Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is the most common

neurodevelopmental disorder in children w/ higher prevalence in males compared to females

ADHD is a chronic illness that can

continue to cause sx throughout adolescence & adulthood

ADHD is characterized by sx of

inattention

hyperactivity

impulsivity

difficulty focusing

easily distracted

trouble staying still

frequently unable to control impulsive behavior

pathogenesis of ADHD

imbalance of catecholamine metabolism, w/ subsequent decreased dopaminergic activity, is thought to play a role

stimulant medications are primary tx for ADHD because

they raise dopamine and NE levels by blocking the reuptake of NE and dopamine

-doses usually titrated up every 7 days as needed to reduce AE

-do not need to be tapered off

tx of ADHD includes

combination of medication and behavioral therapy

1st line tx for preschool-aged children (age 4-5 years) is

parent training in behavior management and/or behavioral classroom intervention

2nd line tx for preschool aged children (aged 4-5 years)

methylphenidate

1st line tx in pt >/ 6yo

ADHD medications + behavioral interventions

diagnostic criteria used for ADHD

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

-based on primary sx, inattention and/or hyperactivity and impulsivity

inattention is defined as

-loses things

-easily distracted

-forgetful

>/ 6 sx of inattention for children / 5 sx for ages >/ 17 yo

sx must be present for AT LEAST 6 months and are inappropriate for the developmental level

hyperactivity & impulsivity

-blurts out answers

-trouble waiting his/her turn

-interrupts or intrudes on others

>/ 6 sx of hyperactivity-impulsivity for children / 5 sx for ages >/ 17 yo

sx must be present for AT LEAST 6 months and are inappropriate for the developmental level

conditions for ADHD that must be met

-several inattentive or hyperactive-impulsive sx present before 12yo

-sx must have been present in 2 or more settings (home, school. work, w/ friends, etc)

-sx interfere w/ functioning and are not caused by another disorder

natural products for ADHD

fish oil -- not routinely recommended

melatonin --used for sleep onset insomnia when taking stimulants

1st line medications for ADHD

stimulants

preferred for children

long acting formulations

-avoid need for a dose during school

-steady sx control

if stimulants do not work well enough (after 2 - 3 medication trials) or the AE are intolerable

a nonstimulant medication can be tried

-atomoxetine

-guanfacine ER

non stimulants are used 1st line when

prescribers worried about stimulant abuse or diversion by pt or family

Almost all ADHD medications are approved for use in

adults and children >/ 6 yo

capsules that can be opened and contents sprinkled on a small amount of ______

-Adderall XR

-Ritalin LA

-Vyanse

Vyvanse capsule contents can be mixed in

water, orange juice or yogurt

Adderall XR or Ritalin LA can be opened and sprinkled on

small amount of applesauce

pt friendly formulations for stimulants

-capsules that can be opened

-chewable tablets (Vyvanse)

-patches (Daytrana)

-suspensions

add on medications for ADHD tx is

-guanfacine ER (intuniv)

-clonidine ER (Kapvay)

medicine to help sleep at night

clonidine IR

diphenhydramine

Melatonin

what stimulant is taken in the evening

Jornay PM

all stimulants are

Control 2 and must be dispensed with a MedGuide

BBW for Stimulants

abuse

misuse (can lead to OD and death)

addiction

CI for Stimulants

do not use within 14 days of MAO inhibitor due to risk of hypertensive crisis when used together

Warnings for Stimulants

-drug diversion for non-medical, illicit use and/or distribution

-incr. level of dopamine and NE can incr. HR & BP & cause serious CV events in children and adults w/ or w/o preexisting cardiac disease

-priapism (prolonged painful erection >/ 4 hrs)

-Raynaud's disease (cold body parts)

-new onset psychosis or mania, or an exacerbation of preexisting psychosis (mixed/manic episodes in bipolar)

-loss of appetite (can decr. child's growth trajectory)

-risk of serotonin syndrome is incr. w/ other serotonergic drugs

-lower seizure threshold which incr risk for seizures

-visual disturbance can occur

methylphenidate brands

Ritalin

Methylin

Concerta

Relexii

Ritalin LA

Aptensio XR

Jornay PM

Quillivant XR

QuilliChew ER

Cotempla XR-ODT

Daytrana

methylphenidate transdermal patch

Daytrana (10mg/9hr patch QAM)

-loss of skin pigmentation at site (resemble vitiligo)

-apply to the hip 2 hours before desired effect

-remove after 9 hours

-alternate hips daily

-discard by flushing down toilet

methylphenidate ER orally disintegrating tablet (ODT)

Cotempla XR-ODT

methylphenidate ER chewable tablet

QuilliChew ER

-contains phenylalanine

-avoid w/ PKU

methylphenidate oral suspension

Quillivant XR

Jornay PM

methylphenidate ER capsule

-20mg QPM (evening)

-outer coating delays initial drug release 10 hours to allow for evening dosing

-inner coating controls the slow release of the drug during the day

methylphenidate ER capsule

Ritalin LA

Aptensio XR

Jornay PM

methylphenidate ER tablet w/ osmotic release oral system (OROS) delivery

Concerta

Relexxi

-18 to 36mg QAM

max 72mg/day

-ghost tablet in stool

-harder to crush (decr. abuse potential)

-do not use either with GI narrowing conditions (motility issues, small bowel disease)

-outer coat dissolves fast to provide Immediate action & rest is released slowly

methylphenidate IR oral solution

Methylin

methylphenidate IR tablet

Ritalin

-5mg BID 30 min before breakfast & lunch

-max 60mg/day

AE of methylphenidate

insomnia

decr appetite/weight loss

headache

irritability

nausea/vomiting

blurry vision

dry mouth

dexmethylphenidate brands

Focalin (BID)

Focalin XR

dexmethylphenidate comes as

IR tablet & ER capsule

-isomer of methylphenidate

-convert from methylphenidate to dexmethylphenidate use 1/2 of TDD of methylphenidate

therefore methylphenidate TDD is 10mg then dexmethylphendiate TDD is 5mg

serdexmethylphenidate/dexmethylphenidate

Azstarys capsule

-prodrug of dexmethylphenidate

-provides extended duration of action following faster acting dexmethylphenidate

dextroamphetamine/amphetamine IR tablet

Adderall

-due to IR tablet w/ dextroamphetamine approved for kids / 3 yo

dextroamphetamine/amphetamine ER capsule

Adderal XR

Mydayis

-due to dextroamphetamine not recommended in kids

amphetamine brands

Adzenys XR-ODT

Dyanavel XR (chewable tablet/oral suspension)

Evekeo

Evekeo ODT

All amphetamine & dextroamphetamine IR products

approved for children >/ 3 yo

EXCEPT

Evekeo ODT

All amphetamine & dextroamphetamine products should not be taken w/

acidic foods such as juice or vitamin C due to decr absorption

All amphetamine & dextroamphetamine ER products

-cannot be substituted for other amphetamine products on mg-per-mg basis

amphetamine ER orally-disintegrating tablet

Adzenys XR-ODT

-cannot be substituted for other amphetamine products on mg-per-mg basis

amphetamine ER tablet (can be chewed)

Dyanavel XR

-cannot be substituted for other amphetamine products on mg-per-mg basis

amphetamine ER oral suspension

Dyanavel XR

-shake suspension prior to use

-cannot be substituted for other amphetamine products on mg-per-mg basis

amphetamine IR tablet

Evekeo

amphetamine IR orally-disintegrating tablet

Evekeo ODT

-not approved for children

dextroamphetamine age group

not recommended in children

Dextroamphetamine brands

Dexedrine

ProCentra

Zenzedi

Xelstrym

dextroamphetamine ER capsule

Dexedrine

dextroamphetamine IR oral solution

ProCentra

dextroamphetamine IR tablet

Zenzedi

dextroamphetamine ER patch

Xelstrym

lisdexamfetamine is

prodrug of dextroamphetamine

lisdexamfetamine brand

Vyvanse

capsule and chewable tablet formulations

-children 20-30mg QAM

-adults 30mg QAM

max 70mg/day

-low abuse potential

-prodrug composed of l-lysine (amino acid) bonded to dextroamphetamine

-hydrolyzed in the blood to active dextroamphetamine

-if injected or snorted the fast effect/rush is MUTED

methamphetamine brand

Desoxyn

tablet

QAM or BID

non stimulants are used

2nd line if trials of stimulant medications fail or side effects are intolerable

-used 1st line if prescriber has concerns of abuse or diversion potential

Selective NE Reuptake Inhibitor Non-stimulants (only as capsules)

Atomoxetine (Strattera)

Viloxazine (Qelbree)

-risk of suicidal ideation

-CI: MAOi in past 14 days

-risks: CV events, psychos/mania

-AE: decr. appetite, insomnia, somnolence, dry mouth, incr BP, incr HR, headache, nausea, abdominal pain

Centrally Acting Alpha 2 Adrenergic Receptor Agonists Non-Stimulant (only as tablets)

Clondine ER (Kapvay)

Clonidine IR

Clonidine ER (Nexiclon XR)

Clonidine patch --for HTN only

Guanfacine ER (Intuniv)

Guanfacine IR -- for HTN only

centrally acting alpha 2 adrenergic receptor agonists non-stimulants warnings, AE, & notes

-do not d/c abruptly (can cause rebound HTN)

-dose/dep CV effects (brady/hypotension/orthostasis/syncope)

-sedation/drowsiness

-additive sedation can occur when used in combo w/ other CNS depressants

-use caution w/ other drugs that decr. BP and HR (BB/nonDHP)

-AE: dry mouth, somnolence, fatigue, dizziness, constipation, decr. HR, hypotension, headache, nausea, abdominal pain

-do not substitute IR formulations for ER formulations

-must be tapered off to decr risk of rebound HTN

taper by: decr dose by

Atomoxetine

Strattera (CYP2D6 substrate)

max 100mg/day

-if take w/ strong CYP2D6 inhibitor (paroxetine) max dose is 80mg/day

-2d6 inhibitors OR inducers can change dose of atomoxetine

-can take in divided doses if needed

-do not open capsule (ocular irritant)

-CI: glaucoma, pheochromocytoma, severe CV disorders

-Warnings: aggressive behavior, hepatotoxicity, priapism, urinary hesitancy and retention, growth delays

-SNRI but MedGuide required

Viloxazine

Qelbree (strong 1A2 inhibitor & weak 2D6 & 3A4 inhibitor)

-max 400mg/day in children < 18yo

-max 600mg/day in adults

-if severe renal impaired reduce dose

-CI: concurrent use of major CYP1A2 substrates (or substrates w/ NTI)

-capsule can be opened and contents sprinkled on 1 teaspoon of pudding or applesauce, which must be swallowed withOUT chewing

-SNRI but MedGuide required

Clonidine ER

Kapvay or Nexiclon XR

-0.1mg QHS incr by 0.1mg weekly and if take BID w/ higher dose at night

-max 0.4mg/day

-decr by

clonidine patch

is used only for HTN

Guanfacine ER

Intuniv

-1mg daily and incr. by

Guanfacine IR

for HTN only

stimulant chewable tablets

vyvanse

QuilliChew ER (avoid in PKU)--methylphenidate ER tablet

methylphenidate IR tablet (no brand name)