Term
| most common neurobehavioral disorder in children |
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Definition
ADHD
seen as a life-span disorder |
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Term
| attention deficit and disruptive behavior disorders |
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Definition
ADHD:
a condition characterized by an impairment in the ability to self regulate arousal and inhibit behavior according to socially acquired rules of conduct
CONDUCTIVE DISORDER (CD):
a pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules (bullies)
OPPOSITIONAL DEFIANT DISORDER (ODD):
a pattern of negativistic, hostile, and defiant behavior |
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Term
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Definition
Combined type (ADHD/C):
inattention and hyperactivity
MOST COMMON: 80% of children diagnosed with ADHD have combined type
predominantly inattentive type (ADHD/I)
predominantly hyperactive-impulsive type (ADHD/HI) |
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Term
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Definition
national prevalence of ADHD is 7%
IN CHILDREN M > F; IN ADULTS IT IS GENDER NEUTRAL
PREVALENCE INCREASES WITH INCREASING AGE (AS CHILDREN)
50% OF CHILDREN WITH ADHD ARE TAKING MEDICATION FOR IT
race: even
ethnicity: less in Hispanics than non-Hispanic
more common in English speaking households
BELOW POVERTY LINE is a known risk factor for ADHD
on average 11% of boys and 4% of girls have behaviors consistent with ADHD
GIRLS ARE MORE PREDOMINATELY DIAGNOSED WITH INATTENTIVE TYPE
ONSET OF ADHD IS TYPICALLY BY THE AGE OF 3 AND BEFORE THE AGE OF 7 |
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Term
increased recognition that ADHD is a heterogeneous disorder with coexisting conditions such as oppositional defiant disorder, conductive disorder, anxiety disorder, mood disorder/depression, and substance use disorder
what substances are commonly abused in people with ADHD? |
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Definition
usually cocaine (attempt to self-medicate
PEOPLE WHO HAVE ADHD AND HAVE APPROPRIATE TREATMENT WILL MOST LIKELY NOT BECOME ADDICTS
PEOPLE WHO ARE NOT APPROPRIATELY TREATED ARE MORE AT RISK FOR ADDICTION |
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Term
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Definition
Catecholamine Neurotransmission:
dopamine, specifically D2/D3/D4/D5 receptors and DOPAMINE ACTIVE TRANSPORTER PROTEIN
NE
?serotonin
Genetic:
twin studies show a major genetic component
1 in 4 children diagnosed with ADHD has biologic parents who have also been diagnosed with ADHD
Environmental (not primary cause of ADHD):
severe marital discord
low social class
large family size
paternal criminality
maternal mental disorder
foster care
Other factors associated with a higher incidence of ADHD:
fetal alcohol syndrome
tobacco exposure
lead poisoning
head trauma
meningitis
genetic resistance to thyroid hormone = hyperthyroidism |
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Term
| 3 classic symptoms of ADHD |
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Definition
inattentiveness
hyperactivity
impulsivity |
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Term
| diagnostic criteria for ADHD |
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Definition
1) six or more of 9 symptoms of INATTENTION for at least 6 months to a degree that is maladaptive and inconsistent with developmental level
OR
2) 6 of the 9 symptoms of HYPERACTIVITY/IMPULSIVITY have persistent for at least 6 months to a degree that is maladaptive and inconsistent with developmental level |
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Term
| symptoms of INATTENTION (more common in girls) |
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Definition
often fails to give close attention to details or makes careless mistakes in schoolwork or other activities
often has difficulty sustaining attention in tasks or play activity
often DOES NOT SEEM TO LISTEN when spoken to directly
often DOES NOT FOLLOW THROUGH on instructions and fails to finish schoolwork, chores (not due to oppositional behavior or failure to understand instructions)
often has DIFFICULTY ORGANIZING TASKS and activities
often avoids, dislikes, or is RELUCTANT TO ENGAGE IN TASKS THAT REQUIRE SUSTAINED MENTAL EFFORT (such as homework)
often LOSES THINGS necessary for tasks or activities
is often EASILY DISTRACTED by extraeous stimuli
is often FORGETFUL in daily activities |
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Term
| symptoms of HYPERACTIVITY |
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Definition
often FIDGETS with hands or feet or squirms in seat
often RESTLESS during activties when others are seated
often RUNS ABOUT or climbs excessively in situations in shich it is inappropriate
often EXCESSIVELY LOUD or noisy during play, leisure, or social activity
is often "ON THE GO" or often as if "driven by a motor"
often TALKS EXCESSIVELY |
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Term
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Definition
often BLURTS OUT ANSWERS before questions have been completed
often has DIFFICULTY AWAITING TURN
often INTERRUPTS OR INTRUDES on others (for example, interrupts conversations or games) |
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Term
| other diagnostic features of ADHD |
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Definition
onset of symptoms must occur before the age of 7 yo and the symptoms must clearly lead to impaired functioning
some impairment from the symptoms is PRESENT IN TWO OR MORE SETTINGS (school and at home)
there must be clear evidence of CLINICALLY SIGNIFICANT IMPAIRMENT IN SOCIAL, ACADEMIC FUNCTIONING |
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Term
| primary functional impairments of ADHD |
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Definition
organization/time management
following directions
academic achievement
social functioning
problem solving difficulties |
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Term
| diagnosis of ADHD according to the American Academy of Pediatrics |
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Definition
RECOMMENDATION 1:
in a child 6-12 yo who presents with INATTENTION, HYPERACTIVITY, IMPULSIVITY, ACADEMIC UNDERACHIEVEMENT, OR BEHAVIOR PROBLEMS, the primary care provider should evaluate for ADHD
RECOMMENDATION 2:
the diagnosis of ADHD requires that the child meet DSM-IV criteria.
children must not only meet the behavioral diagnostic criteria, but also have FUNCTIONAL IMPAIRMENT to be diagnosed with ADHD
symptoms of ADHD should be present in AT LEAST 2 DIFFERENT SETTINGS
the subtypes are as follows:
1) ADHD/C: meets 6 of 9 behaviors in both inattention and hyperactive-impulsive lists
2) primarily ADHD/I: meets 6 of 9 inattention behaviors
3) primarily ADHD/HI: meets 6 of 9 hyperactive-impulsive behaviors
RECOMMENDATION 3:
the assessment of ADHD require evidence directly obtained from parents (through questionnaires/rating scales)
RECOMMENDATION 4:
assessment of ADHD requires evidence directly obtained from the classroom teacher
RECOMENDATION 5:
evaluation of the child with ADHD should include assessment for COEXISTING CONDITIONS:
ODD
CD
anxiety disorder
depression
RECOMMENDATION 6:
other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD, but may include:
elevated blood lead levels
abnormal thyroid hormone levels
brain imaging studies
continuous performance tests |
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Term
| non-pharm therapies for ADHD |
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Definition
no improvement between drugs alone or combination with non-drug therapy
unless there is a comorbidity, meds alone are sufficient for ADHD
psychosocial interventions:
parent training
contigency management (positive reinforcement, timeout)
clinical behavior therapy
cognitive behavioral treatment |
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Term
| MOA of CNS stimulants Methylphenidate and Amphetamine |
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Definition
proposed MOA is increased DA and NE in the synaptic cleft by:
methylphenidate: blocking reuptake of DA and NE at the presynaptic neuron
amphetamine: blocking reuptake of DA and NE, increasing the release of DA and NE (additional MOA)
amphetamines are half the dose of methylphenidate |
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Term
| onset and duration of action of Ritalin (methylphenidate) |
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Definition
quickest onset, shortest lasting
effect in 15-30 minutes and lasts 4-6 hours |
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Term
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Definition
initial: 5 mg/dose given before BREAKFAST AND LUNCH (to avoid insomnia)
titrate by 5-10 mg/day at WEEKLY INTERVALS to desired effect
if TID necessary then given mid-afternoon
MAX: 60 mg/day |
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Term
| dosage forms and dosing of Methylin (methylphenidate) |
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Definition
tablets, chewable tablets, oral solution
dosing same as Ritalin |
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Term
once regular tablets are titrated, sustained release may be given based on 8-hour dosage of Ritalin.
examples of sustained release options |
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Definition
Ritalin SR
Methylin ER
Metadate ER |
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Term
| onset and duration of action of Ritalin LA (methylphenidate) |
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Definition
an extended release capsule that exhibits a bi-modal plasma concentration-time profile
the initial rate of absorption is similar to that of short acting Ritalin (Tmax = 1-3 hours) and a second Cmax approximately 4 hours following the first Cmax |
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Term
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Definition
initial: 10 mg/day
10 mg dose adjustments made on weekly intervals
MAX = 60 mg/day |
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Term
| conversion from non-sustained release methylphenidate or Ritalin SR to Ritalin LA |
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Definition
10 mg MPH BID or 20 mg MPH SR = 20 mg daily Ritalin LA
15 mg MPH BID = 30 mg daily Ritalin LA
20 mg MPH BID or 40 mg MPH-SR = 40 mg daily Ritalin LA
30 mg MPH BID or 60 mg MPH SR = 60 mg daily |
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Term
| onset and duration of action of Concerta (methylphenidate) |
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Definition
absorption is rapid with initial peak reached in 1-2 hours, with maximum peak achieved at about 6-8 hours
OROS technology: osmotic pressure to deliver medication at a controlled rate
[image]
smooth curve with very little fluctuation with peaks and troughs
benefit of maintaining consistent concentrations |
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Term
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Definition
initial dose: 18 mg daily with 18 mg adjustments made in weekly intervals
MAX = 54 mg/day |
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Term
| conversion from non-sustained release MPH or Ritalin SR to Concerta |
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Definition
10-15 mg MPH or Ritalin SR = 18 mg Concerta
20-30 mg MPH or Ritalin SR = 36 mg Concerta
30-45 mg MPH or Ritalin SR = 54 mg Concerta
40-60 mg MPH = 72 mg Concerta |
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Term
| onset and duration of action of Metadate CD (methylphenidate) |
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Definition
has a concentration-time profile that mimics short acting MPH BID dosing with a sharp, initial slope followed by a second peak approximately 3 hours after the first with a gradual decline
[image]
30% is IR and 70% is XR |
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Term
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Definition
initial dose: 10 mg/day with dose adjustment at 10 mg increments weekly
MAX = 60 mg/day |
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Term
| onset and duration of Daytrana (methylphenidate) |
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Definition
EFFECT IN 2 HOURS AND LASTS UP TO 12 HOURS
less first pass effect than oral MPH; hepatic metabolism
GOOD COUNSELING POINT: have to put the patch on at 6 AM for effects to start at 8 AM |
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Term
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Definition
9 hour transdermal patch
initial: 10 mg patch daily for 9 hours, off for 15 hours
increase to next patch strength at weekly intervals
MAX = 30 mg/day (lower dose b/c less metabolism due to avoiding first pass metabolism)
apply to hip 2 hours prior to desired effect and ALTERNATE HIP application sites
EFFECTS MAY PERSIST 3-5 HOURS AFTER PATCH REMOVAL
DO NOT CUT
Disposal: fold in half and flush |
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Term
| drug interactions with methylphenidate |
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Definition
carbamazepine
MAOIs
linezolid
phenobarbital
phenytoin
TCAs
sympathomimetics
warfarin |
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Term
| conversion from MPH to Focalin (dexmethylphenidate, the d-enantiomer of MPH which is more pharmacolocially active) |
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Definition
| 1/2 the dose of racemic MPH = dose of Focalin |
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Term
| onset and duration of Focalin XR (dexmethylphenidate) |
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Definition
an extended release capsule that exhibits a bi-modal plasma concentration-time profile
the initial rate of absorption is similar to that of short acting (Tmax = 1-1.5 hours) and a second Cmax ~5 hours following the first Cmax
[image]
capsule is 50% IR and 50% XR |
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Term
| conversion from MPH to Focalin XR |
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Definition
1/2 the total daily dose of racemic MPH = dose of Focalin XR
changing from Focalin to Focalin XR can be done as equivalent mg dosing with the total dose given in the morning as a one time dose |
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Term
| in general, the dose of amphetamine is ( ) that of MPH |
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Definition
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Term
| onset and duration of dextroamphetamine |
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Definition
rapid onset, short acting
effect in 15-30 minutes and lasts 2-6 hours
spanules absorption and onset of action appear to be more predictable than MPH-SR |
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Term
| dosing of dextroamphetamine (dexedrin, dextrostat, dexedrine spanule) |
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Definition
initial dose: 5 mg BID (morning and mid-day)
titrate to desired effect by 5 mg q3-5d
MAX = 40 mg/day |
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Term
| onset and duration of Adderall |
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Definition
rapid onset, intermediate acting
onset of effect in 45 minutes and lasts 6-8 hours
longer action than non-sustained release MPH |
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Term
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Definition
initial:
children < 3 yo NOT RECOMMENDED
children 3-5 yo - 2.5 mg/day; increase by 2.5 mg weekly
children > 6 - 5 mg/dose da or BID, titrate weekly
MAX = 40 mg/day |
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Term
| onset and duration of Addreall XR |
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Definition
same racemic mixtures as above with 2 types of micotrol beads combined in a 50:50 ratio within 1 capsule
immediate release beads release drug content in a time course similar to Addreall
delayed release beads release drug 4-6 hours after oral administration
[image] |
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Term
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Definition
initial:
children < 3 yo: NOT RECOMMENDED
children 3-5 yo: NOT STUDIED FOR XR
children > 6 yo: 10 mg daily; titrate by 10 mg weekly
MAX = 30 mg/day |
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Term
| conversion from Adderall to Adderall XR |
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Definition
| equivalent mg dosing with the total dose given in the morning as a one time dose |
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Term
| onset and duration of Vyvanse |
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Definition
longer onset, longer duration
vyvanse is a prodrug of dextroamphetamine
the Tmax of the prodrug is ~1 hour and the Tmax of dextroamphetamine is ~3.5 hours |
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Term
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Definition
initial: 30 mg daily (START AT 30 MG regardless of what other doses they are on with other products)
titrate by 10-20 mg weekly
MAX = 70 mg/day |
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Term
| drug interactions with amphetamines |
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Definition
acetazolimide
NaHCO3
MAOIs
linezolid
TCAs
sympathomimetics |
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Term
| ADRs of methylphenidate and amphetamines |
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Definition
CARDIOVASCULAR:
DO NOT HAVE TO DO AN EKG UNLESS PRIOR PROBLEMS
palpitations
tachycardia
increased BP
CNS:
excessive CNS stimulation
PSYCHOSIS (with prolonged use)
dizziness
headache (reduce the dose or divide the dose)
insomnia (give the dose earlier in the day, reduce the last dose of the day)
nervousness
irritability
attacks of Tourette's disease or other tic syndromes
GI:
anorexia (give the dose with meals)
nausea
vomiting
stomach cramps or pain (give with food)
ENDOCRINE/METABOLIC:
weight loss (with prolonged use)
growth suppression (growth rebound occurs after temporary discontinuation of drug) |
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Term
| specific ADRs for methylphenidate |
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Definition
leukopenia (rare)
hypersensitivity reaction
anemia (rare)
blurred vision (rare) |
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Term
| specific ADRs of amphetamine |
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Definition
skin rash or hives
blurred vision (rare) |
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Term
| MOA of atomoxetine (Strattera) |
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Definition
selective NE reuptake inhibitor (SNRI) = no dopamine activity
methylphenidate is better than Strattera, but Strattera is better than no drug
used as adjunct or as monotherapy
ONLY MONOTHERAPY = STIMULANTS OR STRATTERA |
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Term
| dosing of Strattera (atomoxetine) |
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Definition
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Term
| ADRs for Strattera (atomoxetine) |
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Definition
CYP2D6 substrate (paxil and prozac)
dose adjustment with hepatic insufficiency
somnolence
fatigue
dyspepsia
N/V
decreased appetite
increased HR
increased BP
ELEVATED LIVER ENZYMES
INCREASES SUICIDAL THINKING |
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Term
| MOA of clonidine and guanfacine |
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Definition
alpha2 adrenergic agonists
increases NTs
ADJUNCTIVE THERAPY
primarily used for Tourette's |
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Term
| ADRs of clonidine and guanfacine |
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Definition
DO NOT STOP ABRUPTLY, MUST WEAN OFF (risk of rebound hypertension)
somnolence
fatigue
headache
insomnia
hypothension
dry mouth
constipation |
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Term
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Definition
| Kapvay (XR clonidine) is still dosed BID |
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Term
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Definition
| Intuniv is a once a day ER product |
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Term
| use of antidepressants in ADHD |
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Definition
may be considered in children with anxiety, depression, and tic disorders
ADJUNCTIVE THERAPY |
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Term
| onset of action of TCAs (imipramine, desipramine is active metabolite associated with sudden cardiac death...not used!) |
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Definition
onset within 3-5 days of therapy
MUCH SLOWER ONSET |
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Term
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Definition
do not abruptly discontinue therapy, stop by tapering over 1-2 weeks
dry mouth
constipation
blurred vision
sedation
dizziness
tachycardia
may lower seizure threshold |
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Term
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Definition
weak blockade of 5HT and NE reuptake and inhibits neuronal reuptake of DA
WELL STUDIED ADJUNCT TO ADHD THERAPY!!! |
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Term
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Definition
agitation
lowers seizure threshold
insomnia
HA
N/V
constipation
tremor
blurred vision
sedation
dizziness
tachycardia
HTN |
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Term
| use of antipsychotics (haloperidol, risperidone) in ADHD treatment |
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Definition
adjuncts to the stimulants or in cases of violent and destructive behavior
decrease hyperactivity, but will not decreased distractility or increase attention span |
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Term
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Definition
sedation
anxiety
dry mouth
EPS
tardive dyskinesia |
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Term
| methylphenidate: short acting |
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Definition
ritalin
methylin
focalin
duration 3-6 hours |
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Term
| methylphenidate: intermediate acting |
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Definition
ritalin SR
methylin ER
metadate ER
duration 3-8 hours |
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Term
| methylphenidate: long acting |
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Definition
concerta
metadate CD
ritalin LA
daytrana
focalin XR
duration 8-12 hours |
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Term
| amphetamine: short acting |
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Definition
dexedrine
dextrostat
duration 4-6 hours |
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Term
| amphetamine: intermediate acting |
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Definition
adderall
dexedrine spansule
duration 6-8 hours |
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Term
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Definition
adderall XR
vyvanse
duration 8-12 hours |
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Term
| what products can be swallowed or can be sprinkled on a small amount of applesauce? |
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Definition
metadate CD
ritalin LA
focalin XR
adderall XR |
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Term
| what products must be swallowed whole? |
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Definition
ritalin SR
methylin ER
metadate ER
concerta
dexedrine
guanfacine
clonidine |
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Term
| 1st line treatment of ADHD |
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Definition
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Term
| 2nd line treatment of ADHD |
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Definition
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Term
| 3rd line treatment of ADHD |
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Definition
atomoxetine (strattera)
OR
alpha2 agonist
OR
buproprion
ALL ADJUNCTIVELY |
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Term
| treatment of depression with ADHD |
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Definition
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Term
| treatment of anxiety with ADHD |
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Definition
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Term
| treatment of conduct/oppositional defiance with ADHD |
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Definition
stimulant
THEN
antipsychotic |
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Term
| treatment of bipolar disorder with ADHD |
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Definition
| mood stabilizer (lithium, VPA) |
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Term
| treatment of Tic disorder with ADHD |
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Definition
stimulant
PLUS
alpha2 agonist
OR
antipsychotic |
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Term
| clinical pearls for ADHD treatment |
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Definition
initiate short acting (less ADE, cheaper) versus long acting (adherence) titrate weekly to goal
response to one stimulant does not predict response to the others
formulation may be important for patient acceptability (tablets can be crushed, capsules may be opened)
may consider drug-free trial/drug holiday every year |
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