Ch. 66 ADHD

Attention Deficit Hyperactivity Disorder (ADHD)

a psychological disorder marked by

• inattention

• hyperactivity

• impulsivity

What are the primary drugs used in ADHD?

Stimulants (inhibit DA & NE reuptake)

At what age do stimulants become first line for ADHD?

Age ≥ 6 years (Behavioral therapy should be utilized in children younger)

ADHD

DSM-5 Criteria:

≥ 6 symptoms of inattention/hyperactivity in children ≤ 16 years

≥ 5 symptoms of inattention/hyperactivity in those ≥ 17 years

Symptoms must be present for 6+ months (several present before age 12)

Symptoms present in 2+ settings (Home, school, work, etc.)

Symptoms interfere with functioning & not caused by another disorder

DSM-5 Criteria

Inattention

- Fails to pay attention

- Trouble holding attention

- Doesn't pay attention when someone is talking

- Doesn't follow through on instructions

- Fails to finish school work

- Difficulty organizing tasks

- Avoids/dislikes tasks which require mental effort

- Loses things

- Easily distracted

- Forgetful

DSM-5 Criteria

Hyperactivity & Impulsivity

- Fidgets/squirms

- Leaves seat unexpectedly

- Runs about when not appropriate

- Unable to play quietly

- Always "on the go"

- Excessively talks

- Blurts out answers

- Trouble waiting their turn

- Interrupts/intrudes on others

Natural products for ADHD

- Fish oils (improve cognitive function)

- Melatonin (improve sleep onset)

List the Stimulants used for ADHD

- Amphetamine/Dextroamphetamine (Adderall)

- Lisdexamphetamine (Vyvanse)

- Methylphenidate (Ritalin, Concerta, Daytrana patch)

- Dexmethylphenidate (Focalin)

List the Non-stimulants used for ADHD

- Atomoxetine (Strattera)

- Viloxazine (Qelbree)

Add-on medications (or can be used alone)

- Clonidine ER (Kapvay)

- Guanfacine ER (Intuniv)

What medications can be given at night to help sleep onset for those on stimulants?

- Clonidine IR (Catapres)

- Diphenhydramine (Benadryl)

- Melatonin OTC

Symptoms of stimulant abuse

- Dilated pupils

- Increased HR & BP

- Sweating

- Tremor

- Anxiety

Stimulant

Contraindications

• Do not use within 14 days of an MAO inhibitor due to risk of hypertensive crisis when used together

Stimulant

Warnings:

- Drug Diversion

- Increased HR and BP

• Can cause serious cardiovascular events in children and adults

- Priapism

- Exacerbation of preexisting psychosis

- Decreased appetite

- Risk of serotonin syndrome

Stimulant

Side Effects

• Insomnia

• Decreased appetite/weight loss

• Headache

• Irritability

Methylphenidate

Dosing

IR tablet (Ritalin)

• start 5 mg BID

ER tablet with OROS delivery (Concerta)

• start 18-36 mg QAM

ER capsule (Jornay PM)

• QPM

Transdermal patch (Daytrana)

• QAM

Daytrana

Notes

• Apply to the hips 2 hrs before desired effect

• Remove after 9 hrs

• Alternate hips daily

• Discard used patches by flushing down the toilet

SNRI Non-Stimulant

Atomoxetine (Strattera)

Atomoxetine

Boxed Warnings/Contraindications/Notes

Boxed Warnings

• Risk of suicidal ideation

Contraindications

• MAO inhibitor use within the past 14 days

Notes

• Do not open the capsule

Atomoxetine

Side effects:

- Insomnia

- Decreased appetite

- Somnolence

- Dry mouth

- HTN

- Tachycardia

Centrally-Acting Alpha-2 Adrenergic Receptor Agonists

Non-Stimulants

• Clonidine ER (Kapvay)

• Guanfacine ER (Intuniv)

Clonidine, Guanfacine

Side effects:

- Dry mouth

- Somnolence

- Fatigue

- Dizziness

- Constipation

- Decreased HR

- Hypotension

Clonidine ER and Guanfacine ER

Dosing

Clonidine ER

• QHS

Guanfacine ER

• Daily

Clonidine ER and Guanfacine ER

Warnings

• Dose-dependent cardiovascular effects

• Sedation and drowsiness

• Do not discontinue abruptly (can cause rebound hypertension)