RxPrep 2022 - Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD):

Is characterized by symptoms of inattention, hyperactivity and impulsivity

Patients often have difficulty focusing, are easily distracted, have trouble staying still and are frequently unable to control impulsive behavior

Which neurohormone is a primary target for stimulant medications used to treat ADHD?

Dopamine

Inattention Symptoms:

> 6 symptoms of inattention for children up to age

Symptoms must have been present for at least 6 months

Fails to pay attention, has trouble holding attention, does not pay attention when someone is talking, does not follow through on instructions, fails to finish schoolwork, has difficulty organizing tasks, avoids or dislikes tasks which require mental effort, loses things, is easily distracted and is forgetful

Hyperactivity & Impulsivity:

> 6 symptoms of hyperactivity impulsivity for children up to age 16

Symptoms must have been present for at least 6 months

Often fidgets or squirms, leaves seat unexpectedly, runs about when not appropriate, unable to play quietly, is "on the go" as if "driven by a motor," talks excessively, blurts out answers, has trouble waiting his/her turn and interrupts or intrudes on others

The following conditions must be met:

Several inattentive or hyperactive-impulsive symptoms were present before age 12

Symptoms must have been present in 2 or more settings (e.g.,at home, school, work, with friends or relatives, babysitters)

Symptoms interfere with functioning and are not caused by another disorder

What natural products have been shown to modestly improve cognitive function and behavior in children with ADHD?

Fish oil

Young children (and others) who cannot swallow capsules or tablets can use these long-acting formulations:

Capsule

Some capsule contents can be sprinkled on a small amount

of applesauce (e.g., Adderall XR, Ritalin LA)

Vyvanse capsule contents can be mixed in water, orange juice or yogurt

Chewable Tablet

Orally-disintegrating tablet

Patch

Suspension

A patient starting Vyvanse tells the pharmacists they have difficulty swallowing capsules. What can the patient mix the capsule contents with for easier administration?

Orange Juice

Water

Yogurt

What agents are consider first line treatment for ADHD? (HINT: Stimulants - Take in AM)

Methylphenidate

(e.g., Concerta,

Daytrana, Ritalin)

Lisdexamfetamine (Vyvanse)

Dextroamphetamine/Amphetamine (Adderall and Adderall XR)

What agents are consider second line treatment for ADHD? (HINT: Non-stimulants - take if risk of abuse)

Atomoxetine (Strattera)

What agents are available for add on treatment or used alone for ADHD?

Guanfacine ER (Intuniv)

Clonidine ER (Kapvay)

What agents can be given at bedtime to help improve sleep?

Clonidine IR (Catapres)

Diphenhydramine (OTC,25-50 mg)

Melatonin (OTC, 2-5 mg)

True or False: All stimulants are C-II medications and must be dispensed with a MedGuide.

True

Stimulants are contraindicated in combination with:

Monamine Oxidase Inhibitors do not use within 14 days of MAOI due to the risk of hypertensive crisis when used together

Which of the following statements are true concerning stimulants safety concerns?

Stimulant medications have a high potential for abuse and dependence

Increased levels of dopamine and norepinephrine can increase heart rate and blood pressure. This can cause serious cardiovascular events in children and adults with or without preexisting cardiac disease

Which of the following statements are true concerning stimulants safety concerns?

New-onset psychosis or mania, or an exacerbation of preexisting psychosis (e.g., a mixed/manic episode in bipolar disorder) can occur.

A loss of appetite is common. This is especially concerning in children, as it can contribute to a decrease in the child's growth trajectory.

The risk of serotonin syndrome is increased when stimulants are used in combination with other serotonergic drugs

Stimulant medications to treat ADHD have which of the following safety concerns?

Seizures

Delayed growth in children

A prolonged erection in males

Exacerbation of psychiatric conditions

Which of the following agents block the reuptake of norepinephrine and dopamine?

Methylphenidate (e.g., Concerta,

Daytrana, Ritalin)

Dexmethylphenidate

Dextroamphetamine/Amphetamine (Adderall and Adderall XR)

Lisdexamfetamine (Vyvanse)

Methamphetamine (Desoxyn)

What are common side effect of Methylphenidate (e.g., Concerta,

Daytrana, Ritalin)?

Insomnia

Decrease appetite/weight loss

Headache

Irritability

Dry mouth

Blurry Vision

Methylphenidate is available in which of the following formulations?

Oral suspension

Orally disintegrating tablet

Chewable tablet

Transdermal patch

GF is a 7 year old boy who is experiencing outbursts at his school, in ability to sit through dinner, and loss of focus. His physician would like to initiate Methylphenidate (Ritalin). What is the most appropriate starting dose?

5 mg BID

An appropriate starting dose of Concerta is:

18 mg daily

18 - 36 mg QAM

The correct counseling statements for Daytrana patch:

Place on the right hip one morning, then alternate hips daily

When removing, fold the patch half and flush it down the toilet or put it in a lidded trash can

Apply in the morning and remove after 9 hours

Appropriate baseline monitoring for a 10 year old female starting Methylphenidate (Ritalin LA) includes:

ECG

Heart Rate

Blood Pressure

Height and Weight

Which of the following statement are true concerning Methylphenidate (e.g., Concerta, Daytrana, Ritalin)?

Concerta OROS delivery: the outer coat dissolves fast to give immediate action, and the rest is released slowly

Can see a ghost tablet in stool and harder to crush which decreases abuse potential

Jornay PM: outer coating delays initial drug release 10 hours to allow for evening dosing; inner coating controls the slow release of the drug during the day

Daytrana: apply 2 hrs before desired effect (or as soon as the child awakens so it starts to deliver prior to school); remove after 9 hrs; alternate hips daily

Dextroamphetamine/Amphetamine (Adderall)

Misuse can cause sudden death and serious CV events

Which if the following stimulant medication is available as a chewable tablet and capsule?

Lisdexamfetamine (Vyvanse)

What stimulate medication is a prodrug with lower abuse potential?

Key counseling points for Atomoxetine (Strattera) include:

Risk of suicidal ideation

MAO inhibitor use within the past 14 days

Do not open the capsule

Atomoxetine (Strattera) has a boxed warning due to the risk of:

Suicidal Ideation

What is the mechanism of action of Atomoxetine (Strattera)?

Selective Norepinephrine Reuptake Inhibitor

What are common side effects of Atomoxetine (Strattera)?

Decrease appetite

Insomnia

Somnolence

Dry mouth

Hypertension

Tachycardia

Erectile dysfunction

What is the mechanism of action of Clonidine ER (Kapvay) and Guanfacine ER (lntuniv)?

Central Alpha 2A Adrenergic Receptor Agonists

What is the recommended started dose of Clonidine ER (Kapvay)?

Start 0.1 mg QHS - must be tapered

Do not discontinue abruptly (can cause rebound hypertension)

What are common side effects of Clonidine ER (Kapvay) and Guanfacine ER (lntuniv)?

Dry mouth

Sedation

Bradycardia

Somnolence

Fatigue

Dizziness

Constipation

Decrease HR

Hypotension

What is the recommended started dose of Guanfacine ER (lntuniv)?

Start 1 mg daily - must be tapered

Do not discontinue abruptly (can cause rebound hypertension)