ADHD (copy)

What age group is ADHD most common in?

It is the most common neurodevelopmental disorder in childern

ADHD: Symptoms

- inattention, hyperactivity, impulsivity

(pts often have difficulty focusing, are easily distracted, have trouble staying still, and are often unable to control impulsive behavior)

What brain system is thought to mainly contribute to ADHD?

the catecholamine system where dopamine --> epinephrine & norepinephrine

ADHD is thought to be caused by defects in the dopamine pathways that regulate reward anticipation and emotional self regulation

What is the mainstay of treatment for ADHD?

stimulants because they raise dopamine and norepinephrine

When are medications preferred first-line for ADHD?

stimulants for patients at least 6 years old (+ behavioral intervention when possible)

DSM-5 Inattention Criteria

- at least 6 symptoms of inattention for children up to 16 years (need 5 if older)

- symptoms must have been present for at lease 6 months

DSM-5 Hyperactivity & Impulsivity Criteria

- at least 6 symptoms of hyperactivity/impulsivity for children up to 16 years (need 6 if older)

- symptoms must have been present for at least 6 months

DSM-5 Criteria

- Meet inattention, hyperactivity/impulsivity criteria

- Sx must have been present before age 12

- sx must be present in at least 2 settings (ex: home +school)

Natural products for ADHD

- fish oil

- melatonin help pt taking stimulants fall sleep better

Which stimulant formulations are preferred for children with ADHD?

long-acting

What is the brand name for atomoxetine?

Strattera

What is the brand name for guanfacine er?

Intuniv

What is the brand name for clonidine ER?

Kapvay

Patient-Friendly Formulations for Stimulants

Capsule (opened and sprinkled)

Chewable tablet

ODT

Patch

Suspension

Patient-Friendly Formulations for Stimulants: Counseling

when putting capsule contents in for, use a small amount of food and do not warm it up. Each the food right away and do not chew any beads

What schedule are stimulants?

CII

What must be dispensed with a stimulant?

MedGuide

Describe the treatment cascade for ADHD

1. stimulants taken in AM: methylphenidate, lisdexsmphetamine, dexreoamphetamine/amphetamine

2. Non-stimulants (for stimulant ineffective or abuse): atomoxetine

Add Ons: guanfacine Er, clonidine Er

What medications can help patients on stimulants sleep better?

clonidine IR, diphenhydramine , melatonin

Stimulants: BBW

high potential for abuse and dependence

Stimulants: Contraindications

Do not use within 14 days of MAO inhibitor due to risk HTN crisis

Stimulants: Warnings

- increased HR and BP (due to increased dopamine & norepinephrine) which can cause serious CV events in children and adults

- vascular problems like priapism (prolonged erection)

- new onset/exacerbation of psychosis or mixed/manic episode

- seizure risk

- loss of appetite which can impact child growth

- risk of serotonin syndrome

Stimulants: MOA

block reuptake of NE and DA

How are stimulants titrated up?

dose in increased weekly

Do stimulants need to be tapered off?

No (when used as directed and not abused)

What is the brand name for methylphenidate IR?

Ritalin

What are the brand names for methylphenidate ER?

Concerta, Ritalin LA

What is the brand name for the methylphenidate TD patch?

Daytrana

How is Daytrana used?

- put on 2 hours before the desired effect in AM

- remove after 9 hours

- place on the hips and alternate daily

What is the starting dose for Ritalin?

5 mg BID

What is the starting dose for Concerta?

18-36 mg QAM

What ist he brand name for methylphenidate ER that is taken in the evening?

Jornay PM

Stimulants: SEs

insomnia, decreased appetite/weight loss, headache, irritability

Stimulants: Monitoring

Consider ECG, monitor BP, HR, height, weight

Describe Concerta's drug delivery method

OROS delivery

- the outer coat dissolves fast to give immediate dose and rest is released slowly

- can see ghost tablet in stool

- hard to crush which decreases abuse potential

Which form of methylphenidate has the lowest abuse potential and why?

Concerta because it is harder to crush

What is sexmethylphenidate?

active isomer of methylphenidate

What is the brand name for dextroamphetamine/amphetamine IR?

Adderall

What is the brand name for dextroamphetamine/amphetamine ER?

Adderall XR

Dextroamphetamine/amphetamine: BBW

misuse can cause sudden death and serious CV events

What iOS the brand name for lisdexamfetamine?

Vyvanse

What formulations does Vyvanse come in?

capsule, chewable tablet

Can Vyvanse capsules be opened?

Yes they can be opened and sprinkled onto food

Describe the abuse potential of Vyvanse

low abuse potential because it comes a prodrug of l-lysine (an amino acid) attached to dextroamphetamine and will only be active after it is hydrolyzed in the blood first. So if it is snorted or injected the effect will be muted

In what cases are non-stimulants used first line?

if the prescriber is worried about abuse potential of stimulants

Atomoxetine: MOA

selective NE reuptake inhibitor

Atomoxetine: BBW

risk of suicidal ideation

Atomoxetine: Contraindications

MAOi use within 14 days

Atomoxetine: SEs

decreased appetite, insomnia, somnolence, dry mouth, HTN, tachycardia

Can atomoxetine capsules be opened?

No (ocular irritant)

Clonidine: MOA

central alpha 2 agonist

What is the brand name for clonidine IR?

Catapress

What is Catapres used for?

indicated for HTN but can be used in ADHD to help with sleep

When is clonidine given?

at bedtime

Central Alpha-2 Agonists: Warnings

does-dependent CV events, sedation, drowsiness

Can alpha 2 agonists be stopped abruptly? Why/Why not?

No, taper down due to risk of rebound HTN

Central Alpha 2 Agonists: SEs

dry mouth, somnolence, fatigue, dizziness, constipation, decreased HR, hypotension