ADHD:
- characteristics
- which type MC in men? Women?
- neuropathogenesis
-manifests in childhood w/ sx of hyperactivity, impulsivity, and or inattention and present in more than one setting. Sx affect cognitive, academic, behavioral, emotional, and social functioning.
Hyperactive MC in boys, inattentive MC in girls
Neuopathogenesis:
-decreased activation in the basal ganglion and anterior frontal lobe, which are the areas that correlate with impulse control and attention. Increased Dopamine clearance leading to increased NE activity.
Functions of the frontal lobe?
-ability to project future consequences resulting from current action, choice between good and bad actions, override and suppression of socially unacceptable responses
DSM V criteria for ADHD
Need 6 or more sx of inattention or hyperactivity/impulsivity (5 or more for ages 17 and older)
- sx inappropriate for the given age
- negatively impacts social and academic or occupational activites
- sx develop prior to age 12
- sx in two or more settings for at least 6 mo
- sx not better explained byy another psych disorder.
ADHD Inattentive Sx
- failure to give close attention to detail
- difficulty sustaining attention in task
- failure to listen when spoken to directly
- failure to follow instructions
- difficulty organizing tasks and activities
- reluctance to engage in tasks that require sustained mental effort
- loses things necessary for tasks or activities
- easy distractability
- forgetfulness in daily activities
ADHD Impulsive-hyperactivity Sx
- fidgetiness with hands andd feet or squirmms in seat
- difficulty remaining seated in class
- excessive running/climbing in inappropriate situations
- difficulty engaging in quite activities
- is often on-the-go
- talks excessively
- blurts out answers
- difficulty awaiting turns
- interrupting and intruding on others
ADHD Medical Evaluation
Dx and Tx of ADHD in adults
- parents and teacher fill out Vanderbilt form
- refere for vision and hearing tests
- Hx & PE
ADHD IN ADULTS:
-dx should be made by mental health professional
-sx and medications are the same as adolescent ADHD.
ADHD Tx:
- tx of choice?
- therapy types?
- criteria for initiation of medications for ADHD
- what testing/documentation needs to be done prior to pharm therapy?
Tx of choice: stimulants (Ritalin, Adderall, Concerta)
Therapies:
-behavioral therapy (must be used with meds)
Criteria for inititation:
- confirmed ADHD
- older than 6YO
- parental consent
- school is cooperative
- normal HR and BP
- no hx of seizures
- does not have tourette syndrome, autism spectrum disorder, anxiety disorder, substance abuse among household members.
Document -pretreatment Ht, wt, BP, HR, appetite, sleep pattern, HA, abd pain
- medical eval + EKG
- assess for substance use/abuse
What drug classes are used in the tx of ADHD?
Stimulants = first line therapy; Methylphenidate, Amphetamines (Dextroamphetamine, Dextroamphetamine-amphetamine)
Atomoxetine
Alpha-2 adrenergic agonists
Antidepressants (Tricyclics and Buproprion)
Methylphenidate:
- short acting drugs
- time to onset
- duration
- half life
Drugs: Ritalin, Methylin
Onset: 20-60minutes
Duration: 3-5hrs
Half life: 2-3hrs
Methylphenidate:
- long acting drugs
- time to onset
- duration
- formulations
Drugs: Metadate ER, Methylin ER, Ritalin SR, Concerta, Daytrana(patch), Focalin XR (dexmethylphenidate)
Time to onset: 20-60minutes
Duration: 8-12hrs
Formulations: single pulse, sustained release, osmotic release, oral suspension, transdermal
Amphetamines:
- what are the short acting drugs?
- onset of action
- duration
Drugs:
-Dextroamphetamine: Dexedrine, Dextrostat, Procentra
-Amphetamine-dextroamphetamine: adderall
Onset: 20minutes
Duration: 4-6hrs
Amphetamines:
-what are the long acting drugs?
-what is the first line drug? onset of action? duration?
Drugs:
- Lisdexamfetamine (Vyvanase)
- Dextroamphetamine SR
- Amphetamine- Dextroamphetamine (Adderall XR)
Adderall XR is first line; onset is 20min, duration 8-10hrs
What are the non-stimulant medications?
2nd line: Atomoxetine (Strattera)
3rd line:
- alpha-2adrenergic agonists:
- -clonidine (Catapres)
- -Guanfacine (Tenex)
- antidepressants:
- -Tricyclics: Imipramine (Tofranil andd Desipramine (Norpramin)
- -Buproprion (Wellbutrin)
Atomoxetine (Strattera)
-whats minimum age required for this med?
-how long until effects are noticed?
-
Must be older than 6YO
This may take 1-2wks before effects are noted, with stimulant medication effects are noted right away.
How often do we monitor therapy once starting a new ADHD med?
assess weekly during titration stage (may last 1-3mo)
after titration phase pts seen monthly to monitor weight, heart rate, and BP on a stable dose without new SE.
Once on a stable dose f/u should be every 3-6mo
What SE are essential to assess at every follow up visit? If these SE occur how do we manage them?
Decreased appetite:
- eat after/at mealtimes
- eat nutrient dense food
Poor Growth:
-drug hoidays
Dizziness:
- monitor BP and pulse
- ensure adequate fluid intake
Insomnia/nightmares:
- omit, reduce the last dose of the day
- consider short acting
Mood Lability: sx that may occur as med wears off can be averted by using a longer acting formulation or increasing from BID to TID if short acting.
Rebound: sx taht occur as med wears off; may improve by stepping dose down at end of day
Tics:
-conduct drug trial at different doses including no meds to be sure that they are related to meds,
Psychosis:
-assess for suicidality, hallucinations, increased aggression; verify dose is appropriate and refer to mental health specialist
Diversion/Misuse:
- monitor sx and Rx refills for evidence of misuse
- long acting stimulants have less potential for abuse
- open discussion
Reasons for tx failure?
- lack of adherence to medication regimen
- are tx goals and expectations realistic?
- is there another comorbid psychiatric dx?
- if fail multiple stimulants or intolerable SE then trail of Atomoxetine (Strattera) or an alpha-2 adrenergics
What medications cannot have drug holidays?
- atomoxetine or alpha-2-adrenergic agonists
* b/c of extended half life, these take awhile to build up in your system to be effective.
Termination of Therapy
- may abruptly discontinue stimulants or atomoxtine(Strattera)
- alpha-2-adrenergic agonists and tricyclics should be tapered off over several weeks.
Ritalin
- MOA
- SE
- how often can you dose this medication?
MOA: inhibits reuptake of dopamine and NE
- SE:
- -anxiety
- -wt loss
- -psychiatric sx: psychosis, aggression, hallucinations
- -heart problems in at risk people
- -easy bruising n
- -high potential for abuse/addiction
- Schedule II Drug
Can dose short acting (4hrs), intermediate (8hrs), or long acting (12hrs)
Adderall
-SE
SE:
- high potential for abuse/addiction
- anxiety
- wt loss
- psychosis, hallucination, aggression
- heart problems in at risk people (sudden death)
- Schedule II drug
Dextroamphetamine; DEXEDRINE
- previous uses?
- SE
previously used at OTC diet pill
SE:
- heart problems in those with heart problems
- psychiatric problems (Bipolar)
- increased BP and rate
- Children/Teenagers:
- -seeing things or hearing voices
- -believing things that are not true
- -new manic sx
Lisdexamphetamine (Vyvanase)
-converted to what after oral ingestion?
dextroamphetamine.
* less addictive but still a schedule II drug
Atomoxetine (Strattera)
- works on what NT?
- BBW?
- SE
Works on NE
BBW: increased risk of suicidal behavior less than 25YO (is this only because it was initially used as an anti-depressant?)
SE: dry mouth, insomnia, nausea, decreased appetite, constipation, decreased libido, Erectile dysfunction, urinary hesitancy, dizziness, sweating
-chest pain, SOB, arrhythmias, psychosis, jaundice
