ADHD Patho & Treatment

What is the usual age of diagnosis?

7 years

What are some common co-morbidities?

• Tic disorders

• anxiety

• ODD

• Conduct disorders

• SUD

What are the 2 major NTs in ADHD

NE and DA

Is there an increase or decrease in the DA pathway?

decrease

According to DSM-5-TR, how is ADHD defined

• persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development

For the diagnosis of ADHD, symptoms have to be present before what age?

12

Symptoms must be present in _____ or more settings

two

How many inattentive symptoms or hyperactive symptoms must persist for how many months?

6 or more for 6 or more months

Boys have more _____ symptoms whereas the girls tend to have _____ symptoms

hyperactive, inattentive

In the adolescence stage, what features of ADHD are seen more

impulse and inattentive symptoms

SUD may begin

oppositional and socially aggressive behaviors continue

What clinical features of ADHD in adulthood are seen?

inattention persists

hyperactivity and impulsivity decreases

Hyperactivity is usually seen by age ___

4

Inattention is usually seen around age ___

8

What is 1st line for 4-5 years old

behavior therapyW

What is 1st line for 6+ years old

stimulant (MPH or AMP)

What is the 2nd line for 4-5 y.o?

MPH

What is second line for 6+ y.o?

atomoxetine, guanfacine ER, clonidine ER

What are some non-pharm treatments?

• BPT (behavioral parent)

• BCM (behavioral classroom)

• BPI (behavioral peer intervention)

• CBT (adults with ADHD)

MOA of stimulants

increase DA and NE

How does MPH differ from AMP?

MPH: inhibits presynaptic reuptake of DA and NE

AMP: stimulates the release of DA and NE into the presynaptic nerve terminal

All the stimulants are class ____ drugs

II

Pros of MPH?

• less likely to suppress appetite

• less likely to cause tics or insomnia

Cons of MPH?

• erratic concentrations

• too short of half life with IR/SR

Avoid concerta if you have _____

GI obstruction

What is the name of the transdermal patch?

Daytrana

True or false: Daytrana dose is equivalent to oral formulation dose

false

Daytrana can cause what rare ADR

permanent loss of skin color

Jornay PM is given at what time of day?

evening

This is an active enantiomer of MPH

Focalin, XR

Pros of AMP products

• more predictable kinetics with long-acting formulations

Cons of AMP

• greater abuse potential

• worsen tics

• greater growth suppression

Which AMP has the longest duration

Mydayis, 16 hours

This AMP is a AMP pro drug

Vyvanse

Boxed warning for stimulants

high potential for abuse and dependence

What are the warnings and precautions for stimulants?

• Sudden death may occur with pre-existing cardiac conditions/misuse

• modestly increase BP and HR

• exacerbation of previous psychiatric illness

• lowers seizure threshold

• can exacerbate tics and Tourette’s

• priapism

Contraindications for stimulants

• symptomatic CVD

• moderate to severe HTN

• Hyperthyroidism

• Hx of SUDs

• glaucoma

• MAOI use in the last 14 days

• agitated states

ADR of stimulants

• appetite suppression (normally @ lunch)

• insomnia

• GI distress

• irritability

• headache

• growth suppression (controversial)

• worsening of tics

Drug-drug interactions with stimulants include:

• MAOIs

• TCA use

• other stimulants

• antiHTNs

• antacids, PPIs

How should you titrate stimulants?

Within 1st month, titrate weekly or biweekly until achieve clinical response

Can titrate at 3-7 days

Monitoring with stimulants

• efficacy

• BP and HR

• Ht, wt

• appetite

How often should you monitor efficacy for stimulants?

monthly

If taking afternoon dose of IR formulation, the last dose should be given ___ hours before bedtime

>6

True or false: you can take stimulants with food

true but a high-fat meal may delay absorption

You should not mix stimulants with what foods?

Hot foods (temp.)

How long does atomoxetine take for therapeutic onset

2-4 weeks and up to 6 weeks

Boxed warning for atomoxetine

increased suicide ideation in children and young adults

Contraindications with atomoxetine

• narrow-angle glaucoma

• pheochromocytoma

• severe cardiac or vascular disorders

• MAOI use within 14 days

• severe liver injury

Atomoxetine interacts with which CYP 450 enzyme?

CYP 2D6 inhibitor

This non-stimulant can be swallowed whole or opened and sprinkled on applesauce

Qelbree

True or false: Qelbree has a faster onset

true (around 1 week)

What are the ER formulations FDA approved for ADHD

• clonidine XR

• guanfacine ER

Guanfacine is more selective toward _______ receptors

post-synaptic alpha 2a

What type of non-stimulants can be combined with stimulants?

alpha-adrenergic agonists

Warnings and precautions of alpha 2 adrenergic agonists

• syncope

• hypotension

• bradycardia

• heart block

Guanfacine is a CYP _____ substrate

3A4

ADR of alpha 2 adrenergic

• hypotension

• dizziness

• dry mouth

• rebound hypertension if abruptly stopped

Counseling points for alpha 2 adrenergic agonists

• do not crush or chew

• do not take with high fat meal

• do not discontinue abruptly

• dose at bedtime to help dizziness

What do you need to assess at each visit for the alpha 2 adrenergic agonists?

BP and HR

What are some of the non-FDA approved medications?

• bupropion hcl

• SNRIs

• TCAs

What are some natural products for ADHD?

• polyunsaturated fatty acids

• iron supplementation

• ginkgo biloba

• magnesium

• zinc