PSYC 15: ADHD

What are the 3 core symptoms of ADHD

Inattention, hyperactivity, impulsivity

Epidemiology of ADHD

1) What is the heritability based on twin studies

2) More males or females

3) Often comorbid with what 5 conditions

1) 76%

2) > Males (3:1) (probably underestimates tho)

3) ODD, ASD, tics, anxiety, depression

—> ODD = Oppositional Defiant Disorder

DSM-5 Criteria for ADHD

1) You must have had several symptoms onset before what age

2) Does expression change over lifet ime? If so, how

3) ___+ symptoms from inattentive and/or hyperactive/impulse criteria

4) Symptoms must persist for more than ____ months

5) Symptoms must appear in ___ or more settings

6) Symptoms must cause functional impairment in ___ or more settings

7) How many symptoms required for patients 17 and up

8) What is the critera score called

1) 12 years old

2) Yes, (More inattentiveness in adulthood)

3) 6+

4) 6 months

5) 2 or more

6) 1

7) 5+

8) SNAP-4 scale

Pathophysiology

1) Disregulation of what neurotransmitters

2) Abnormalities in what brain regions (5)

3) What is DLPFC

4) What is VLPFC

5) What is PC

6) When it comes to the neurotransmitters, what do they both regulate?

7) What networks do you have a dysfunction in (4)

1) Dopamine and norepinephrine circuits

2) Frontal lobe, basal ganglia, cerebellum, caudate nucleus, nucleus accumbens

3) Working memory (executive functioning)

4) Decision making / planning

5) Orientation of attention

6)

• DA = movement, mood, learning, memory

• NE = Mood, stress, attentiom, arousal, signal awareness

7) Networks:

• Executive function

• Reward processing

• Alerting

• Default mode networks

What does the SNAP-IV-26 variant include:

__ symptoms of ___ that are separate from ADHD but commonly co-occur

8 Symptoms of ODD (Oppositional Defiant Disorder)

ADHD Rating Scales… What is:

1) SNAP-IV

2) ADHD-RS-IV/5

3) WFIRS-P

4) ASRS-v1.1

1. Parent/Teacher rated, covers DSM ADHD Criteria + ODD

2. Research oriented

3. Functional impairment across 6 domains (school, family, social, etc)

4. Adult screening tool

Pharmacologic:

1) Stimulants: ___% respond; most effective for core symptoms

2) Name 4 non-stimulants

1) 75%

2) Atomoxetine, guanfacine XR, clonidine, bupropion

MTA Study Bottom Line

Medications > Behavioural therapy for symptom control

BUT combined not superior for core symptoms but it helps with functioning

How do amphetamines inhibit the reuptake of DA and NE

Amphetamines also promote ____ of endogenous DA and NE from ____

Binds directly to the transporter and acts allosterically

• Goes INTO transporter itself

• Sometimes gets taken by the cell

Release; synaptic cleft

How do methylphenidate based stimulants inhibit the reuptake of DA and NE

Binds BESIDE the transporter, doesn’t actually go into the transporter

1) IR

2) CR

3) SR

4) DR

1) Immediate release

2) Controlled release

3) Sustained release

Dextroamphetamine (Dexedrine)

1) What formulations does it come in (2)

2) For the “longer acting” version, it contains 50% ___ and 50% ____ granules

1) IR and spansules

2) 50% IR; 50% DR (delayed release by 4 hours)

Mixed Amphetamine Salts: Adderall XR

1) Mix of ___ different amphetamine salts containing ___% D-AMP and ___% L-AMP

2) The capsule itself is ___ formulation

3) The beads in the capsule itself are 50% ___ beads and 50% ___ beads

4) What is D-AMP

5) What is L-AMP

1) 4 different salts, 75% D-AMP, 25% L-AMP

2) XR

3) IR beads, DR beads

4) More dopaminergic (dextro)

5) More norepinephrine effect (levo) [HR/BP effects]

In Vyvanse: what is the lysine moiety cleaved off by to make d-amphetamine

+ what are they located on

Hydrolytic enzymes on RBCs

Acidic pH ____ elimination and ___ drug level, whilst,

Alkaline pH ____ elimination and ___ drug levels 

Acid = Speeds elimination = decrease drug level

Alkaline = slows elimination = increase drug level

Methylphenidate Ritalin

1) What forms does this come in

1) IR (immediate) and SR (sustained)

Methylphenidate MLR Multi-Layer Release BIPHENTIN

1) Made of ___% ___ beads and ___% ___ beads

2) Initial peak at ___ hours, 2nd peark at ____ hours

1) 40% IR , 60% CR 

2) 2 hours, 6-7 hours (total duration = 10-12h)

Methylphenidate MLR FOQUEST

1) ___% beads, __ % __ beads

2) Intended duration

3) Approved for ages ___+

1) 20% IR, 80% CR

2) 16 HOURS

3) 6+

Methylphenidate (Quillivant ER) CHEW TABS

1) Clinical caveat to remember (not exchangeable with what)

2) __ % __ ; __ % __ (bound to SPS exchange resin)

3) What kind of tablet is this

4) Which size can you NOT cut

5) Which dosage can be cut (2)

6) Does this need to be taken with food

7) What should you avoid and why

8) Banana flavoured chew tabs contains ___ so it is contraindicated in __ patients

1) Not interchangeable with suspension form

2) 30% IR, 70% ER

3) Chewable

4) 40 mg

5) 20 mg , 30 mg

6) No

7) Alcohol, it can speed up release of drug from resin

8) Aspartame; CI in PKU patients

Which methylphenidate brand comes as extended release chewable tablets and suspension  

Quillivant ER 

Methylphenidate (Quillivant ER) Suspension

1) Ratio + What formulations

2) More rapid onset or less than chew tab

1) 20% IR, 80% ER (bound to SPS exchange reson)

2) More rapid onset 

Methylphenidate OROS: CONCERTA

1) __ % of dose is in the __ of capsule and __ ___

2) What happens in the push compartment

1) 22% in the skin; dissolves immediately

2) Polymer expands once H2O hits it, as it starts to swell, it pushes the drug contents up into the 1st / 2nd compartments

____ generics are NOT ___, rather they are ___-____ MPH tablets

—> Most common side effect of this generic

Concerta generics are NOT OROS, they are long lasting MPH tablets

—> NOT BIOEQUIVALENT

—> Loss of symptom control in the afternoon hours

Health Canada bioequivalence definition

1) What to factors

2) Within what range

Cmax + AUC need to be within 80-120% of original drug

You want to caution and avoid stimulants in

1) What 6 medical conditions

2) Patients taking _____ ____ (drug) + why

3) Untreated ___ ___

Q1:

• Prior serious ADRs

• Acute psychosis

• Uncontrolled seizures

• Angle closure glaucoma

• Heart / cardiac problems

2) MAO inhibitors 

• Inhibiting the removers would increase DA and NE too much and lead to HTN crisis 

3) Untreated bipolar disorder