ADHD- Krysiak

PRACTICE

What 2 NT’s are most directly targeted by first-line ADHD meds?

a. Ach and NE

b. DA and NE

c. 5-HT and NE

d. DA and 5-HT

b. (DA and NE are the most widely implicated in ADHD)

ADHD is a state of _________ arousal.

a. hyper

b. hypo

b.

For ADHD age ranges…

• preschoolers is age ___-___ years

• school age is age ___-___ years

• adolescence is age ___-___ years

(i would just recognize)

• preschoolers is age 3-5 years

• school age is age 6-11 years

• adolescence is age 12-18 years

Symptoms of ADHD:

• inattention

  • careless mistakes

  • difficulty sustaining attention

  • poor organization

  • avoids mentally demanding tasks

  • seems not to listen

  • fails to finish tasks

  • easily distracted

  • forgetful in daily life

  • loses essential items

• hyperactivity and impulsivity

  • fidgets

  • leaves seat unexpectedly

  • restless

  • loud/disruptive play

  • blurts

  • interrupts/intrudes

How is ADHD diagnosed?

• 6 or more symptoms must be present for at least 6m, significant impairment must be seen in 2 or more settings

• only 5 symptoms are required in older adolescents and adults (17+)

PRACTICE

To diagnose ADHD in a 10 year old, how many symptoms and for how long must they persist?

a. ≥6 symptoms for ≥1 year

b. ≥5 symptoms for ≥1 year

c. ≥5 symptoms for ≥6 months

d. ≥6 symptoms for ≥6 months

d. ≥6 symptoms for ≥6 months

What are the different classifications of ADHD?

• idk how imp

• ADHD—> combined type

• ADHD—> predominantly inattentive type

• ADHD—> predominantly hyperactive-impulsive type

Which ADR warrants IMMEDIATE dose reduction or discontinuation?

a. mild appetite decreases

b. new-onset hallucinations

c. insomnia >3 nights a week

d. mild vomiting

b.

In most cases of ADHD, _____________ are considered 1st-line therapy.

stimulants— should only be considered about thorough diagnosis

Roughly how long after applying the MPH patch do clinical effects begin?

a. 30 min

b. 2 hours

c. immediately

d. 6 hours

b. (pay attention to what she’s asking with patch questions)

List the stimulants used for ADHD:

Amphetamines (AMP) and Methylphenidate (MPH)

Does lack of response to methylphenidate mean you shouldn’t try Amphetamines?

Why or why not?

• NO!!!! If failure to methylphenidate, you can still try amphetamines (vice versa)

• why? bc they work through slightly dif mechanisms

  • MPH: inhibits presynaptic reuptake of DA and NE (minimal effect on periphery)

  • AMP: stimulates release of DA and NE into presynaptic nerve terminal—> enhances release of NE in periphery

Difference in dosing between immediate and extended release stimulants?

• IR: required BID or TID dosing

• ER: required daily or BID dosing

How do stimulants interact with food?

• delays absorption and onset of IR and ER formulation

• IS NOT NECESSARILY A BAD THING!!!!!!!!!!!

ADRs of stimulants:

• most common?

• reduced appetite ± weight loss

• GI distress

• insomnia

• HA

• irritability/jitteriness

• decreased growth? no significant effect though?

• rare:

  • HALLUCINATIONS

  • dysphoria

  • zombie

  • tics/abnormal movements

  • HTN

Warnings of stimulants:

• BBW

• other warnings:

• BBW: high abuse potential

• others: priapism, MPH-OROs should be avoided in pts. with GI obstruction

All MPH products are approved for children __ years of age and older.

6

List the formulations of Methylphenidate and Dex-MPH that can be used for ADHD tx:

• IR (Ritalin)

• SR, ER (Ritalin SR, Metadate ER)

• MPH-LA (Ritalin LA)

  • 50% dose released immediately – 30 – 60 minutes

  • Second peak occurs 5 – 6 hours after ingestion

• MPH-CD (Metadate CD)

  • 30% of MPH dose is release immediately

  • 70% is released continuously causing a second peak 5 – 6 hours after ingestion

• MPH-OROS (Concerta)

  • uses osmotic release delivery system

  • total duration of action is approximately 10-12 hours

• Transdermal MPH (Daytrana)

• Jornay PM

• Dex-MPH immediate release, XR (Focalin, Focalin XR)

• Serdexmethylphenidate + Dexmethylphenidate (Azstarys)

For the TRANSDERMAL PATCH of MPH

• onset of action occurs __ hours after placement

• clinical effects seen for up to ___ hours after removal

• patch should be removed after __ hours

KNOW THIS!!!!!!!!

• onset of action occurs 2 hours after placement

• clinical effects seen for up to 3 hours after removal

• patch should be removed after 9 hours

What’s unique about Jornay PM formulation of MPH?

given once daily in the EVENING

What’s unique about Concerta?

osmotic delivery system

T/F: The MPH patch can be cut.

FALSE

WHAT formulations of Amphetamines are approved for ages 3 and up?

• ages 6 and up?

• Dextroamphetamine products

• IR mixed amphetamine salts

Note: ALL OTHER FORMULATIONS ARE APPROVED FOR 6+

Elimination half-life for amphetamines are faster in what pt. population?

children

What is Adderall?

a. amphetamine salt

b. methylphenidate salt

c. dextroamphetamine salt

d. dextroamphetamine+ amphetamine salt

d.

What formulations of amphetamines are available for use in ADHD?

• mixed amphetamine salts (Adderall)

• dextroamphetamine IR (Dexedrine)

• Lisdexamfetamine (Vyvanse)

• amphetamine ER (Adzenys XR-ODT and ER, Dyanavel XR)

• amphetamine (Evekeo, ODT)

• dextroamphetamine patch (Xelstrym)

Lisdexamfetamine is a prodrug that is converted to what?

dextroamphetamine and L-lysine in the gut—> helps deter from abuse

Most stimulants should be taken in the _________.

morning

What counseling point should be told with ALL extended release stimulants?

do not crush or chew

If the pt. cannot swallow a tablet, what products can be opened and sprinkled on applesauce?

• MPH-LA

• MPH-CD

• Dex-MPH-XR

• mixed amphetamine XR

What stimulant formulation can be opened and dissolved in a glass of water to be consumed immediately?

Lisdexamfetamine

Stimulants may counteract the effect of __________________.

antihypertensives

D/I with stimulants

MAOIs within 14 days= hypertensive crisis

Nonstimulants are SECOND LINE for ADHD.

List the nonstimulants:

• Guanfacine ER

• Clonidine ER

• Atomoxetine

Clonidine and Guanfacine ER are more effective for what symptoms of ADHD?

hyperactive > inattentive

How do the effects of Clonidine ER compare to Guanfacine ER?

Guanfacine has a longer half-life, duration of action, and greater selectivity for the α2A –receptor compared with clonidine AND causes less sedation

Atomoxetine (Strattera) is metabolized by what CYPs?

2D6 and 2C19

Atomoxetine (Strattera) requires WHAT MONITORING?

• HEPATOTOXICITY

• Efficacy may take up to 4 weeks

• increased suicide risk

What is a new SNRI, approved in 2021, that has a dual mechanism and is currently indicated for pts. 6 years and older with ADHD?

Viloxazine

can long-acting formulations be used as initial tx for ADHD?

YES!

What is the recommended tx for each age group? therapy or drugs?

• preschool age

• elementary age

• adolescents

• preschool age

  • 1st line- BEHAVIOR therapy

  • may add methylphenidate if behavior therapy not working

    • reminder: >6

• elementary age

  • 1st line- FDA approved meds

• adolescents

  • 1st-line- FDA approved

Prior to initiating medication, what must be done for 1 month?

How often should it be done after?

• 1 month before meds- document baseline symptoms and complaints

• q3 months after starting meds document