pharm III adhd and insomnia

ADHD

-Attention deficit hyperactivity disorder

-Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with function or development

ADHD Executive functions

-Patients are considered neurodivergent

-Not a marker for intelligence

-Brain processes and holds info differently

-Low brain activity in areas of executive functions

ADHD Inattention Symptom criteria

-> Six symptoms of inattention for children up to age 16 years

-> Five for people aged 17years and older

-present for at least 6 months

-inappropriate for developmental level

ADHD Inattention Symptoms

-Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

-Often has trouble holding attention on tasks or play activities.

-Often does not seem to listen when spoken to directly.

-Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

-Often has trouble organizing tasks and activities.

-Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

-Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

-Is often easily distracted

ADHD Impulsivity/Hyperactivity Symptom criteria

-> Six symptoms of hyperactivity-impulsivity for children up to age 16 years

-> five or more for people age 17 years and older

-symptoms of hyperactivity-impulsivity have been present for at least 6 months

-disruptive and inappropriate for the person's developmental level

ADHD Impulsivity/Hyperactivity Symptoms

-Often fidgets with or taps hands or feet, or squirms in seat.

-Often leaves seat in situations when remaining seated is expected.

-Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

-Often unable to play or take part in leisure activities quietly

-Is often "on the go" acting as if "driven by a motor"

-Often talks excessively

-Often blurts out an answer before a question has been completed

-Often has trouble waiting their turn

-Often interrupts or intrudes on others (e.g., butts into conversations or games)

Adult ADHD

< 20% of patients receive diagnosis and care

• High functioning ADHD

• Associated with depression, anxiety

stimulants examples (2)

Methylphenidate

Amphetamines

stimulants MOA

-Not well described

-Sympathomimetics

-Increase NE and DA in brain by blocking reuptake

-High potential for abuse and dependence

-CII

stimulant abuse

-Intranasal (Similar to cocaine)

-Orally (Smart Drugs, Study Drugs)

-Cognitive enhancers

stimulants warnings/CI

CV

-Sudden death, CVA and MI reported in adults

-Sudden death in kids with structural abnormalities

-Need thorough cardiac history—personal and family

-Psychosis exacerbation

-Growth suppression

-Peripheral vasculopathy

-Raynaud's

-Contraindicated with MAOIs, anxiety, agitation

stimulants ADRs

-Insomnia

-Decreased appetite

-Diminished growth

-1-2 cm from predicted adult height

-First 2 years of treatment

-Weight loss

-Abdominal pain

-Headache

-Increased B/P, HR

Rare: Hallucinations, psychosis

Atomoxetine (Strattera) MOA

Selective NE reuptake inhibitor

T/F Atomoxetine (Strattera) is a controlled substance

false, not a controlled substance

Atomoxetine (Strattera) warnings

-Increased risk of suicidal ideation in children and adolescents

-CV events

-Increased B/P, HR

-Liver injury

-Psychosis

-Urinary retention, priapism

Atomoxetine (Strattera) ADRs

Peds: N/V, decreased appetite, fatigue, somnolence

Adults: Constipation, dry mouth, nausea, fatigue, decreased appetite, insomnia, erectile dysfunction, urinary hesitation, urinary retention, dysuria, dysmenorrhea, and flushing

Atomoxetine (Strattera) drug interactions

2D6 inhibitors, MAOIs, albuterol

Viloxazine (Qelbree) MOA

Inhibition of norepinephrine reuptake (SNRI)

Viloxazine (Qelbree) CI

MAOIs, CYP1A2 drugs

Viloxazine (Qelbree) warnings and ADRs

-B/P, HR

- Activation of mania/hypomania

-Screen patients for bipolar disorder

-Somnolence/fatigue

-No driving or operating heavy machinery

-Other ADRs: decreased appetite, nausea, headaches, insomnia, dry mouth, constipation

Non stimulants examples

Antihypertensives, Guanfacine, Clonidine

Pediatric ADHD treatment guidelines

-Pre-school kids (age 4 - 6): PTBM, methylphenidate if moderate to severe symptoms

-Peds (age 6 - 12):

-First-line: Parent training and behavioral management (PTBM) + medication

-Adolescents (age 12 -18): medications, educational interventions

-Include patient in decision-making

-Plan for transition to adult care

adult ADHD treatment guidelines

-Currently under development

-Adults:

-First-line: stimulants

-Second-line: non-stimulants

-Education, cognitive and behavioral skills training, psychotherapy, coaching, mindfulness meditation

1st line ADHD meds for adults

stimulants

Insomnia

-Most common sleep disorder in general population

-Difficulty with sleep initiation, duration, or quality despite adequate opportunity for sleep

-Results in daytime impairment

-Sleep history

- Specifics

-Falling asleep, staying asleep or both

-r/o and treat potential other causes

American Academy of Sleep Medicine Guidelines of what to use

-Suvorexant, zaleplon, triazolam, doxepin for sleep maintenance

-Ramelteon for sleep onset

-Eszopiclone, zolpidem, temazepam for sleep onset and sleep maintenance

American Academy of Sleep Medicine Guidelines of what not to use

-Trazodone

-Diphenhydramine

-Tiagabine

-Melatonin

-Valerian

-Tryptophan

BZDs for insomnia

-No longer used frequently

-daytime sedation

-cognitive impairment

-increased risk of falls in elderly

-Tolerance and dependence

Temazepam (Restoril): Short-term treatment up to 2 weeks

Triazolam (Halcion): Amnestic; used for pre-op anxiety

meds used for sleep maintenance (4)

Suvorexant, zaleplon, triazolam, doxepin

med used for sleep onset (1)

Ramelteon

meds used for both sleep maintenance and sleep onset (3)

Eszopiclone, zolpidem, temazepam

med used for pre operative anxiety

Triazolam (Halcion)

BDZ receptor agonists (bzras) MOA

-Selectively binds GABA receptor at BDZ 1 site

-Targeted to sedation

-No anxiolysis, anticonvulsant effects

-Lower risk of dependence than BDZ

BDZ receptor agonists(bzras) indications

-First-line for short-term treatment of insomnia

-Was up to 4 weeks

-Now considered to have long-term efficacy without tolerance up to 12 months

-Take on empty stomach

-CIV

First-line for short-term treatment of insomnia

BDZ receptor agonists (bzras)

Zolpidem (Ambien, Edluar) information

-Used for sleep-onset and sleep-maintenance insomnia

- Short half-life so need CR form for sleep maintenance

-Lower starting dose for women

-5 mg vs 5 - 10 mg for men

-6.25 mg vs 6.25 - 12.5 mg for extended release

-Take immediately before bedtime

-Best to limit use to 2 - 4 weeks

-CR form used up to 6 months

Zolpidem (Ambien, Edluar) ADRs

-Rebound insomnia

- Drowsiness, dizziness

-Allergic reaction, angioedema

-Dry mouth

-Abdominal pain

-HA

-Parasomnias: Sleep driving, Sleep eating

-Abnormal thinking

-Strange behavior

-Next day impairment

-Counsel patients on avoiding driving next day, particularly with CR formulation

Zolpidem (Ambien, Edluar) drug interactions

-3A4 substrate

-Pregnancy Category C

Eszopiclone (Lunesta) information

-Used for sleep onset and sleep maintenance

-Quick onset

-Longer half-life

-Dose when pts have at least 7 - 8 hrs to sleep

- Dose dependent: 1mg - 2 mg for sleep latency. 3 mg for sleep maintenance

-Start low and titrate up

-Elderly, liver abnormalities

Eszopiclone (Lunesta) ADRs

-Unpleasant taste (1/3)

- Headache, infection

-Next day impairment

-Parasomnias

- Anaphylaxis, angioedema

Eszopiclone (Lunesta) drug interactions

-3A4 substrate

-Interactions with CNS depressants like EtOH

-Pregnancy category C

Zaleplon (Sonata) info and side effects

-Rapid onset, short half-life

- Good for sleep latency with rare next day impairment

- Can be taken upon nocturnal awakening if pt has 4 hrs left to sleep

-Well-tolerated

-HA, dizziness, somnolence

-Complex behaviors

-anaphylaxis

melatonin MOA

-Hormone produced by pineal gland

- Influenced by day/night

-Light inhibits secretion

- darkness stimulates secretion

-Maintenance of normal circadian rhythm

-Insomniacs tend to have lower melatonin levels

Ramelteon (Rozerem) information

-Indicated for sleep onset

-Trials up to 6 months

-Take on empty stomach w/in 30 min of going to bed

-Not a controlled substance

-CYP 1A2

Ramelteon (Rozerem) ADRs

-Somnolence, fatigue, dizziness

-Take on empty stomach

-Avoid in patients with liver problems

Ramelteon (Rozerem) MOA

-Melatonin receptor agonist

-Maintenance of normal circadian rhythm

melatonin indications

-Used for sleep latency

- Jet lag, insomnia: dose in evening

- Works similar to temazepam

melatonin side effects

-Well tolerated

-daytime drowsiness, HA, dizziness

-No driving or operating heavy machinery 4 - 5 hrs after use

-Perimenopausal women: resumption of menstrual flow

melatonin drug interactions

potentiates anticoagulants, inhibits AEDs, decreased B/P, increased hyperglycemia

Tasimelteon (Hetlioz) indication

Indicated for Non-24-Hour Sleep-Wake Disorder

Suvorexant (belsomra) MOA

-Orexin receptor antagonist

-Thought to suppress wake drive

-Gene mutations in orexin lead to hereditary narcolepsy

-Orexin: neurotransmitter promotes wakefulness

Suvorexant (belsomra) indications

sleep latency and sleep maintenance

Suvorexant (belsomra) CI

-Contraindicated in narcolepsy

-Take no more than 30 min before bed

-Need at least 7 hours available for sleep

-CIV

Suvorexant (belsomra) ADRs

-dose-dependent, next-day impairment, complex behaviors, depression, decreased resp fxn, hallucinations, sleep paralysis

-3A4 substrate: lower dose with inhibitors

Doxepin (Silenor) info

-Antihistamine effects for sleep onset and maintenance

-lower dose than antidepressant dose (TCA)

Doxepin (Silenor) CI

-urinary retention, glaucoma, MAOIs

-Warning for suicide risk

Doxepin (Silenor) ADRs

Daytime sedation, dry mouth, dry eyes, orthostasis, arrhythmias

examples of antidepressants that can be used in insomnia tx

Doxepin, amitriptyline, nortripyline, mirtazapine

med used for insomnia in patients with anxiety

hydroxyzine (antihistamine)

Valerian root info

-sedative-hypnotic, anxiolytic, antidepressant, anticonvulsant, and antispasmodic effects

-Likely safe up to 4 weeks of use

-Modest improvement in sleep latency

-Well-tolerated

-HA, GI upset, mental dullness, excitability, uneasiness, cardiac disturbances, insomnia

-Associated hepatotoxicity but may have been adulterating substances