ADHD - dr krysiak

2 hours => 10 questions

T/F prescriptions for ADHD medications has increased in adults only

FALSE — increased in all age groups

note: more commonly diagnosed in boys than girls

what brain structure changes are seen in ADHD?

• reduced cortical white and gray matter volume have been reported (varies)

• reduced frontal and temporal lobe volumes have been observed

• delay in cortical thickening

what neurotransmitters’ dysfunction are most likely the cause of ADHD, therefore effective treatments modulate them? (SATA)

a. DA

b. GABA

c. NE

d. H

a. c.

checkpoint

which 2 neurotransmitters are most directly targeted by first-line ADHD meds?

a. 5-HT and GABA

b. DA and NE

c. ACh and DA

d. glutamate and NE

b.

idk if important

what age are most cases first realized?

a. preschoolers; 3-5 years

b. school age; 6-11 years

c. adolescence; 12-18 years

d. adults

b.

how is ADHD diagnosed?

• ≥ 6 symptoms present for ≥ 6 months

• significant impairment must be seen in ≥ 2 settings

• sx documented by parent, teacher, and clinician

• only 5 sx required ≥ 17 y.o.

what is the most common subtype of ADHD?

a. combined type

b. predominantly inattentive type

c. predominantly hyperactive-impulsive type

a.

checkpoint

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

a. ≥ 6 symptoms for ≥ 6 weeks

b. ≥ 5 symptoms for ≥ 6 months

c. ≥ 6 symptoms for ≥ 6 months

d. ≥ 5 symptoms for ≥ 12 months

c.

practice

to diagnose ADHD in a 25 year old, how many symptoms and for how long must they persist?

a. ≥ 6 symptoms for ≥ 6 weeks

b. ≥ 5 symptoms for ≥ 6 months

c. ≥ 6 symptoms for ≥ 6 months

d. ≥ 5 symptoms for ≥ 12 months

b.

list nonpharm tx options for each age

• preschool and school age

  • parent and family education

  • parent/caregiver training on behavioral management

  • classroom management instruction for teachers

• adolescent

  • breakup hw assignments into manageable segments

  • structured schedule

• adolescent and adult

  • ADHD-specific cognitive behavioral therapy

  • metacognitive therapy

what is first line therapy in most cases of ADHD?

when is pharmacotherapy considered?

first line: stimulants

pharmacotherapy considered when a thorough diagnostic assessment results in the diagnosis

what is the most beneficial therapy for ADHD?

a. pharmacotherapy

b. behavioral therapy

c. combo of pharmacotherapy and behavioral therapy

c.

what stimulants are used for ADHD?

• amphetamines

• methylphenidate

what is the MOA of methylphenidate?

• mild CNS stimulant

• selectively inhibits the presynaptic reuptake of DA and NE

• inhibition of monoamine oxidase

what is the MOA of amphetamines?

• stimulates release of DA and NE into the presynaptic nerve terminal

• enhances the release of NE in the periphery from adrenergic nerve terminals

• higher doses —> stimulates release of serotonin

• inhibition of monoamine oxidase

  • more than methylphenidate

what kind of dosing is needed for immediate release stimulants?

when is the maximal response seen?

BID or TID dosing

maximal response during absorption phase

what kind of dosing is needed for extended release stimulants?

how long do we see symptom control?

daily or BID

symptom control: 8-12 hours

what stimulant formulation is preferred?

once daily (ER)

if someone takes a stimulant with food, what happens?

delays absorption and onset of effect

• IR: 30 min-1 hour

• ER: 1-2 hours

list ADRs of stimulants

• reduced appetite w/w/o weight loss

• GI distress

• insomnia

• headache

• irritability/jitteriness

• growth

• hallucinations

  • stimulant may be d/c, reassess diagnosis

• priapism

  • MPH after prolonged exposure, dose incr., or drug withdrawal

________ may cause severe allergic contact sensitization, may cause permanent loss of skin color at site

MPH transdermal patch

_______ should be avoided in patients with GI obstruction

MPH-OROS

checkpoint

which adverse effect warrants immediate dose reduction or discontinuation?

a. mild decreased appetite

b. insomnia < 3 nights

c. new-onset hallucinations

d. mild abdominal pain

c.

all methylphenidate (MPH) products are approved for what age?

a. ≥ 6 years old

b. ≥ 3 years old

c. ≥ 12 years old

d. ≥ 8 years old

a.

how often do we titrate MPH?

a. daily

b. every 2-3 days

c. weekly

d. monthly

c.

idk if we need to know

if a patient was on oral MPH and is transitioning to the transdermal treatment, what dose do we start with?

10 mg

list the IR methylphenidate products and how they’re dosed

• ritalin

• methylin

dosed twice a day (morning and noon)

list the SR and ER methylphenidate products and how they’re dosed

• MPH-SR (ritalin SR)

• MPH-ER (metadate ER)

dosed twice daily

how is MPH-LA (ritalin LA) dosed?

how is MPH-CD (metadate CD) dosed?

once daily dosing — ER beaded technology simulates twice daily dosing

LA: 50% dose released immediately, second peak at 5-6 hours

CD: 30% released immediately, 70% released continuously, second peak at 5-6 hours

what methylphenidate product uses an osmotic-release delivery system to simulate 3 times a day dosing, with a total duration of action of 10-12 hours?

a. MPH-SR (Ritalin SR)

b. MPH-LA (Ritalin LA)

c. MPH-CD (Metadate CD)

d. MPH-OROS (Concerta)

d.

when do we see clinical effects with the methylphenidate transdermal patch (Daytrana)?

when is the patch removed?

how long do we see effects after removal?

effects seen 2 hours after placement

remove after 9 hours

effects seen for up to 3 hours after removal

when is jornay PM (methylphenidate product) given?

once daily in the EVENING

peak occurs 14 hours after dosing

what is the brand name of serdexmethylphenidate + dexmethylphenidate?

when is it given?

Azstarys

given once daily in morning without regard to meals

checkpoint

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

a. 30 minutes

b. 2 hours

c. immediately

d. 6 hours

b.

what age are dextroamphetamine products and IR mixed amphetamine salts approved for?

a. ≥ 6 years old

b. ≥ 3 years old

c. ≥ 12 years old

d. ≥ 8 years old

b.

what age are all amphetamine products (exception: dextroamphetamine and IR mixed amphetamine salts) approved for?

a. ≥ 6 years old

b. ≥ 3 years old

c. ≥ 12 years old

d. ≥ 8 years old

a.

do younger children eliminate amphetamine faster or slower?

a. faster

b. slower

a.

what is the difference between Adderall (dextroamphetamine + amphetamine IR) and Adderall XR (dextroamphetamine + amphetamine XR)?

IR: duration of action 4-6 hours

XR: once daily dosing; simulates twice daily dosing; duration 10-12 hours

what amphetamine product is a prodrug that is converted to dextroamphetamine and L-lysine in the GUT (deters from abuse)?

a. mixed amphetamine salts (adderall)

b. dexedrine

c. lisdexamfetamine (vyvanse)

d. dyanavel XR

c.

what amphetamine products are a combination of immediate- and extended-release? (SATA)

a. lisdexamfetamine (vyvanse)

b. adzenys XR-ODT and ER

c. dyanavel XR

d. xelstrym

b. c.

what is the brand name of the dextroamphetamine paatch?

xelstrym

when should all stimulants be taken?

a. morning

b. noon

c. dinner

d. bedtime

a.

what products should not be crushed or chewed?

ALL ER PRODUCTS

what products can be opened and sprinkled on APPLESAUCE?

• MPH-LA

• MPH-CD

• Dex-MPH-XR

• mixed amphetamine salts XR

________ can be opened and dissolved in a glass of water to be consumed immediately

lisdexamfetamine capsule

where should Daytrana (MPH patch) be placed?

can we cut it?

when do you apply and wear for how long?

place on lateral hip (rotate every day)

do NOT CUT

apply 2 hours before dessired effect and wear for 9 hours

_____ should not be given concomitantly or within 14 days of stimulant therapy as this may cause hypertensive crisis

MAOIs

if you take TCAs with MPH, what can happen to TCA levels?

a. increase

b. decrease

a.

list the nonstimulants that are used second line

• ER guanfacine (Intuniv)

• ER clonidine (Kapvay)

• atomoxetine (Strattera)

what are nonstimulants more effective in treating?

a. inattentive symptoms

b. hyperactive symptoms

b.

which nonstimulant has a longer half-life, duration of action, greater selectivity for the alpha_2a-receptor, and causes less sedation?

a. clonidine

b. guanfacine

b.

what are the pregnancy categories for the nonstimulants?

what one do we know is excreted in breast milk?

• guanfacine: category B

• clonidine and atomoxetine: category C

• breast milk: clonidine (use caution)

who are clonidine ER and guanfacine ER most beneficial in?

• comorbid tic disorders

• ADHD associated sleep disturbances

what is atomoxetine (strattera) dosed based on?

a. symptoms

b. serum levels

c. weight

d. pt preference

c.

what do we monitor with atomoxetine?

• hepatotoxicity

• incr. risk of suicidality

• efficacy may take up to 4 weeks

what new drug is metabolized by CYP2D6 (like atomoxetine) and has the same monitoring parameters as atomoxetine?

viloxazine (qelbree)

if a patient has more symptoms early in the morning, what products should we use?

delivers more of the active drug early

• MPH-LA

• IR formulation of MPH or dextroamphetamine

if a patient has more symptoms later in the afternoon, what products should we use?

longer-acting formulations

• OROS-MPH

• mixed amphetamine salts-XR

can we use long-acting formulations as initial treatment, or do we need to start with IR formulation first?

YES we can use long-acting initially

documentation of baseline symptoms and complaints over a ___________ period is essential

1 month pre-medication period

what do we need to document at baseline and every 3 months?

• height and weight

• eating and sleeping patterns

• BP and HR

T/F most children should be given a drug-free trial every year (“drug holiday”)

TRUE