Pharm III (Exam 1) - ADHD Meds

indicated for ADHD, narcolepsy, exogenous obesity, and BED

stimulants

stimulants increase ________________ and _________________ avaoilibility

dopamine, norepi

Dopamine and norepinephrine reuptake inhibitor and releaser (DN-RIRe):

_________-containing

•Inhibits presynaptic reuptake

•Allows neurotransmitters to accumulate in the synapse

MPH

Dopamine and norepinephrine reuptake inhibitor and releaser (DN-RIRe):

_________-containing

•Promote release of dopamine and norepinephrine from storage sites in the presynaptic nerve

AMP

With oral administration of stimulants, the time to peak may be delayed ~ ______ hours by a ________ meal

2-3, high fat

MPH: Transdermal absorption increases when patch applied to inflamed or ________ exposed skin

heat

AMP: Mixed salts of amphetamine and lisdexamfetamine should be avoided in __________

ESRD

Duration of action/effect of stimulants is dependent on the _______________ of each formulation (extended-release products contain both ________ beads and ________ beads - overall duration longer than IR med alone)

delivery system, IR, ER

stimulant contraindication

MAOI within 14d

stimulant warnings

CV

stimulant BBW

abuse potential

stimulant warnings:

•Growth ____________ - children not growing or gaining weight should stop treatment, at least temporarily

•May worsen motor and phonic _________, Tourette’s syndrome

•May worsen symptoms of thought disorder and behavioral disturbance in patients with ___________

•May lower the__________threshold

•May lead to emergence or worsening of activation and ___________

suppression, tics, psychosis, seizure, agitation

stimulant warning mitigation strategies:

•Prescribe _________ and include documentation of appropriate use

•Avoid __________ use

•Provide close __________ for ________ and drug ___________

sparingly, prolonged, monitoring, tolerance, dependence

stimulants may counteract the effects of _____________________

antihypertensives

opioid analgesics and other sympathomimetics ________________ concentrations of stimulants

increase

_______________________ can have an additive effect on the increased BP or HR when taken w stimulants

Psychostimulants (e.g., caffeine, modafanil [Provigil])

Antacids, proton pump inhibitors, and H2 blockers can affect ___________ of stimulants

absorption

when is reduced appetite from stimulants the greatest

lunch

management of reduced appetite and weight loss from stimulant

high cal breakfast and dinner, switch med

management of stomachache from stimulant

decrease dose, take on full stomach

management of N/V from stimulant

take w food, switch med

management of insomnia from stimulant

give earlier, reduce dose, change med, add sedative

management of headache from stimulant

decrease dose, take w food, take analgesic, change md

management of irritability or jitteriness from stimulant

decrease dose, change med

Evaluate need for dosage adjustment of stimulants at least once _________ until symptoms have stabilized, then several times per _______

monthly, yr

Stimulant monitoring:

•Appetite, BP, HR, height, and weight - _________ and each follow-up

•__________ symptoms

•__________ suppression

baseline, cardiac, growth

Stimulant _________________:

•May limit growth suppression

•Reassess symptoms and decrease potential longer-term effects

•Hold medication over the weekend

•Discontinue over the summer

drug holidays

stimulant controlled substance class

C-II

Untreated ADHD increases the risk of ___________________ compared with children with treated ADHD

substance misuse

Sx of stimulant withdrawal typically begin around _________hrs after last use and can last _______d

24, 3-5

S/Sx:

•Agitation

•Irritability, anxiety

•Depression, mood changes, suicidal ideation

•Fatigue

•Hypersomnia or insomnia

•Increased appetite

•Muscle aches

•Poor concentration

stimulant withdrawal

___________ stimulants to avoid withdrawal

taper

Stimulant ____________ following chronic therapeutic use may unmask symptoms of the underlying disorder and may require follow-up and ________________ of treatment

withdrawal, reinstitution

Careful supervision is required during withdrawal from stimulant misuse since severe ____________ may occur

depression

Titrate stimulants at ___________ intervals until clinical response is observed

weekly

stimulants are given _________ times daily depending on formulation

1-3

Short acting stimulants take effect on behavior seen within _______ minutes, persist for ______ hr

30-60, 3-5

Mid-day dosing (~ noon) during school typically required

short acting stimulant

Can be used in addition to longer-acting formulations for symptom control early in the morning or to prolong duration and smooth withdrawal in late afternoon

short acting stimulant

_____ short acting stimulant products are usually given at least twice a day, morning and noon

IR

Preferred stimulants for patients weighing < 16 kg because of limited long-acting stimulants that are available in low enough doses

IR short acting

An ______________ dose of stimulants may be prescribed if rebound symptoms occur, but avoid giving the dose too late in the day (i.e., no less than 6 hours before bedtime) to reduce risk of insomnia

afterschool

________________ stimulants:

•Slower onset, longer duration of action

•Good option for patients who are sensitive to stimulant side effects

•Unfortunately, are highly variable in efficacy and duration

intermediate acting

____________________ stimulants most contain a combination of IR plus DR/ER components, i.e. 50/50, 20/80, 40/60

•Example: 50/50 = 50% IR beads plus 50% enteric-coated DR beads

long acting

long acting stimulant onset of action is __________min and duration of action is _______hrs

20-60, 8-16

only stimulant taken at BEDTIME:

DR/ER taken at night to provide effect on awakening and slow release throughout the day

Methylphenidate long-acting (Jornay PM)

stimulants in multiple forms including Cap to sprinkle on food, chewable tab, ODT, oral suspension, transdermal patch

long acting

ODT stimulants:

•Place on ________ immediately after removing from blister pack

•Allow to dissolve, then ________

•Do not ______________ tablet

tongue, swallow, chew or crush

stimulant available as a suspension

MPH-OROS (Concerta)

MPH-OROS (Concerta):

•Avoid in patients with ___________________ or narrowing

•Contains _____________ acid (metabolite of benzyl alcohol)

•Associated with ____________ reactions

GI obstructions, benzoic, allergic

Stimulant transdermal patch:

•Apply the patch to a clean, dry area of the ____________ beneath the underwear, avoid the waistline, and rotate sites ________

•Apply the patch _____ hours before the desired effect needed

•Wear the patch for up to 9 hours: on ____ hr, off ____ hr

•Do not exceed 9 hours

•OK to have on for less time – tailor to patient’s needs

•After removal, fold onto itself and dispose into the toilet or a lidded container

•Effects last ____ hours after removed

lateral hip, daily, 2, 9, 15, 3

Transdermal stimulant ADE:

Mild ____________ should resolve in 24-36 hours after patch removed; patient should be instructed to contact provider if persists > ________

erythema, 2d

Transdermal stimulant ADE:

•_____________________ sensitization characterized by intense local reactions that can spread beyond the patch site

•symptoms include edema, vesicles, and papules at the ______________ site

•Manage by removing the patch, monitoring reaction, and seeking medical attention if symptoms do not resolve within ______ hours

allergic contact, application, 24

Transdermal stimulant ADE:

•Permanent loss of skin color at the site of application

•Difficult to predict - can occur 2 months to 4 years after initiating treatment

chemical leukoderma

An afternoon dose of MPH-_____ may be necessary if symptoms occur

IR

once daily dosing of ____________ can eliminate hassle/difficulties of lunchtime dosing at school

Lisdexamfetamine (Vyvanse)

Patient must take _____________ first thing in the morning - if they delay taking until later in the day, the risk of insomnia is greatly increased

Lisdexamfetamine (Vyvanse)

Selective norepinephrine reuptake inhibitor

Atomoxetine (Strattera)

Atomoxetine (Strattera):

•Inhibits _________ reuptake of _________

•Therapeutic effects in ADHD without _________ potential

presynaptic, norepi, misuse

Atomoxetine (Strattera) metabolism via ______________:

-UM: _________________

-PM: _________________

CYP2D6, less effective, toxic

Atomoxetine (Strattera) contraindications

CV, MAOI within 14d

Atomoxetine (Strattera) bbw

SI

Atomoxetine (Strattera) warnings

liver injury, priapism, hostile/aggressive, psychosis/mania

management of GI discomfort from Atomoxetine (Strattera)

take w food

management of headache, drowsiness, and insomnia from Atomoxetine (Strattera)

take in morning

management of dizziness Atomoxetine (Strattera)

take at night, divide dose

Atomoxetine (Strattera) takes effect in __________

2-4wks

Splitting the Atomoxetine (Strattera) dose twice daily may decrease __________

ADEs

Atomoxetine (Strattera) availability

oral

stimulants have a ____________ onset and are more likely to suppress ___________

quicker, suppress

Atomoxetine (Strattera) has a ___________ onset, ______________ risk of dizziness, fatigue, and sedation, and is a good option for pts w ________________ disorders

delayed, higher, substance misuse

Do NOT discontinue ________________________ abruptly due to risk of rebound hypertension

alpha 2 adrenergic agonists

alpha 2 adrenergic agonists ADE

Dizziness, dry mouth, headache, hypotension, bradycardia

CNS depressants and antihypertensives have additive effects when taken with _________________________________

alpha 2 adrenergic agonists

check _______ and ______ at every visit when taking alpha 2 adrenergic agonists

BP, HR

___________ can be used to treat tics

Guanfacine ER (Intuniv)

Stimulants may result in increased risk of _________ birth and _______ birth weight (Newborns may experience _________ effects)

premature, low, withdrawal

____________________ may decrease breast milk production

amphetamines

Infants may experience increased irritability, agitation, and crying

amphetamines

Atomoxetine in pregnancy and breastfeeding

unknown, use caution

If a stimulant is needed in the elderly, consider _______________ or _____________________

modafinil (Provigil), armodafinil (Nuvigil)

______________________________ should be used with caution in the elderly due to decreased hepatic, renal, and cardiac function

Lisdexamfetamine (Vyvanse)

________ and _________ may be decreased in ADHD and may be used as adjunctive therapy in children and adolescents

omega 3, omega 6

May be used as adjunctive ADHD therapy in children and adolescents at risk for low iron concentrations

ferrous sulfate