ILE XI ADHD Objectives

What are the three proposed etiologies of ADHD?

Neurotransmitters, genetics, environment

Which neurotransmitter is responsible for attention and arousal?

Norepinephrine

Which neurotransmitter is responsible for reward, risk and impulsiveness?

Dopamine

Which three general symptoms are associated with ADHD?

Inattention, Hyperactivity, Impulsivity

Which ADHD symptom is related to careless mistakes, not listening, forgetfulness, and easily distracted?

Inattention

Which ADHD symptom is related to fidgeting, inability to stay seated, talking excessively, and moving excessively?

Hyperactivity

Which ADHD symptom is related to blurting answers before questions are complete, interrupting/intruding, and difficulty waiting turns?

Impulsivity

What combined approach is the preferred treatment for ADHD?

Behavioral therapy and stimulants

In which age group should behavioral therapy ONLY be initiated for the treatment of ADHD?

4-6

In patients being treated for ADHD, when should the patients be checked for cardiac history and other psych disorders in relation to treatment initiation?

Before

Which stimulant medication is the better drug to start with for preschool children if behavioral therapy alone is not enough?

Methylphenidate

How are the following related to patients with ADHD?

Tourette Disorder

Bipolar Disorder

ASD

CD/ODD

Anxiety

Depression

Coexisting Disorders

Which stimulant class works by inhibiting dopamine reuptake and direct release by acting as a dopamine transporter to DI receptors, opening HCN channels and shunt out synaptic inputs?

suppresses the "noise"

Methylphenidate

Which stimulant class works as a noradrenaline agonist by acting as a noradrenaline transporter to alpha-2A-adrenergic receptors, closing HCN channels and conducting synaptic inputs?

strengthen the "signal"

Amphetamine

Which nonstimulant is a selective norepinephrine reuptake inhibitors (SNRI) that binds to norepinephrine transporter and inhibit the reuptake of norepinephrine?

Viloxazine

Which nonstimulant is a selective norepinephrine reuptake inhibitor (SNRI) which an R-enantiomer that is 10x more potent than the S with virtually NO activity at the other neuronal reuptake pumps or receptor sites?

Atomoxetine

Which nonstimulants are alpha-2 adrenergic agonists that reduce norepinephrine release and, therefore, reduce sympathetic nerve impulses, resulting in reduced sympathetic outflow and subsequent decrease in vasomotor tone and heart rate?

Guanfacine, Clonidine

Which alpha-2 adrenergic agonist is less selective for the presynaptic receptor?

Clonidine

Which nonstimulant is a weak dopamine and norepinephrine reuptake inhibitor with no significant direct effect on serotonin or MAO and active metabolites that augment noradrenergic and dopaminergic function?

Buproprion

Which nonstimulant has a higher exposure in children (6-12) when compared to adolescent (13-17) and, therefore, requires dose considerations?

Guanfacine

How should patients with moderate or severe hepatic impairment be managed when prescribed atomoxetine?

Reduce Dose

With what renal indication should dose adjustments be considered for patients prescribed viloxazine?

GFR < 30

What drug class is contraindicated within 14 days of viloxazine or atomoxetine?

MAOI

What nonstimulant required dose adjustments with concomitant strong CYP3A4 inducers and inhibitors?

Guanfacine

What ADR associated with guanfacine, clonidine, buproprion may require discontinuation and monitoring if it is severe?

Rash

What ADR associated with guanfacine and clonidine typically subsides after 2-3 weeks of therapy?

sedation

What ADR associated with atomoxetine is rare, but requires abrupt discontinuation if it occurs?

Liver Injury

What ADR associated with buproprion can resolve over time or with slower dosage titration?

Nausea

How should patients experiencing insomnia due to buproprion be counseled?

Dose Early

In which type of glaucoma is atomoxetine NOT recommended due to an associated risk of mydriasis?

Narrow Angle

Which nonstimulant should be discontinued upon recognition of pregnancy due to the potential for maternal harm?

Viloxazine

Which nonstimulant should NOT be imitated in patients with seizures or eating disorders due to a report of increased risk of seizures?

Bupropion

How often should clinician rated scales, height, weight, and eating and sleeping patterns be recorded for patients undergoing pharmacologic treatment of ADHD?

Baseline and every 3 months

When should adequate response be expected for patients being treated with nonstimulants?

2-6 weeks

How should patients properly discontinue guanfacine or clonidine in order to prevent rebound hypertension or behavioral dyscontrol?

Taper

How often should weight, lipids, and fasting glucose be monitored in ADHD patients being treated with antipsychotics?

every 6 months

What is the primary treatment goal and efficacy outcome for treatment of ADHD?

Reduced Symptoms

Which stimulant is contraindicated in patients with GI abnormalities due to the drug not being able to properly dissolve?

Concerta (methylphenidate)

Which stimulant is an active isomer and, therefore, metabolically deactivated at a slower rate to extend the duration?

Focalin XR (dexmethylphenidate)

Which stimulant is a liquid medication that is indicated down to 6 years old?

Quillivant XR (methylphenidate)

Which stimulant class is highly pH dependent and, therefore, may be eliminated faster in children due to them typically having lower pH urine?

Amphetamine

What dose dependent deficit is associated with stimulants in the first 2 years of use, but diminishes in year 3?

Growth

What ADR associated with stimulants requires immediate discontinuation?

Hallucinations