 56

alpha 2 agonists are approved in kids how young

Answer 56

6 years and older

Question 57

AE of clonidine

Answer 57

orthostasis, hypotension, headache, dizziness, dry mouth, sedation, nightmares rebound hypertension if not tapered properly! guanfacine has these side effects too, but they are less severe bc more selective for a2a receptors in the prefrontal cortex and not the rest of the body

Question 58

a pediatric patient was given methylphenidate oral solution 5mg twice daily. in the afternoons, his symptoms have still not improved what to do

Answer 58

increase the frequency to 5mg TID

Question 59

pediatric patient got methylphenidate 5mg TID after 5mg BID was not working in the afternoons at school now, they come back to the clinic and the afternoon symptoms STILL haven't improved and now he is having trouble sleeping at night also, the child refuses to get pulled from class to take the med bc he's embarrassed what should we do

Answer 59

switch to methylphenidate ER tablets (concerta) 18mg QD (dont increase the dose of the solution! will just increase AE)

Question 60

patient was prescribed methylphenidate QD he's been throwing it up an hour after taking. what should we do

Answer 60

if he's throwing up that soon after taking - he's barely getting any drug. it's not working switch to methylphenidate ER suspension 20mg ONCE A DAY when he can actually take the med - it seems to work. stick on methylphenidate. he was previously on a liquid and not throwing up