ADHD

Question 1

ADHD - Core symptoms (3)

Answer 1

HII:

• Hyperactivity
• Inattentiveness
• Impulsivity

Question 2

ADHD is seen as early as age ___.

Answer 2

3

Question 3

Is an ECG required for every patient prior to starting stimulant therapy?

Answer 3

No, according to CADDRA guideline, only those who have a personal or family history of cardiac problems, or raised blood pressure or heart rate on examination.

Question 4

ADHD - Diagnosis

Answer 4

1. Inattention or hyperactivity/impulsivity
2. Onset before 7 years
3. Symptoms present in 2 or more settings
4. Significant impaired functioning
5. Duration at least 6 months

Certain symptoms may predominate: inattentive vs hyperactive vs combined subtypes

Question 5

Non pharmacologic choices for treatment

Answer 5

• Behavioral therapies(CBT) - not as effective as pharmacotherapy
• Mind body therapies such as neurofeedback or hypnosis(currently studied)
• Eliminating certain foods from diet such as sugars, dyes, or preservatives(observational evidence only)

Question 6

Patients who do not respond to one type of stimulant should switch to another after ___ weeks.

Answer 6

3-4 weeks

Question 7

Onset of psychostimulants should be within ___. An adequate trial of stimulant is considered to be ____.

Answer 7

• 2 days but may take up to 2 weeks
• 3-4 weeks.

Question 8

At least ___ % of patients on psychostimulants will have a significant decrease in core ADHD symptoms.

Answer 8

70%

Question 9

CADDRA stands for

Answer 9

Canadian Attention Deficit Disorder Resource Alliance

Question 10

Advantages of long acting psychostimulants (3).

Answer 10

• Duration is up to 12 hours, possible compliance increase
• Decreased abuse potential
• Decreased risk of rebound hyperactivity

Question 11

Disadvantages of long acting psychostimulants (2)

Answer 11

• More expensive
• Difficult to tiitrate initially

Question 12

Immediate release formulations of methylphenidate and dextroamphetamine have durations of ___ hours.

Answer 12

3-6 hours

Question 13

Long acting and Extended Release formulations of methylphenidate and dextroamphetamine have durations of ___ hours.

Answer 13

8-12 hours

Question 14

The longest duration psychostimulant is ___.

Answer 14

Lisdexamfetamine (up to 14 hours)

Question 15

This drug is not in the amphetamine class but also has stimulant effects that help ADHD. Not officially approved for it though. Name and dose.

Answer 15

Modafinil.

170-425mg/day.

Question 16

ADHD - Second line therapy

Answer 16

• Norepinephrine Reuptake inhibitor: Atomoxetine (Strattera) –> not classified as a stimulant
• Antidepressants: TCAs(desipramine, imipramine, nortripyline), Buproprion, Venlafaxine.
• Alpha 2 Agonist: Clonidine

Question 17

Atomoxetine MOA

Answer 17

NRI: Norepinephrine Reuptake Inhibitor

Question 18

Atomoxetine onset of effect

Answer 18

3-4 weeks

Question 19

Atomoxetine dosing

Answer 19

• Dosing depends on weight.
• Less than 70kg: 0.8-1.2mg/kg/day (titrate up)
• More than 70kg: 40-80mg/day

Maximum 100mg/day regardless of weight.

Question 20

Which antidepressant class is not useful in ADHD?

Answer 20

SSRI’s

Question 21

If using TCAs must do this test before. Why?

Answer 21

Do a baseline ECG.

Because TCAs have a quinidine like effect on the heart(QT prolongation)

Question 22

TCAs may require ___ weeks to take effect.

Answer 22

3-4 weeks.

Question 23

Can antipsychotics be used as treatment?

Answer 23

Only if all other options have been tried.

Only good for behavioral symptoms (ie not good for inattentiveness).

Risperidone: 0.25-0.5mg po HS.

Question 24

Kids on stimulant medications are generally shorter than kids not on it (True or False)

Answer 24

True (kids will catch up in adolescence but likely permanently attenuated)

Question 25

Capsules such as Adderall XR, Dexedrine spansules, Vyvanse, and biphentin capsules can be opened up and sprinkled on soft foods like ice cream, applesauce or yogurt (True or False)

Answer 25

True. But must consume within 30 minutes. Also do not chew.

Question 26

ADHD Treatment is generally lifelong, however parents may..

Answer 26

Try a drug holiday (try weaning their kids off for 2-3 weeks in the summer to re-assess behavior and see if they require for new school term.

Question 27

Side effects of psychostimulants

Answer 27

SHADING: - Stomach pain - Headaches (goes away in 1-3 weeks) - Appetite decrease/Anorexia (give with high calorie meals) - Dry mouth (dexedrine) - Insomnia/Irritability (take meds early in day, avoid caffeine, naps) - Nausea - GI upset

Question 28

Side effects of atomoxetine

Answer 28

Similar to psychostimulants(N/V/HA) but especially increase in BP and HR

Question 29

Dextroamphetamine is CI in pregnancy (true / false)

Answer 29

False. It has the most evidence vs MP and atomoxidine. Low birthweight but no teratogenicity.

Question 30

Atomoxidine has risk of suicidal ideations (true/false)

Answer 30

True. Although risk is small, should discuss with pts and family.

Question 31

Psychostimulants are approved for kids aged ___ years.

Answer 31

at least **6** years old

Question 32

Buproprion MOA. Is it effective for ADHD?

Answer 32

Norepinephrine and Dopamine reuptake inhibitor Moderately effective as per RCTs.

Question 33

Venlafaxine MOA. Is it effective for ADHD?

Answer 33

**SNRI**: Serotonin and Norepinephrine reuptake inhibitor Unlabeled use for ADHD, not studied. *Possibly effective* especially with adult ADHD.

Question 34

Clonidine MOA. Is it effective for ADHD?

Answer 34

- _Alpha 2 adrenergic agonist_ - 2nd or 3rd line use for ADHD. It primarily reduces symptoms of **aggression**, **hyperactivity**, not inattentiveness.