3 - ADHD

Question 1

What are the 3 hallmark symptoms?

Answer 1

• hyperactivity
• impulsivity
• inattention

Question 2

When do symptoms present?

Answer 2

usually before age 12, can persist into adulthood

*late-onset ADHD can also occur

Question 3

For the diagnosis of ADHD, what do the symptoms need to cause and where do they need to be present and for how long?

Answer 3

• need to cause interference with normal development
• present in 2 or more settings (home, school, sports, etc.)
• present for > 6 months

Question 4

Medications are as effective as therapy, so why bother with therapy?

Answer 4

• Therapy provides coping methods for both child and parent/caregiver
• Gives the child tools to practise and use in the future when they potentially come off of ADHD medication

Question 5

What are non-pharms?

Answer 5

• Therapy!! (very important)
• exercise
• sleep
• dietary restrictions (reduce sugars, dyes, preservatives) - this is not based on evidence but observation

Question 6

What are the two MAIN classes of drugs for ADHD?

Answer 6

Stimulants:

• dextroamphetamine (Dexedrine)
• methylphenidate (Concerta, Ritalin)
• mixed salts amphetamine (Adderall)
• lisdexamfetamine (Vyvanse)

Non-stimulants:

• atomoxetine
• guanfacine
• clonidine

Question 7

What is first line for ADHD?

Answer 7

stimulants

Question 8

What are some contraindications to stimulant use?

Answer 8

• CV disease
• MAOi use
• History of drug abuse

Question 9

How long should a trial of stimulants be?

Answer 9

3-4 week trial is reasonable

improvement in symptoms observed in the first week

reasonable to continue for 6-12 months

Question 10

If no response at 3-4 weeks, then what?

Answer 10

switch stimulants

Question 11

Can stimulants affect weight and height?

Answer 11

• Yes - long term stimulants may decrease height and weight

- Get a baseline measurement and then need to monitor growth every 3-6 months (dose-dependent s/e)

Question 12

Are drug holidays a good idea?

Answer 12

Yes - good way to reassess need - do this for a few weeks in the summer.

Question 13

If diversion of stimulants is suspected, what do you do?

Answer 13

Switch to a non-stimulant:

• Atomoxetine (Straterra)
• Guanfacine (Intuniv)

**lower abuse potential

Question 14

Out of the stimulants, what is first line?

Answer 14

long-acting agents should be first line

• amphetamine, methylphenidate, lisdexamfetamine
• once daily dosing, less abuse potential

Question 15

What is atomoxetine and who is it used for?

Answer 15

• NE reuptake inhibitior
• used for those > 6 yo with ADHD
• not a stimulant, not a controlled substance

Question 16

How long do you need to treat for with atomoxetine to assess efficacy?

Answer 16

• 6-12 weeks

- may take 3-4 weeks too see benefit

Question 17

Contraindications to atomoxetine?

Answer 17

• CV problems
• narrow angle glaucoma
• MAOi use

Question 18

List the alpha 2 agonists used for ADHD

Answer 18

• clonidine

- guanfacine

Question 19

What ADHD symptoms do alpha 2 agonists help with?

Answer 19

• less benefit for inattention

- help with aggression, hyperactivity, impulsivity

Question 20

Compare clonidine and guanfacine

Answer 20

Guanfacine has more selective neuronal activity and longer DOA, resulting in less sedation and less hypotension

Question 21

Antidepressants role in ADHD?

Answer 21

2nd or 3rd line or adjunctive tx

Question 22

What antidepressants can be used in AHDD?

Answer 22

• Buproprion (NDRI) - moderately effective for ADHD
• Venlafaxine (some evidence for it)
• TCAs (short term) - less effective than stimulants

Question 23

Out of the antipsychotics, which one can be used for ADHD?

Answer 23

low doses of risperidone (does not help with inattention)

Question 24

What stimulants are safe in pregnancy?

Answer 24

amphetamine and dextroamphetamine
*one study with 1.8 million pregnancies showed they were not associated with increase risk of congenital malformations or cardiac malformations

Question 25

Caution which stimulant in pregnancy, especially 1st trimester?

Answer 25

methylphenidate (Concerta, Ritalin) *may be associated with elevated risk of cardiac malformations

Question 26

What are other options for ADHD in pregnancy?

Answer 26

TCAs, venlafaxine, bupropion - appear to be safe - but less effective for ADHD

Question 27

For breastfeeding, is methylphenidate safe?

Answer 27

- transfer of methylphenidate into breast milk appears to be low, but effects on neurological development have not been studied - monitor baby for agitation and poor weight gain

Question 28

For breastfeeding, are amphetamines safe?

Answer 28

- they are transferred into breast milk - but use appears to be safe, although neurological impact on the infant is also unknown - monitor for insomnia, agitation, irritability and poor weight gain in the infant

Question 29

Is atomoxetine safe in breastfeeding?

Answer 29

no studies done

Question 30

Are alpha 2 agonists safe in breast-feeding? (clonidine and guanfacine)

Answer 30

- they may decrease milk production | - may cause side effects (ex. hypotension) in the infant so other options are preferred

Question 31

Can risperidone be used in breastfeeding?

Answer 31

limited information about this, use other agents instead

Question 32

Can you use TCA, bupropion or venlafaxine in breastfeeding?

Answer 32

yes, monitor baby for sedation, weight gain and irritability

Question 33

Which one can be mixed in water?

Answer 33

Vyvanse

Question 34

Which ones can be opened and sprinkled into soft foods?

Answer 34

Adderall XR Dexedrine spansules Vyvanse and Biphentin capsules

Question 35

stimulants can exacerbate ___ in some individuals

Answer 35

tics

Question 36

____ alone or in combination with stimulants is also effective in improving both ADHD and tic symptoms in patients with both conditions

Answer 36

clonidine