Attention Deficit Hyperactivity Disorder (ADHD) – Part 2: Treatment Flashcards
Goals of Therapy
- Prevent/Minimize Morbidity
- Signs and Symptoms * Eliminate or significantly decrease ADHD symptoms
- Quality of Life * Improve social/occupational/academic function
- Improve self-esteem
- Prevent ADRs
Holistic Approach to Treatment
“Generally considered to be a chronic lifetime disorder, ADHD requires a
comprehensive, collaborative and multimodal treatment approach tailored to meet the
unique needs of the person with ADHD” [2]
“Medications are an important aspect of treatment and assist the facilitation of
changes… by improving focus, self-regulation and decreasing impulsivity/hyperactivity
and thus allowing the individual to use psychosocialstrategies more effectively” [2]
Note: Psychosocial interventions alone are first line for preschoolers according to many overseeing bodies
Non-Pharm Interventions
- Psychoeducation – to educate and empower by providing information about ADHD
overall it’s informing the family and or the patient what this condition is. What does it look like? How does it present? What are triggers? How can you tackle these types of behaviors and what can we do in the environment to make this child and or adult function better? - Psychosocial interventions – to promote success in different settings/interactions
- Manualized interventions
- Exercise, Sleep Hygiene, Diet
- Psychoeducation
- Discover what the patient/family already knows about ADHD
- Demystify common myths about ADHD
- Instill hope that interventions exist and are often effective
- Educate on ADHD symptoms and treatment
- Empathize with challenges of diagnosis
- Encourage nurturing of strengths and talents
- Be culturally sensitive (ethnicity gender, cultural issues may shape beliefs)
- Promote a balanced lifestyle (sleep, exercise, diet – instilling routine – self-care)
- Provide resources(print, online, community supports – local/national/international
- Psychosocial Interventions
Home
* Instructional (ex: small, short, clear instructions – repetition)
* Behavioural (ex: clear/achievable goals, praise, empathy, de-escalation, breathing)
* Higher rate of emotional dysregulation – short-fuse/frustrated easily
* Environmental (structure/routine, united parenting, prioritization, frequent breaks)
School – similar tactics to “Home” plus:
* Environmental (ex: proximity to teacher/attentive students, remove distractions)
* Academic (ex: appropriate level activities, extended time, quiet room, ear-plugs)
* Executive Function (ex: tutor, agenda, time management)
Work – similar tactics to “School” and “Home”
- Manualized Interventions
Parent Management Training Models
* Training modules: reinforce positive behaviors - ignore low-level provocative behaviors -
provide clear, consistent, safe responses to unacceptable behaviours
Social Skills Training – miss social cues, misunderstand social conventions
* No evidence for benefit at this time (Cochrane 2011)
Cognitive Behavioural Therapy – focuses on interaction between cognition, behaviour, emotion
* Evidence of benefit in adults; in adolescents we see benefit when paired with medication
Mindfullness Training – increasing mindful attention to one’s own thoughts and actions
Pharmacotherapy Options
Stimulants
a. Amphetamines
b. Methylphenidate
Non-Stimulants
a. Atomoxetine
Alpha-2a Receptor Agonist
a. Guanfacine
b. Clonidine
Other Agents
a. Modafinil
b. Others (TCA, SSRI, NDRI)
Pharmacotherapy Considerations
- Does weight predict optimal dosage? No (for psychostimulants)
- it’s not weight-based dosing. So that’s kind of interesting because we talk about children were often using weight-based dosing.
- Does symptom profile, family history, genetic testing help predict medication appropriateness? No – recall trial and error is common in ADHD treatment, comorbidities complicate
it’s not that you can look at them and say, Well, they’re presenting in this way. So I’m going to use the stimulant over that one. There’s not a lot of guidance to show that there’s actually a very many differences between presentation in which stimulant you’ll use - Childbearing age/Pregnancy/Breastfeeding? – Unknown (risk/benefit – caution MP in 1st trimester – obs. trial suggested “potential” cardiac malformations)
Methylphenidate in the first trimester, there has been observational trials suggested that there could be potential cardiac malformation. - Swallowing concerns? – some formulations chewable/sprinkled
- Although not every medication has received an ‘official’ approval for all ages, we see
widespread use of most ADHD medicationsthroughout all ages - Maximum Age? – No (unless compelling precaution/contraindication)
- When are symptoms most prevalent? What settings require symptom control?
When is therapy onset/peak/trough? – think practically/flexibly
Treatment of ADHD + Comorbidities
- Treat the most impairing disorder
first [2], unless both conditions can
be treated simultaneously or with
identical therapy(ies) - Treat psychosis, severe mood
disorder, SUD,
suicidality/violence first - AKA severe presentation/harm –
don’t use this as a be-all-end-all
First-Line Therapies
Long-acting stimulants are considered first-line therapy (amphetamine or
methylphenidate based) for uncomplicated ADHD * Improved adherence (compared to SA)
* Decreased toxicity (less peaks)
* Privacy, compliance, symptom coverage – How?
- uncomplicated ADHD from the perspective of ADHD by itself or ADHD that we’re managing where there may be a co-morbid condition that’s either already controlled or that we might try to control with, with similar therapies.
- Diminished diversion potential
- Diminished rebound
- Increased cost – don’t underestimate the cost barrier here (very $$$, often not covered)
Recommended to trial both an amphetamine AND methylphenidate before a trial of a
second-line agent
uncomplicated ADHD from the perspective of ADHD by itself or ADHD that we’re managing where there may be a co-morbid condition that’s either already controlled or that we might try to control with, with similar therapies.
Second-Line Therapies
Short/intermediate-acting stimulants are considered second-line therapy
(amphetamine or methylphenidate based) for uncomplicated ADHD * Lower cost (than LA), flexibility in dosing/effect
* Decreased adherence, increased risk for abuse/diversion
Atomoxetine and guanfacine XR therapies are considered second-line therapy for uncomplicated ADHD in patients with a contraindication to stimulants * Low abuse potential, alternate SE profile compared to stimulants
atomoxetine works on norepinephrine receptors are re-uptake receptors, and guanfacine is an alpha-2 agonist.
- Less robust evidence, delayed-onset
May see in combination with a long-acting stimulant (first line treatment) for augmentation in
sub-optimal responders
We will also sometimes see combination therapy. So you can see combination therapy of a stimulant and atomoxetine and a stimulant and guanfacine, okay. These options have low abuse potential because they’re not stimulants. These two are not stimulants.
Third-Line Therapies
Not indicated in uncomplicated ADHD unless contraindications to first and
second-line therapies
Multiple agents may be used - selection based off patient comorbidities
* Clonidine (a2-adrenergic agonist)
* Bupropion (NDRI)
* Imipramine (TCA)
* Modafinil (unclear MOA – CNS “stimulant” – DA activity)
Generally reserved for tx-resistant cases – often specialized care at this point
vDrug Therapy Considerations
CV Considerations
* Increased HR/BP (incr w/ stimulants/atomoxetine, decr in guanfacine)
\ Guanfacine actually is an anti-hypertensive. Think of clonidine, it’s an anti-hypertensive. This is the same family. So we actually would see a decrease in blood pressure or heart rate,
Appetite and Growth Considerations
* Medication-related growth delay – minor variations, “catch-up” once d/c tx
PNS Considerations (PNS contributes to CV and appetite effects)
* Dry mouth, headache, sleep change, GI upset, etc
“Rebound”
* Symptom return (or sometimes appearing worse than when untreated)
once the medication wears off (short period of time)
What can we do if we notice rebound? LA stimulant in AM à wearing off too early!
1) Divide daily dose into two tablets taken at different times to ensure they wear off
over a longer period (ex: 9 AM dose and noon dose)
2) Supplement with a low dose of a SA stimulant to overlap the end of the LA
requires 50 mg or 40 mg of Vi vans, Let’s say we’ll give them 20 mg in the morning when they wake up and we’ll give them 20 mg again at 12:00 to ensure that the rest of the dose is pulling through
or increase dose
Drug Holidays/ Weekend Breaks
May consider over school holidays and summer months
* Avoids exposure to side effects
* Increases opportunities for “normal” growth – I personally don’t believe this is necessary
and did not find strong evidence to support this
* Allows for reassessment of therapy
* Remember - upwards of 50% of children/adolescents with ADHD will not have ADHD as
adults
BUT ALSO REMEMBER >50% will continue to be symptomatic LIFELONG – do not participate in
stigmatization of therapy!
Managing Common Side Effects and Comorbidities
nsomnia
- AM dosing preferred, avoid late-afternoon/evening doses if possible
- Strict sleep schedule and sleep hygiene
- Non-pharmacologic/pharmacologic therapies for sleep if necessary
Rebound hyperactivity - May be due to wearing off of therapy
- Consider using LA product if not already or supplemental IR dose
Psychosis/Anxiety
- Not an absolute contraindication to stimulant therapy
- Collaborate, consider adjunct antipsychotic, antidepressant, or stabilizing therapy
- Titrate slowly
Reduced Appetite / Growth
- Dose with meals rather than before OR supplement meals with Boost/Ensure
- Schedule meals to accommodate hunger
- Drug Holidays if necessary
CV Risk - Monographs and most professional societies recommend baseline ECG and cardiac
evaluation if any history of symptomatic CVD – if no history, then not necessary!
