ADHD ~ Peters

ADHD Target Symptoms

inattention, hyperactivity, impulsivity

ADHD Non-Pharm

CBT, support groups, education on management

ADHD Treatment Guide

1st Line: Stimulants ~ Amphetamine [AMP] + Methylphenidate [MPH-children only]

2nd Line: Norepinephrine Reuptake Inhibitors [NRIs]

3rd Line: Alpha-2 Receptor Agonist, Bupropion

Stimulant Overview

incr availability of DA & NE → incr sympathomimetic activity in CNS

improve: attention, hyperactivity, impulsivity, self-control, aggression, academic performance

Stimulant Assessments

mental health + social assessment [pt social + family history]

cardiovascular history [exercise induced syncope, breathlessness], HR, BP, fam hx

height & weight!!!

Stimulant Dosing Guidelines

IR:

• BID [morning & noon] → no doses within 6h of bed

• MPH preferred if <16 kg

• AMP ok for use at age 3 [all others >6yo]

ER:

• preferred for steady, longer-term control

• may require “booster” IR dose after school

absorption delayed when taken with a high-fat meal [breakfast]

avoid OROS tab [osmotic release] in pt w/ history of GI abnormality

Stimulant ContraIndications

MPH: CVD, thyrotoxicosis, marked anxiety & agitation, family hx or hx of tourette’s

AMP: CVD, hyperthyroidism, glaucoma, agitation, hx substance abuse, MAOI use in past 14d

Stimulant Warnings

CV effects: incr BP & HR, or sudden cardiac death

hx of substance abuse disorder

suppress appetite but lower seizure threshold [incr seizure risk]

worsen psychiatric disorders [psychosis, mania, visual disturbances]

MPH Transdermal Patch

chemical leukoderma

issues with dose dumping

admin 2h prior to desired effect

MPH OROS [osmotic release]

no admin if hx of GI abnormality

not all generic MPH ER products are OROS formulations

Jornay PM Dosing

take between 6:30pm & 9:30 pm, no effect until next morning

Lisdexamphetamine [Vyvanse] Overall

prodrug = less misuse potential

approved for binge eating disorder too

Stimulant AE & Management

appetite suppression = take after breakfast, eat larger meals w/ breakfast + dinner

insomnia = ensure dose timing is appropriate, change to short acting agent

GI discomfort = take with food/ switch agents, resolves with time

irritability = decr dose or change to non-stimulants, asses for mood disorder

HA = decr dose/change agents, give with food, PRN analgesia [APAP]

~ drug holidays can always be an option

Atomoxetine [Strattera] MOA

inhibit NE reuptake [no effect on DA] ~ not as rapid onset as stimulants

improve attention, hyperactivity, & impulsivity

Atomoxetine [Strattera] Adult Dosing

- Initial 40mg/day

– Increase every 3 days by 20-40mg

– Max dose 100mg/day

Atomoxetine [Strattera] Dosing

– Weight < 70kg – start 0.5mg/kg/day

– Increase after 3 days to 1.2mg/kg/day

– Max dose 1.4mg/kg/day or 100mg (whichever is less)

Atomoxetine [Strattera] ContraIndications

use within 14d of MAOi, severe CVD, hx of pheochromocytoma, narrow-angle glaucoma

Atomoxetine [Strattera] BBW

incr risk of suicidal idealation in children and young adults under age 24

Atomoxetine [Strattera] AE

common: GI discomfort, HA< insomnia, irritable, lost appetite, dizzy

severe: incr BP, risk for hepatotoxicity

Voloxazine [Qelbree] MOA

NE Reuptake inhibitor

Voloxazine [Qelbree] Dosing

– Age 6-11 = 100mg daily initially. Max 400mg/day

– Age 12-17 – 200mg daily initially. Max 400mg/day

– 50% reduction if CrCl < 30 mL/min

** only approved for ages 6-17

Voloxazine [Qelbree] AE

incr BP [diastolic >15mmHg] + incr HR [>20BPM]

somnolence, decr appetite, irritability

BBW: suicidal idealation

ER Alpha-2 Agonist: [Clonidine + Guanfacine] MOA

block NE release [no effect on DA] + incr blood flow in prefrontal cortex

definite benefit for hyperactivity, marginal for impulsivity, none for attention

useful adjunct for: disruptive/aggressive behavior, tics, sleep

ER Alpha-2 Agonist: [Clonidine + Guanfacine] Dosing

___ -BID

___- daily

~ largest portion of dose given at bedtime

ER Alpha-2 Agonist: [Clonidine + Guanfacine] AE

sedation, hypotension, bradycardia, dizziness

**dosed at night due to sedation

guanfacine conc incr >70% w/ high fat meal

do not sop abruptly to avoid hypertensive rebound

Bupropion [Wellbutrin] MOA

inhibit DA & NE Reuptake

off-label use

max efficacy ~4 weeks

Bupropion [Wellbutrin] AE

insomnia, lower seizure threshold, appetite suppression - contraindicated in eating disorder

Pregnancy

stimulants & atomoxetine & alpha-2 ag- should be avoided unless benefits > risk

Lactation

stimulants- not reccomended, decr __ production

atomoxetine, use in caution

gunafacine- minor sedation in infants