Neuro/Psych Exam 4 Part 2: Bipolar Disorder, ADHD

Bipolar Disorder

Dr. Lambert

What are the 3 Bipolar disorders?

- Bipolar I

- Bipolar II

- Cyclothymic Disorder

Bipolar Disorder Epidemiology:

- Overall prevalence in US sis 4.4% with __________ being slightly more common than _______

- Symptoms usually present __________, ______ _______ (MOST BEFORE age _______)

- BP I has __________ rates between males and females

- BP II, mixed presentation or depression is more common in __________

- HIGH RISK OF ___________!!!

- BP II >> BP I

- late teens, early adult (18)

- similar

- female

- suicide

Mood Episodes: Mania

- Mood, energy level are abnormally __________ with _______ functional impairment for at least __________

- elevated ; marked ; 1 week

Mood Episodes: Hypomania

- Mood, energy level are _______ with ______ functional impairment for at least _________

- elevated ; less ; 4 days

Mood Episodes: Euthymia

- A _______, _________, "________" mood

- normal, tranquil, "baseline"

Mood Episodes: Depression

- Mood, energy level are _________ _________

- abnormally decreased

Mania Causes: Medical Conditions

- _________ disorders ===> Brain _______, ________, systemic lupus erythematosus, temporal lobe ________, MS, Huntington’s disease, _______, subdural hematoma

- ____________ ===> Encephalitis, neurosyphilis, sepsis, HIV

- __________ or __________ abnormalities ===> Ca/Na fluctuations, ________ extremes (high or low)

- ___________ or _________ dysregulation ===> Addison’s, Cushing, Thyroid (hyper or hyp), Perimenopausal, menstrual-related or pregnancy-related

- CNS ===> tumor, stroke, seizures, TBI

- infections

- electrolyte or metabolic ===> glucose

- Endocrine or hormonal

Mania Causes: Medications

- _________ intoxication

- Drug withdrawal

- ________

- CNS ________

- Xanthines

- Hallucinogens

- ________ intoxication

- NE-augmenting agents

- _________

- _________ medications

- OTC weight loss drugs

- OTC _____________

- St. John wort

- alcohol

- antidepressants

- stimulants

- cannabis

- steroids

- thyroid

- decongestants

Bipolar I Disorder Diagnostic Criteria

- MUST meet criteria for MANIC EPISODE = A distinct period of abnormally and persistently _______, _______, or _______ mood and abnormally and persistently increased _______ or _______, lasting at least ________ and present most of the day, nearly every day (or any duration if _________ is necessary)

- ______________ additional symptoms

- Significant functional impairment __________ and ___________ common (potential for _________ or harmful to others)

- No other possible causes

- _________ episode and/or _________ episode

- elevated, expansive or irritable ; activity or energy ; 1 week (hospitalization)

- 3 or more

- psychosis and hospitalization (self-harm)

- hypomania and/or depressive

Bipolar I Disorder: Need 3 of the following symptoms

1. __________________

- Boasting of future achievements

2. __________ ___________ ______ __________

- Days w/o sleep or very little sleep (often just before mania episode)

3. ____________ _____________

- Talking more and faster than usual

4. __________ ____ __________

- Thoughts are coming faster than can be verbalized

5. ____________

- Unable to maintain focus and decreased productivity

6. ___________ ____________ _____________

- Feels energetic, enthusiastic, motivated, creative

7. Excessive Involvement in ___________ ___________ with ___________ ____________

- Spending sprees, sexual indiscretions, reckless driving, risk taking

1. Grandiosity

2. Decreased need for sleep

3. Pressured speech

4. Flight of Ideas

5. Distractibility

6. Increased Psychomotor Agitation

7. Pleasurable activities with serious consequences

Bipolar II Disorder: Diagnostic Criteria

- Must meet criteria for ___________ episode AND ________ _________ _________: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least _____________ and present most of the day, nearly every day.

- ___________ additional symptoms (same as Bipolar I)

- _________ _________ __________, NO ____________, NO ____________

- No other possible causes such as medical conditions or medications

- hypomania AND major depressive episode ; 4 consecutive days

- 3 or more

- less functional impairment, NO hospitalizations, NO psychosis

Cyclothymic Disorder: Diagnostic Criteria

- MULTIPLE episodes of __________ and _________ that are "___________", not enough to meet diagnosis

- Lasts for ___________ and cannot go without symptoms for more than ___________

- Must less functional impairment

- No other possible causes such as medical conditions or medications

- Increased risk for developing ________ or ________

- hypomania and depression ; "subclinical"

- 2 years ; 2 months

- BP I and BP II

Medications for Bipolar Disorder: Aripiprazole (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Abilify

- SGA

- yes

- yes

- no

Medications for Bipolar Disorder: Aripiprazole (_______ _______)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Abilify Maintena

- SGA

- no

- yes

- no

Medications for Bipolar Disorder: Asenapine (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Saphris

- SGA

- yes

- yes

- no

Medications for Bipolar Disorder: Carbamazepine (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Equetro

- anticonvulsant

- yes

- yes

- no

Medications for Bipolar Disorder: Cariprazine (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Vraylar

- SGA

- yes

- no

- no

Medications for Bipolar Disorder: Divalproex (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Depakote

- anticonvulsant

- yes

- yes

- no

Medications for Bipolar Disorder: Lamotrigine (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Lamictal

- anticonvulsant

- no

- yes

- no

Medications for Bipolar Disorder: Lithium carbonate (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Eskalith

- lithium salts

- yes

- yes

- no

Medications for Bipolar Disorder: Lithium citrate (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Cibalith-S

- lithium salt

- yes

- yes

- yes

Medications for Bipolar Disorder: Lumateperone (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Caplyta

- SGA

- no

- no

- yes

Medications for Bipolar Disorder: Lurasidone (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Latuda

- SGA

- no

- no

- monotherapy only

Medications for Bipolar Disorder: Olanzapine (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Zyprexa

- SGA

- yes

- yes

- no

Medications for Bipolar Disorder: Olanzapine + Fluoxetine (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Symbyax

- SGA + SSRI

- no

- no

- yes

Medications for Bipolar Disorder: Quetiapine (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Seroquel

- SGA

- yes

- yes

- monotherapy only

Medications for Bipolar Disorder: Risperidone (_______, ________ ________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Risperdal, Risperdal Consta

- SGA

- yes (risperdal)

- yes (risperdal consta)

- no

Medications for Bipolar Disorder: Valproic Acid (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Depakene

- anticonvulsant

- yes

- yes

- no

Medications for Bipolar Disorder: Ziprasidone (_________)

- Drug Class = __________

- Acute Mania = _________

- Maintenance = ____________

- Acute BP Depression = ___________

Geodon

- SGA

- yes

- no

- no

Lithium is considered the _________ ________ for maintenance, acute mania and acute depression in Bipolar Disorder.

- NOT _______, _________ excreted

- Only 1 of 2 agents indicated for _____________ ____________

ADRs Upon Starting

- _______ related

- Worse ________ after dose

- GI: anorexia, N/V/D, abdominal pain, _________ can be serious

- CNS: sedation, ataxia, abnormal gait, confusion, lethargy, memory impairment, slurred speech, headache

ADRs Long-Term

- ________ and _________ with and without diabetes insipidus

- _________ issues

- ____________ more common in females, requires hormones

- __________ ________ from fluid retention, high calorie beverages, and slowed metabolic rate

gold standard

- NOT metabolized, renally

- suicide prevention

- dose

- 1-2 hours

- dehydration

- polydipsia and polyuria

- cardiac

- hypothyroidism

- weight gain

How can ADRs of Lithium be managed when first starting?

- lower starting dose

- take dose with food

- use ER formulation

- once daily at bedtime

Lithium Monitoring

Before starting

- Complete physical exam with ______ screening and _______ test

- ________ with diff and electrolytes

- Metabolic screening: fasting _______, _______ panel, _______

- Renal and thyroid function tests

- _________ screening

Every 6-12 months

- ________ with diff and electrolytes

- Metabolic screening: fasting _______, _______ panel, _______

- Renal and thyroid function tests

- _________ screening

- SUD ; pregnancy

- CBC

- glucose, lipid panel, weight

- dermatologic

- CBC

- glucose, lipid, weight

- dermatologic

Anticonvulsants Valproate and Divalproex are the most commonly prescribed __________ ___________ and only FDA approved for _______ _______ and _________ ________ treatment, although still used for ___________. Usually one of multiple drugs in a regimen.

MORE effective for ________ ________, _________ ________, comorbid ________ than Lithium

mood stabilizers ; acute mania and mixed episodes ; maintenance

rapid cycling, mixed features, SUD

True/False

Valproate and Divalproex are equally effective for pure mania as lithium and olanzapine

true

Anticonvulsants Valproate and Divalproex

ADE

- CNS ===> _________, fine tremor, _________, ataxia, asthenia, ___________

- GI ===> __________ (_________), anorexia, constipation, dyspepsia, weight gain

- _________

- ___________ __________ __________

- Elevated ammonia levels, hyperandrogenism, hyperinsulinemia

- Life-threaten and rare ===. Hepatotoxicity with liver failure, Pancreatitis

Monitoring

- Complete physical exam with ______ screening and _______ test (before starting)

- ________ with diff and electrolytes

- Metabolic screening: fasting _______, _______ panel, _______

- Liver function tests

- _________ screening

- sedation ; dizziness ; headache

- GI upset (N/V/D)

- alopecia

- polycystic ovarian syndrome

- SUD ; pregnancy

- CBC

- glucose, lipid, weight

- dermatology

Anticonvulsants Valproate and Divalproex

Drug Interactions

- Plasma levels LOWERED by: ____________, ____________, _________, ___________, ____________

- Plasma levels INCREASED by: ____________, ___________, _____________, ____________, topiramate, cimetidine, ___________ and ____________

- When used with Valproate, decrease ___________ dose by __________

- carbamazepine, phenytoin, ethosuximide, phenobarbital, rifampin

- felbamate, chlorpromazine, fluoxetine, fluvoxamine, erythromycin and ibuprofen

- decrease lamotrigine by 50%

Carbamazepine is structurally related to TCAs.

- NOT __________, generally reserved for lithium-refractory, ________ _______ or ________ ________

- Long-term effectiveness is unclear

- Often used for treatment-resistant patients in _______ episode with lithium + valproate + antipsychotics

Drug Interactions

- Increases hepatic metabolism of _________, _________ and _________, which is problematic since these can be used first line for bipolar disorder

- Strategy is to ________ doses

- NOT 1st-line ; rapid cyclers, mixed states

- manic

- antidepressants ; anticonvulsants ; antipsychotics

- increases

Oxcarbazepine is related to CBZ, but has less data supporting its use.

- Generally ___________ for __________ episodes

- NO FDA approval for Bipolar disorder

- __________ _________ __________

- Dose-related ADE: cognitive and _________ ________, _________, coordination difficulties, ___________

- 3rd line for mania

- Stevens-Johnson syndrome

- psychomotor impairment, somnolence, hyponatremia

Lamotrigine is an __________ and has _________-__________ effects

- Somewhat less effective for acute mania, but has _________ ________ ________ to mania (i.e. ________________)

- Beneficial in _________ therapy for treatment-resistant BP I and BP II

- Most effective in ____________ of ___________ ____________

ADE:

- Headache, nausea, dizziness, ataxia, diplopia, drowsiness, tremor, rash, pruritus

- __________ _________, Stevens-Johnson syndrome

Drug Interactions

- ___________ significantly inhibits metabolism of lamotrigine ---> half-life __________

antidepressant ; mood-stabilizing

- low switch rate (not as sudden)

- maintenance

- prevention of bipolar depression

- maculopapular rash

- valproate ---> half-life doubles

Lamotrigine Rash

Risk Factors

- ____________ patients (especially patients < _____ yr)

- Patients with a history of drug-induced rash

- Exceeding recommended _______ ______ _______

- Rapid dose _________

- Concomitant use of ________

- Patient in first ____ weeks of treatment

Prevention and Management

- Initiate at recommended starting dose

- Follow recommended titration regimen

- Both starting dose & titration regimen depend on patient’s ________ __________

- Starting doses vary between 25 mg QOD to 50 mg daily

- _______ __________ as soon as rash develops

- pediatric (<13)

- initial starting dose

- escalation

- valproate

- 6 weeks

- other medications

- stop lamotrigine

Antipsychotic Medication

- Prefer ________>>>________

- Role in therapy = _________ _________ as monotherapy and adjunctive therapy, particularly episodes with _______ + _________ ________

- Some oral preparations have approval as monotherapy for __________

Dosing

- May need _______ _______ _______ in acute setting, then taper and discontinue once controlled

- Try maintenance on _______ _______ _________

- _________ or _________+__________ best for acute BP depression

- For rapid cycling and refractory BP -----> __________ monotherapy for __________ __________

- SGA >> FGA

- acute mania ; psychosis + psychomotor agitation

- maintenance

- higher initial doses

- mood stabilizer alone

- Quetiapine or fluoxetine + olanzapine

- Clozapine ; suicide prevention

Hypomania Treatment Guideline

FIRST STEP = _________ __________

- Start or optimize current

- _________, __________, _________, or __________

- Add __________ for agitation or insomnia

- ____________

SECOND STEP = ____________ _____________

- If inadequate response after 1st step

- _________ plus _________ or _______

OR

- _________ + ________ or __________

mood stabilizer

- Lithium, valproate, carbamazepine, SGA

- benzo

- olanzapine

2 drug regimen

- Lithium + antiseizure or SGA

- antiseizure + antiseizure or SGA

Mania Treatment Guidelines

FIRST STP = _________ _______

- Optimize previous regimen or begin ________ regimen

- AND ________ and/or _______

- CBZ is an option

SECOND AND THIRD STEPS

- 2nd ===> 3 drug combo ===> ________ + ________ + _________ OR _______ + ________ + _________

- 3rd ===> ___________ __________ if psychosis or catatonia

- Can consider _________

mood stabilizer

- 2-3 drug

- AND benzo and/or SGA (not two SGAs)

- lithium + antiseizure + SGA OR antiseizure + antiseizure + SGA

- electroconvulsive therapy

- clozapine

Depression Treatment Guidelines

Mild to Moderate Depression

- Begin or Optimize ________ _________

- Alternative #1: antiseizure meds ===> __________, _________

- Alternative #2: antipsychotic meds ===> _________/_________ combo, _________, __________

Severe Depression

- 1st step ---> _________, _________, Lurasidone, ________/_________ combo

- If _________, optimize SGA or add cariprazine, lumateperone

- Alternative antiseizure meds = ________, _________

- 2nd step ----> _________ or __________

- 3rd step -----> _________ + __________ or __________ + ___________

- 4th step -----> _________ for treatment-resistant BP and depression, especially if psychosis or catatonia

- mood stabilizer

- lamotrigine, valproate

- fluoxetine/olanzapine, cariprazine, lumateperone

- lithium, quetiapine ; fluoxetine/olanzapine

- psychosis

- lamotrigine, valproate

- CBZ or antidepressant

- lithium + lamotrigine or quetiapine + antidepressant

- ECT

Antidepressants for BP Depression: Concerns for use

- Increased risk of _______-_______ BP in 1st year of treatment

- History of ________ after depressive episode

- Did not appear to protect from depression

AVOID in patients:

- At risk for treatment-emergent affective switch

- With depression with ______ ______, ________ _______, history of poor response to these medications

- AVOID _____________ when possible

- rapid-cycling

- mania

- mixed features, rapid cycling

- avoid monotherapy

ADHD

Dr. Johnson

ADHD is a CHRONIC condition characterized by ____________, _________ and ___________

hyperactivity, inattention and impulsivity

Deficiency of what 2 neurotransmitters are associated with ADHD ?

Dopamine and Norepinephrine

Dopamine Deficiency is responsible for aspects of cognitive function such as (4 things)

executive function

serial learning

sustaining attention

verbal fluency

Norepinephrine Deficiency is responsible for mediating modification of behavior (3)

energy/fatigue

motivation

sustaining attention

Diagnostic Criteria for ADHD with DSM-V

- Presence of _________ or more symptoms from the ________ and/or ________/__________ category (in patients ≥17 years of age, _______ or more symptoms)

- Symptoms present for at least ___________

- Onset of symptoms before _________

- Symptoms in at least ______ different settings

review symptoms slide 22

- 6 ; inattention and/or hyperactivity/impulsivity ; 5

- 6 months

- 12 yr old

- 2

DB is a 10 year-old boy who presents to the clinic today with his mom. Mom reported that her son has been doing poorly at school. He usually forgets his books at home, doesn't remain focused during lectures, and doesn't listen when spoken to as reported by his teachers. Mom noticed same symptoms at

home plus he doesn't play quietly, always interrupts others and very talkative.

Does this patient meet the ADHD diagnostic criteria?

A. Yes

B. No

A. Yes

What neurotransmitters are shown to be involved in ADHD?

A. Serotonin & epinephrine

B. Serotonin & dopamine

C. Epinephrine & dopamine

D. Dopamine & norepinephrine

D. Dopamine & norepinephrine

Drug Selection Algorithm

3-5 years old:

- Step 1 = ___________

- Step 2 = ___________

6-17 years old

- Step 1 = ___________ or ___________

- Step 2 = ___________ (_________ has less abuse potential)

- Step 3 = __________, _________, __________, or __________

- Step 4 = ___________ or __________

≥18 years old

- Step 1 = ___________ (________ has less abuse potential)

- Step 2 = _________ or ___________

- Step 3 = ___________, ___________, ___________ or ___________

- Step 4 = _________ or ___________

- methylphenidate

- amphetamine

- methylphenidate or dexmethylphenidate

- amphetamine (lisdexamfetamine)

- atomoxetine, clonidine, guanfacine or viloxazine

- bupropion or TCAs

- amphetamine (lisdexamfetamine)

- methylphenidate or dexmethylphenidate

- atomoxetine, clonidine, guanfacine or viloxazine

- bupropion or TCAs

Comparisons Between Stimulants: Methylphenidate, Dexmethylphenidate

Advantages

- Better tolerability in ______ and _________

- Lower growth and appetite suppression

- Lower _________

- Lower _____ ______

Disadvantages

- More ______ pharmacokinetics

- High differences between brand and generic formulations

- children and adolescents

- insomnia

- tics worsening

- erratic

Comparisons Between Stimulants: Amphetamines

Advantages

- More ________

- More ________ pharmacokinetics

• Lisdexamfetamine has less ________ potential

Disadvantages

- Higher ______ and _______ suppression

- More ________

- Higher tics worsening

- potent

- predictable

- less abuse

- growth and appetite

- insomnia

Choosing Methylphenidate/Dexmethylphenidate Formulations:

- Rapid Onset / Short Duration ==> Taken __________ ==> _________, ________ and _______

- Rapid Onset/Intermediate ===> Taken _________ ==> __________, _________ and ________

- Slow Onset/Intermediate ===> Taken _________ ==> __________and _________

- Rapid Onset/Long ===> Taken ________ ==> ________ and ________

- Slow Onset/Long ===> Taken ________ ==> __________ and ________

- BID-TID ===> methylin, ritalin, focalin

- daily-BID ===> metadate CD, ritalin LA, focalin XR

- daily-BID ===> metadate ER, ritalin SR

- daily ===> concerta and azstarys

- daily ===> daytrana and jornay PM

Methylphenidate/Dexmethylphenidate Formulations: Rapid Onset and Short Duration

- ____________ = Methylin and Ritalin

- ____________ = Focalin

- Onset = ____________

- Duration = ___________

Review counseling points slide 43

- methylphenidates

- dexmethylphenidate

- 20-60 min

- 3-5 hours

Methylphenidate/Dexmethylphenidate Formulations: Rapid Onset and Intermediate Duration

- ____________ = Metadate CD, Ritalin LA

- ____________ = Focalin XR

- Onset = ____________

- Duration = ___________

Review counseling points slide 45

- methylphenidates

- dexmethylphenidate

- 20-60 min

- 6-8 hours

Methylphenidate/Dexmethylphenidate Formulations: Rapid Onset and Long Duration

- ____________ = Concerta

Onset = ____________

Duration = ___________

- __________ = Azstarys

Onset = __________

Duration = ________

review counseling points slide 48

- methylphenidate ; 20-60 min ; 12 hours

- serdexmethylphenidate/dexmethylphenidate ; 30 min ; 13 hours

Methylphenidate/Dexmethylphenidate Formulations: Slow Onset and Intermediate Duration

- ____________ = Metadate ER, Ritalin SR

- Onset = ____________

- Duration = ___________

review counseling points slide 50

- Methylphenidate

- 1-4 hours

- 6-8 hours

Methylphenidate/Dexmethylphenidate Formulations: Slow Onset and Long Duration

- ____________ = Daytrana (patch)

Onset = _______

Duration = _________

- ____________ = Jornay PM (oral capsule)

Onset = __________

Duration = __________

review counseling points slide 53

- Methylphenidate ; 60 min ; 12 hours

- Methylphenidate ; 10-14 hours ; 12 hours

Amphetamine Products Formulations: Rapid Onset and Short Duration

- Amphetamine/Dextroamphetamine = __________

- Dextroamphetamine = __________ and ___________

- Amphetamine = ______________

- Onset = __________

- Duration = ___________

Review counseling slide 56

- adderall

- dexedrine, dextrostat

- evekeo

- 20-60 min

- 4-6 hours

Amphetamine Products Formulations: Rapid Onset and Long Duration

- Amphetamine/Dextroamphetamine = __________

- Dextroamphetamine = __________ ___________

- Amphetamine = ____________ / ________

- Onset = __________

- Duration = ___________

review counseling slide 58

- Adderall XR

- Dexedrine Spansule

- Adzenys XR / ODT

- 20-60 min

- 8-10 hours

Amphetamine Products Formulations: Slow Onset and Long Duration

- Lisdexamfetamine = __________

Onset = _________

Duration = __________

- Dextroamphetamine = __________ and __________

Onset = __________

Duration = ___________

Review counseling slide 61

- Vyvanse ; 1-3 hours ; 10-12 hours

- Xelstrym ; 1 hour ; 9 hours

Stimulant Considerations in Age Groups:

Preschool Children

- __________ products only stimulants with FDA-labeled for children 4-5 years of age, but little evidence to support their safety/efficacy

- Evidence to support BOTH efficacy & safety ____________ in children 4-5

years of age but has no FDA-labeled indication

- _______________ is first line

Adolescents

- _______ and _________ symptoms are common symptoms

- Assess for symptoms of substance use/abuse & risk of diversion prior to starting stimulants

- ___________® (lisdexamfetamine) could be preferred stimulant

Adults

- _________ symptoms most common symptoms

- Cognitive defects and unstable relationships noted with adults who have ADHD

- Comorbid conditions can ↑ chance of ADHD extending into adulthood

- Same agents can be used in adults, but to think about ________ interactions, underlying __________, & maximum doses

- amphetamine

- methylphenidate

- nonpharmacological

- inattention and impulsivity

- Vyvanse

- inattention

- drug-drug ; comorbidities

What are 6 common ADE associated with stimulants?

- Reduced appetite, weight loss

- stomach ache

- insomnia

- headache

- rebound symptoms

- irritability

Stimulants ADE Management: Reduced Appetite, Weight Loss

- Give __________ meal at breakfast or bedtime

- Consider adding _________

- high-calorie

- cyproheptadine

Stimulants ADE Management: Stomach Ache

- Administer stimulant on _______ ________

- ________ _______ if possible

- full stomach

- lower dose

Stimulants ADE Management: Insomnia

- Give dose _____________

- Lower the _________ of the day

- Switch to ________ or ________ acting agent

- Consider _______ at bedtime

- earlier in day

- last dose

- short or intermediate

- sedation

Stimulants ADE Management: Headache

- ________ _______

- Give with _________

- Give an __________

- divide doses

- with food

- analgesic

Stimulants ADE Management: Rebound Symptoms

- Consider __________ stimulant trial or __________ or ____________

- longer-acting ; atomoxetine ; antidepressant

Stimulants ADE Management: Irritability

- Assess _______ _______

- _________ ________

- Consider _______ ________ or _________ __________

- comorbid condition

- reduce dose

- mood stabilizer or atypical antipsychotic

What are the 2 BBW of stimulants?

- sudden cardiac death

- new onset or worsening psychiatric manifestations

A 10-year-old boy who was given a diagnosis of ADHD. The physician would like to use a methylphenidate product that will last at least 10 hours.

Which medication would you recommend from the following?

A. Adderall XR®

B. Methylin®

C. Ritalin SR®

D. Concerta®

D. Concerta®

CM is a 16-year-old girl who was diagnosed today with ADHD. The physician believes his patient CM may have some substance abuse potential and wants to prescribe an amphetamine based product that is a prodrug.

Which agent would you recommend?

A. Vyvanse®

B. Dexedrine Spansule®

C. Dextrostat®

D. Adderall XR®

A. Vyvanse®

TJ is a 8 year old boy who is currently on Adderall® 5 mg daily (7am). Teacher has noticed that TJ started to display signs & symptoms of ADHD during last few periods.

What may be helpful for TJ?

A. Take Adderall® 5 mg at noon

B. Switch to Adderall XR® 5 mg daily

C. Switch to Ritalin® 5 mg daily

D. Switch to Daytrana® 20 mg daily

B. Switch to Adderall XR® 5 mg daily

Non-Stimulant: Atomoxetine (_________)

MOA:

- Selective __________ reuptake inhibitor

Indications

- Step 3 for all ADHD symptoms

- Patients with ______________/________ __________

Pearls:

- Takes _________ to see effect

- Shown to be 63-80% effective without stimulant therapy

- Shown to be ________ effective in patients who FAILED stimulant therapy

- Metabolized by __________ and ________ so poor metabolizers may have decreased efficacy

- DO NOT ________ ________ due to it being an irritant

Dosing:

- Initial for ≤70 kg : __________, daily to BID

- Initial for >70 kg : ___________, daily to BID

- Titrate to target dose every ___________

Safety Considerations

- Abdominal pain, anorexia, __________

- Increased fatigue, sedation and dizziness compared with stimulants or bupropion

- BBW = ________ _________

Strattera

- norepinephrine

- tic disorder/Tourette syndrome

- 2-4 weeks

- 55%

- CYP2D6 and CYP2C19

- open capsule

- 0.5 mg/kg/day

- 40 mg

- 1-2 weeks

- insomnia

- suicidal ideation

Non-Stimulant: Alpha-2 Adrenergic Agonists, Clonidine (______, ________) and Guanfacine (________ , ________)

MOA:

- Primarily blocks release of ____________ presynaptically and increases blood flow to ________ _________ postsynaptically

Indications:

- _________ in all ADHD symptoms

- Monotherapy or adjunct agent for children and adolescents ____________ or ____________ stomach upset or insomnia with stimulants

- Patients with ______ or _________ __________

Pearls:

- 60-70% effective but especially for __________/___________ symptoms

ADE:

- Abdominal pain, nausea

- Dizziness, fatigue, irritability, __________

- __________

- Less common but serious = convulsions, syncope

- Agents should NOT be _________ ________, so should be tapered

Catapres, Kapvay ; Tenex, Intuniv

- norepinephrine ; prefrontal cortex

- step 3

- unresponsive to or not tolerating

- tics or Tourette Syndrome

- hyperactivity/impulsivity

- somnolence

- hypotension

- NOT abruptly discontinued

Non-Stimulant: Viloxazine (_________)

MOA:

- Selective ___________ reuptake inhibitor

Indications:

- _______

- Potential option for patients with _________ and _________

Dosing/Dosage Forms:

- ER capsule

- Initial dose 6-11 yr = ________ once daily

- Initial dose 12-17 yr = _________ once daily

- Titrate _________ to target dose

Safety Considerations

- ADE: increased _______, fatigue, insomnia, _________ _________

- BBW: _________ __________

Contraindications

- Concomitant administration of ________ or within 14 days

- Concomitant administration of sensitive __________ substrates

Qelbree

- norepinephrine

- Step 3

- depression and ADHD

- 100 mg

- 200 mg

- weekly

- BP ; decreased appetite

- suicidal ideation

- MAOI

- CYP1A2

Non-Stimulant: Bupropion (________)

MOA:

- Monocyclic antidepressant inhibits __________ and _________ reuptake

Pearls:

- Used off-label for ADHD, mainly for ___________ symptoms

- DO NOT ________ _________

Indications:

- _________

- Considered for patients with ________ and ________

Dose/Dosage Forms

- IR/ER/SR tablets

- Initial dose ≥6 yr = ___________, daily to BID

- Titrate ________ to target dose

Safety Considerations:

- Dry mouth, sedation, dizziness, anxiety, insomnia

- Less appetite suppression and weight loss compared with stimulants

- Greater risk for ________, DO NOT use in patients with these or ________ _________

- BBW = ______ _______

Wellbutrin

- dopamine and norepinephrine

- hyperactive

- abruptly discontinue

- step 4

- depression and ADHD

- 1.5 mg/kg/day

- weekly

- seizures ; eating disorder

- suicidal ideation

Non-stimulants: Tricyclic Antidepressants

MOA:

- Inhibit ________ and _________ reuptake mainly to treat __________ symptoms (70% efficacy)

Indications

- _______

- Patients with _________/___________/ ___________ and ADHD

Agents:

- _________ (Pamelor)

- __________ (Norpramin)

ADE:

- Constipation, sedation, dizziness, weight gain

- __________

- BBW = ________ ________

- norepinephrine and serotonin ; hyperactive

- step 4

- depression/tic disordes/enuresis

- nortriptyline

- desipramine

- cardiotoxicity

- suicidal ideation

Non-stimulants: Lithium

MOA:

- Influence reuptake of ________ and/or ________

Indication:

- Patients with ________ and concomitant __________ __________

ADE:

- Serotonin syndrome

- Hypothyroidism, monitor calcium, TSH, and PTH.

- Facilities for serum lithium determinations should be available before initiating therapy

- Dehydration, renal impairment, and __________ ↑ the risk

- BBW – _______ _________

- serotonin and/or NE

- ADHD ; bipolar disorder

- hyponatremia

- lithium toxicity

Non-Stimulants: Valproic Acid

MOA:

- Increases ___________

Indication:

- Most well-studied anticonvulsant for __________ with ADHD

- Indicated for patients with ADHD and concomitant _______ ________

ADE:

- Common: alopecia, abdominal pain, anorexia, _________, thrombocytopenia, dizziness

- BBW = __________ (<2 yr), __________ (any age), and ________ _______ ________

- GABA

- aggression

- bipolar disorder

- tremor

- hepatotoxicity ; pancreatitis ; neural tube defects

ADHD Treatment with Comorbidities

Bipolar Disorder

- 1st ---> __________, __________ or ___________

- 2nd ----> add stimulant

Depression

- 1st ---> __________/_______/__________

- 2nd ---> add stimulant

Epilepsy

- 1st ----> _________ (_________)

- 2nd ----> add stimulant

- antipsychotic, anticonvulsant or lithium

- SSRI/TCA/Bupropion

- anticonvulsant (valproic acid)

TC is a 14-year-old girl (weight 40 kg) who presents to the clinic with severe insomnia for one week. Medication reconciliation shows that the dose of her ADHD medication was recently doubled. TC never tried other medications for ADHD, and her symptoms improved since starting therapy.

Which is most likely causing TC's symptoms?

A. Strattera®

B. Ritalin SR®

C. Kapvay®

D. Intuniv®

What would you recommend to manage TC's insomnia symptoms?

A. Give dose late evening

B. Increase dose of Ritalin SR®

C. Switch to Ritalin®

D. Add Methylin® in the evening

B. Ritalin SR®

C. Switch to Ritalin®

TK is a 13-year-old female (weight 50 kg) with a diagnosis of ADHD. Which of the following is recommended as first-line therapy?

A. Strattera®

B. Ritalin SR®

C. Kapvay®

D. Wellbutrin®

B. Ritalin SR®

LM is a 12-year-old girl (weight 35 kg) with a past medical history of bipolar disease is diagnosed in the clinic today with ADHD. She is currently being managed on lithium. Which agent is the most appropriate to initiate for LM?

A. Qelbree®

B. Strattera®

C. Ritalin SR®

D. Kapvay®

C. Ritalin SR®

AB is a 14-year-old boy (weight 45 kg) with a history of ADHD has been on Vyvanse® (20 mg capsule) one capsule by mouth once daily for 6 months, and he has had significant improvement in his symptoms. However, his pediatrician has noted a significant weight loss since he has been on this therapy. Which of the following would be the best strategy to address this concern?

A. Add cyproheptadine

B. Switch to Jornay PM®

C. Switch to Strattera®

D. Continue Vyvanse® but have AB take with food

A. Add cyproheptadine