Chapter 65. ADHD

How do stimulant medications help treat ADHD?

raise dopamine and norepinephrine levels

First-line treatment for ADHD

Medications in patients ≥ 6 years old

DSM-5 Criteria for ADHD Diagnosis

Inattention

≥6 sx for children up to 16 (≥5 for 17+)

• sx present for at least 6 months

Hyperactivity and Impulsivity

≥6 sx of hyperactivity/impulsivity

• sx present for at least 6 months

Following Conditions MUST be Met:

• Several sx were present before age 12

• Sx must have been present in ≥ 2 settings (e.g. home, school, etc)

What may be used for sleep onset insomnia in individuals taking stimulants?

melatonin

Patient-Friendly Formulations for Stimulants

Young children/people who cannot swallow: Long acting formulations, capsules that can be opened

- if opening cap, do not warm food, use a small amount, and eat right away without chewing

Capsules That Can Be Opened

• LA caps (e.g. Adderall XR, Ritalin LA) can be opened and sprinkled on applesauce

• Vyvanse can be mixed in water, OJ, or yogurt

Chewable = Vyvanse

ODT

Patches = Daytrana

Suspensions

Treatment of ADHD (Study Tip Gal)

Stimulants are first-line (take in AM)

• Methylphenidate (e.g. concerta, daytrana, ritalin)

- Journay PM taken in evening

• Lisdexamfetamine (Vyvanse)

• Dextroamphetamine/Amphetamine (Adderall, XR)

Non-Stimulants are 2nd line

• Atomoxetine (Strattera)

• Viloxazine (Qelbree)

Add on or Alone

• Guanfacine ER (Intuniv)

• Clonidine ER (Kapvay)

To Help Sleep at night

• Clonidine IR

• Diphenhydramine

• Melatonin

Boxed Warning for stimulant medications

hight potential for abuse and dependence

Contraindications/Warnings for Stimulants

• Contraindicated within 14 days of MAOI (risk of hypertensive crisis

• Risk for drug diversion

• Increased HR, BP -> risk of CV events in children and adults with or without pre-existing disease

• Priapism

• Psychosis exacerbation

• Loss of appetite = decrease in growth in children

• Serotonin syndrome risk

How often can stimulants be titrated up?

Every 7 days

Do stimulants need to be tapered on cessation?

NO

Methylphenidate brands/formulations

• Ritalin (IR tablet) - start 5mg BID

• Ritalin LA (ER cap)

• Concerta (OROS delivery) - start 18-36mg QAM

• Daytrana (patch) - QAM

• Jornay PM - QPM

What is the active isomer of methylphenidate?

Dexmethylphenidate

Methylphenidate side effects/monitoring

Side Effects

• Insomnia

• Decreased appetite/weight loss

• headache, irritability

Monitoring

• ECG prior to tx

• BP and HR

• Height and weight

Daytrana patch counseling

• Apply to hip 2 hrs before desired effect

• Remove after 9 hours

• Alternate hips daily

• Discard by flushing down toilet

Concerta (OROS) counseling/notes

• Outer coat dissolves fast for immediate action, rest is released slowly

• Ghost tablet in stool

• Hard to crush = decreased abuse potential

Lisdexamfetamine (Vyvanse) formulations

capsule, chewable tablet

*low abuse potential d/t being a prodrug

*if snorted, the rush is muted

Dextroamphetamine/Amphetamine brand names

• IR tablet = Adderall

• ER Capsule = Adderall XR

Which drugs for ADHD can be used alone or in combination with a stimulant?

Clonidine ER (Kapvay) - QHS and Guanfacine ER (Intuniv) - QD

*Centrally-acting alpha 2 adrenergic agonist

Warnings/Side effects of central-acting alpha 2 adrenergic agonists

• dry mouth

• somnolence, fatigue, sedation, drowsiness

• dizziness

• constipation

• decreased HR, hypotension

• Must taper! do not dsc abruptly = rebound hypertension

• Dose-dependent CV effects

Atomoxetine (Strattera) side effects/contraindications

Selective Norepinephrine Reuptake Inhibitor

Boxed Warning = risk of suicidal ideation

• Contraindicated w MAOI use within last 14 days

• Decreased appetite

• Insomnia

• Somnolence

• Dry mouth

• Increased BP and HR

• Do not open capsule - ocular irritant