Psych Exam 4: ADHD (Waters)

3 ADHD characteristics

innattentive, hyperative, and/or impulsive

what type of disorder is ADHD?

it's considered cognitive (not behavioral)

what does diagnosis require for ADHD

requires extensive evalution of current and previoius symptoms, functional impairment

TikTok and ADHD-related videos

<50% of claims aligned with DSM-5

seems more common and worse than it really is

DSM-5 diagnosis of ADHD

a. for >/=6 months, a persistent pattern of inattention and/or hyperactivity-impulsivity exists

-symptoms are inconsistent with developmental level and have negatively impacted social, academic, and/or occupational functioning

b. several symptoms present before age 12 and occur in 2+ setting

c. symptoms are not solely a manifestation of another psych disorder, SUD, or medical condition

2 subclassees of ADHD

1. inatttention

2. hyperactivity and impulsivity

inattention DSM-5 diagnosis of ADHD

>/= 6 symptoms

>/= 5 if 17 y/o or older

-frequently forgets daily activities

-easily distracted by external stimuli

-unable to listen when spoken to directly

-loses items

-trouble organizing

-difficulty maintaining attention

-unable to follow instructions and fails to finish tasks/work

-fails to focus on details or makes careless mistakes

hyperactivity and impulsivity DSM-5 diagnosis of ADHD

>/= 6 symptoms

>/= 5 if 17 y/o or older

-talks excessively

-difficulty waiting turn

-impulsively blurts out answers

-runs or climbs in unacceptable situations

-inability to remain seasted when necessary

-fidgets with hands or feet or squirms in seat

-unable to play/engage in quiet, leisure activities

-often on the go or acts as if driven by a motor

-interrupts activities/conversations

DSM-5 subtypes of ADHD

1. combined: criteria are met for both inattentive and hyperactivity

2. predominantly inattentive

3. predominantly hyperactive/impulsive

symptoms of ADHD in adolescence

-disorganization

-forgetfulness

-inattention

-overreaction

-procrastination

-reckless driving, risky behaviors

symptoms of ADHD in adulthood

-inability to sit through class or meetings

-excessive talking

-need to get to places quickly

-impulsive symptoms: frequent job changes, low frustration tolerance, unstable relationships

-inattentive symptoms: poor time management, poor motivation and concentration, forgetfulness, excessive mistakes

ADHD rating scales

-some specific for children or adults

-some child rating scales include observer input

ADHD prevalence in gender

-males more likely to be diagnosed in childhood

-females less likely to present with hyperactive symptoms

-equal across gender in adulthood but women may have better awareness of their own deficits in attention/organization

risk factors for ADHD

-low birth weight/prematurity

-exposure to smoking during pregnancy

-FH of ADHD

-perinatal stress

-fetal alcohol syndrome

-lead poisoning

-traumatic brain injury

-adverse child-parent relationship

infancy ADHD signs/symptoms

-difficulty being soothed because of irritability, fidgeting, crying

-short periods of sleep/very little sleep

-when crawling, in constant motion

clinical course- preschool age

-initial symptom onset occurs

-hyperactivity and impulsivity dominate

s/s less stable, vary between settings

clinical course- school age

-initial doagnosis usually occurs

M: hyperactivie/impulsive

F: inattentive

oppositional/socially aggressive behaviors may emerge

clinical course- adolescence

-hyperactive s/s decrease, impulsive/inattentive persist

-inattentive may be more prominent

-oppositional/social behaviors continue to-SUDs may begin to develop

common comorbidities with ADHD in children

2/3 have comorbid condition

-disruptive/conduct problems (oppositional defiant disorder, conduct disorder)

-anxiety

-depression

-autism spectrum disorder

-tourette's/ tic disorder

common comorbities with ADHD in adults

-MDD

-any mood disorder

-SUD

-anxiety disorder

-bipolar disorder

-cluster B and C personality disorders

most common SUDs with ADHD

alcohol

cocaine

nicotine (stronger physical dependence compaired with general population)

cannabis

morbidity and mortality with ADHD + SUD

-earlier onset of substance use

-increased likelihood of suicide attempts

-more hospitalizations

-higher rates of polysubstance use

-less likely to achieve abstinence

-lower rates of treatment adherence

neurotransitters of ADHD

less DA

first line therapy for children + ADHD

-behavioral therapies if mild, diagnosis uncertain, medication not referred by parents, or ,6 y/o

-stimulants (MPH, AMP)

first line therapy for adults + ADHD

-stimulants (MPH, AMP)

-atomoxetine if risk of stimulant misuse

second line therapy for children + ADHD

-alternative 1st line

-atomoxetine

-guanfacine

-clonidine

second line therapy for adults + ADHD

-alternative first-line

when is pharmacologic therapy a mainstay of ADHD treatment

over 5 years old

what schedule are stimulants

CII

MPH v. AMP

considered equally effective

slightly different MOAs- pts may respond better to one type

MOA of MPH

-inhibits reuptake of DA>>> NE by binding to transporters

-MAOI (reduced breakdown of catecholamines)

MOA of AMP

-inhibits reuptake of NE and DA by binding transporters

-increases release of DA and NE into synapse from presynaptic terminal

-enhances release of NE in periphery from adrenergic nerve terminals

-MAOI (more than MPH)

dexmethylphenidate vs MPH

dexmethyphenidate is the D-isomer of MPH which is more active

can use 50% dose of MPH

advantages of MPH IR

-can be split/crushed

-simple to DC

-generic available

-can be added to longer-acting formulations in afternoon

disadvantages of MPH IR

-short half life

dosed 2-3 times/day--> requires 2nd dose at school

advantages of MPH intermediate release

-less abuse potential

-less frequent dosing than IR

-fewer ADEs than IR

disadvantages of MPH intermediate release

-delayed peak (effect may not be felt until afternoon)

-can't be split/ crushed

advantages of MPH long-acting

-some can be opened and sprinkled on applesauce

-less abuse potential for kids

-dosed once/day

disadvantages of MPH long-acting

-not optimal for pts who don't need all day coverage

-increased risk of insomnia

biphasic MPH products contains what

can contain IR and ER beads at a different ratio

biphasic MPH PK

causes multiple peaks throughout the day although only administered once daily

more consistent levels than BID administration of IR MPH

concerta is what type of drug and dosage from

MPH-OROs system

osmotic controlled-release oral delivery system

MOA of MPH-OROS system (concerta)

12 hours duration

1. IR MPH overcoat dissolves within 1 hour for first dose

2. orfice is then revealed and water can permeate through drug membrane

3. water causes contents to expand and push MPH out through the orfice (2nd dose)

4. rigid tablet shell is eliminated in the stool

MPH IR dose conversion to concerta (MPH-OROS)- 5mg 2-3times/day

18mg daily

MPH IR dose conversion to concerta (MPH-OROS)- 10mg 2-3times/day

36mg daily

MPH IR dose conversion to concerta (MPH-OROS)- 15 mg 2-3 times/day

54mg daily

MPH IR dose conversion to concerta (MPH-OROS)- 20mg 2-3 times/day

72 mg daily

name of oral liquid MPH

quillivant XR

name of long-acting chewable MPH

quillichew ER

name of TD patch MPH

daytrana

not bioequivalent with oral dosage forms

jornay PM

MPH dosage form that is admin at night

Tmax= at 14 hours

MPH PK features

poor PO absorption

-most formulations better absorbed with food

-take 30-45 min before meal

metabolism of MPH

-not a CYP450 substarte

-minimal DDIs

ritalin LA absorption

is pH dependent- avoid with antacids, PPIs, H2 blockers

range of intermediate MPH onset and duration

are both very long

dosing of MPH meds

-initiate at lowest dose and increase weekly as needed

when is MPH IR preferred

for pts <16kg

afternoon doses of MPH IR

may be required if rebound symptoms occur after long-acting formulation wears off

but increased risk of insomnia

mixed AMP salts

contains dextro-amphetamine which is more potent and levo-amphetamine

what does aderall contain

both d-AMP and l-AMP in a 3:1 ratio of d:l

what is AMP's prodrug

lisdexamphetamine

abuse potential of lisdexaohetamine compared to AMP

may be less than AMP

AMP PK

good oral absorption

-high fat meals may delay time to peak concentration by up to 2 hours

2 active metabolites of AMP

1. norephedrine

2. 4-hydroxyamphetamine

metabolism of dextroamphetamine

CYP2D6

AMP dosing

initiate at lowest dose and titrate weekly until response observed

frequnecy of IR products of AMP

at least BID

when is IR AMP preferred

pts < 5 y/o

afterschool dose may be needed if rebound symptoms occur after long-acting formulation wears off

CV stimulant contraindications

• Symptomatic CV disease

• Moderate to severe htn

• Cardiac arrhythmias

• Heart failure

• Recent MI

-advanced arteriosclerosis

other stimulant contraindications

• Hyperthyroidism

• Glaucoma

• Agitation

• H/o SUD

• MAOI within 14 days

-Tic disorder (lisdexamphetamine)

BBW of stimulants

-high potential for abuse

-prolonged administrtion may lead to dependence

-misuse can cause sudden cardiac death, serious CV events

stimulant warning of priapism, which drug and when

with MPH prolonged exposure, dose increase, or during a period of drug withdrawal

MPH patch warning

Severe allergic contact sensitization

• Edema, vesicles, papules that can spread beyond patch site

• Chemical leukoderma: Permanent loss of skin color at site of application

MPH-OROS warning

avoid with GI obstruction or severe narrowing

cardiac stimulant warnings

HTN, tachycardia

stimulant psychiatric warning

Exacerbation of psychosis, induction of manic/mixed

episode with comorbid bipolar disorder, treatment-emergent psychotic

seizure stimulant warning

in pts with a prior Hx of seizures

visual stimulant warning

blurred vision

tic warning with stimulants

exacerbation of motor/phonic tics and Tourette's disorder

growth warning with stimulants

long-term growth suppression

common stimulant advserse effects (bold most common)

• Decreased appetite

• Weight loss

• Headache

• Insomnia

• GI distress

• Dizziness

• Nervousness

• Emotional lability

• Dry mouth

• Mild erythema (MPH patch)

risks of stimulant excessive use

• Irregular heartbeat

-CV failure

• Hypertension

• Paranoia

**Risk increases significantly when used IV or intranasally (snorting)

stimulant decreased appetite management

effect may be largest at lunch--> rec pts eat nutritious high-calorie breakfast and dinner

GI distress with stimulant management

admin with food

insomnia with stimulant management

-reduce afternoon doses or give earlier in day

-change to a shorter-acting stimulant or a non-stimulant

-clonidine, guanfacine also manage evening hyperactivity

headache with stimulant management

divide dose, decrease dose, or give with food

erythema from patch stimulant management

-rotate application site to avoid worsening erythema

-if >2 days, recommend evaluation by provider

multiple proposed mechanisms of pediatric growth suppression from stimulants

1. Decreased appetite --> decreased caloric intake

2. Suppression of growth hormone secretion by dopamine

3. slow growht of cartilage tissue--> effect on bone growth

how to help with growth suppression with pediatric stimulants

drug holiday or switch to non-stimulant

stimulant DDI with other psychostimulants (caffeine, modafinil)

additive effects (HTN, tachycardia)

stimulant DDI with other antihypertensives

stimulants may counteract antihypertensive effect

stimulant DDI with MAOIs

contraindicated within 14 days of stimulants

stimulant DDIs with TCAs

MPH can increase TCA concs

stimulant DDIs with antacids, PPIs, H2 antagonists

can affect absorption of MPH (esp LA version)

stimulant DDIs with opioids

AMP concs may be increased

stimulant DDIs with CYP2D6 inhibitors

may increase exposure to mixed AMP salts

stimulant efficacy monitoring

Evaluate need for dose adjustment at least once monthly until symptoms have stabilized then several times/year

stimulant safety monitoring

• Every visit: Appetite, BP, HR, height (pediatrics), weight

• Consult cardiologist if known CV history

• Cardiac evaluation if pt develops chest pain, syncope, other symptoms of CV disease

RX stimulant misuse

-increased inpatient psych hospitalizations and ED visits

-but misuse of stimulants has been negativey associated with academic performance

types of prescription stimulant misuse

Alternative route of administration (ex: intranasal)

Higher dose than prescribed

Mixing medication with other drugs/alcohol to feel intoxicated

Selling or giving away personal medications

Taking medication for any use other than treating ADHD