ADHD

Question 1

What is the way that ADHD is characterized?

Answer 1

• By symptoms of inattention, hyperactivity & impulsivity

Question 2

What is the pathogenesis of ADHD?

Answer 2

• NOT well defined BUT is due to imbalences in catecholamine metabolism (like dopamine and Norepi) - why stimulant meds are given

Stimulants = Increase dopamine and Norepi levels

Question 3

What is considered first line for the treatment of ADHD?

Answer 3

• Parent Training for Behavior managment is 1st line for kids 4 - 5 yo
• ADHD MEDS are 1st line for those > 6 yo

Question 4

What is the DSM-5 Diagnostic Criteria for Inattention? What are the symptoms?

Answer 4

• > 6 symptoms of Inattention for kids to 16 yo (> 5 if 17 yo or older)
• Symptoms: Fails to pay attention, cant hold attention, not listening to someone talking to them, doesnt follow instructions, cant finish tasks, bad organization, avoids tasks that requires mental effort, forgetful…

Question 5

What is the DSM-5 Criteria for Hyperactivity & Impulsivity? What are the symptoms?

Answer 5

• > 6 symptoms of hyperactivity-impulsivity for kids to 16 yo (> 5 for 17 yo or older)
• Symptoms: fidgets, leaves seat unexpectedly, runs around Inappropriately, unable to play quietly, “on the go”, talks excessively, blurts out anwsers, cant wait their turns…

Question 6

What are some of the following conditions that must be met in order to disgnose someone with ADHD?

Answer 6

• Several symptoms (of both) present before age 12
• Symptoms must have been present in 2 or more settings (i.e.; home, school, work, with friends…)
• Symptoms are NOT caused by other disorders

Question 7

What are some natural products that can help with ADHD?

-

Answer 7

• Fish oils not recommended BUT do have some cognitive help
• Melatonin can be used fro sleep in those taking stimulants

Question 8

What are some of the Drug Treatments for ADHD?

Answer 8

• Stimulants (1st line) - normally the long acting are better for maintaining symptoms
• Non-stimulants - normally tried after stimulatns do not work well enough (after 2 - 3 meds)

Stimulants take in AM (1st line)
Non-Stimulants (2nd line)
Add-ons (used in combo or alone)
Sleep meds too

Question 9

What are some of the patient friendly formulations for stimulants that patients can use?

Answer 9

• Capsules can be opened (Adderall, Ritalin and Vyvanse)
• Chewable Tabs
• ODTs
• Patches (daytrana)
• Suspensions

Question 10

What are some of the saftey concerns for the stimulant medications?

Answer 10

• All are C-II and must be dispensed with a MedGuide

Question 11

What are some of the boxed warnings for the stimulant medications

Answer 11

• ALL have a high risk of abuse and dependence - could lead to substances use disorders and addiction

Question 12

What are some of the contraindications for the Stimulant medications;

Answer 12

• DO NOT use within 14 days of an MAOi due to hypertensive crisis risk

Question 13

What are some of the warnings for the stimulant medications?

Answer 13

• Abuse and Missuse (boxed warning)
• Increased HR and BP - could lead to serious cardio events
• Prispism (Refer to ED section)
• New onset psychosis or exacerbation of it
• loss of appetite - leads to decrease growth in kids
• Serotonin syndrome

Question 14

What are some of the stimulant medications that are used for ADHD?

Answer 14

• Methylphenidate (Ritalin - IR Tab, Concerta - ER Tab, Daytrana - Patch, Jornay PM - ER Cap)
• Dexmethylphenidate (Focalin, Azstrays)
• Dextroamphetamine/Amphetamine (Adderall)
• Lisdexamfetamine (Vyvanse)
• Methaphetamine

ALL should be titrated up every 7 days and do not need to be tapered off

Question 15

What is the MOA for the Stimulant medications?

Answer 15

• Blocks the reuptake of Norepi and Dopamine

Question 16

What are some dosings for Methylphenidate used for ADHD?

Answer 16

• Start at 5 mg BID - Ritalin
• Start 18 - 36 mg QAM - Concerta

Question 17

What are some side effects for Methylphenidate used for ADHD?

Answer 17

• Insomnia, Decreased Appetite/Weight Loss, Headache, Irritability

Question 18

What are some things to monitor for with methylphenidate used for ADHD?

Answer 18

• ECG prior to start (bc of HR/BP)
• Height and Weight (bc of decreased appetite/weight loss)

Question 19

What are some additional notes for methylphenidate used for ADHD?

Answer 19

• OROS delivery (Concerta ER): outer coat dissolves fast to give immediate action and the rest is released slowly - ghost tab is possible
• Jornay PM: best used in the evening
• Daytrana: apply to hip 2 hours before you would need it - remove 9 hrs, alternate hips, discard by flushing it down toilet

Question 20

What are some additional notes for Dexmethylphenidate used for ADHD?

Answer 20

• Active isomor of methylphenidate - to convert from Methyl to Dexmethyl = 1/2 total daily dose

Question 21

What is Azstrys and what are some additional notes about it?

Answer 21

• Serdemethylphenidate/ Dexmethylphenidate (Capsule)
• Serdexmethyl is a Prodrug to Dexmethyl = extended duration

Question 22

What are some additional notes for Dextroamphetamine/ Amphetamine used for ADHD?

Answer 22

• IR products (Adderall Evekep) approved in kids > 3 yo [Except Evekeo ODT]
• NO Dextroamphetamine (i.e.; Dexedrine, ProCentra, Zenzedi, Xelstrym) in kids < 5 yo
• DO NOT take with acidic foods (juices or vitimans) - decrease absorption

Question 23

What are some additional notes for Lisdexeamfetamine used for ADHD?

Answer 23

• Low abuse potental
• Prodrug
• If injected or snorted; the fast effects (“Rush”) is muted

Question 24

What are the non-stimulants that are used for ADHD?

Answer 24

• Selective Norepinephrine Reuptake Inhibitors (Atomoxetine [Strattera], Qelbree)
• Centrally-Acting Alpha-2 Adrenergic Receptor Agonists (Clonidine ER [Kapvay], Guafacine [Intuniv]]

These are not the SNRIs fro Depression (have the same side effects tho)

Question 25

What are some **boxed warnings** for **selective norepinephrine reuptake inhibitors** used for **ADHD**?

Answer 25

- Risk of **suicidal ideations** - should monitor for this ## Footnote One of the cards about worsening depression and suicidal thoughts

Question 26

What are some **Contraindications** for **selective norepinephrine reuptake inhibitors** used for **ADHD**?

Answer 26

- if used **MAOi** within past **14 days**

Question 27

What are some **Side effects** for **selective norepinephrine reuptake inhibitors** used for **ADHD**?

Answer 27

- Decreased appetite - Insomnia - Somnolence - Dry Mouth - Increased HR & BP

Question 28

What are some **additional notes** for **selective norepinephrine reuptake inhibitors** used for **ADHD**?

Answer 28

- Atomoxetine: **DO NOT** open the capsule - Qelbree: Can open and sprinkle on 1 teaspoon of pudding or applesauce

Question 29

What are the **centrally-acting Alpha-2 adrenergic receptor agonists** that are used for **ADHD**

Answer 29

- Clonidine ER (Kapvay) - Guanfacine ER (Intuniv)

Question 30

What are some **warnings** for the **centrally-acting alpha-2 adrenergic receptor agonist** used for **ADHD**?

Answer 30

- Dose dependent cardio effects (bradycardia, HYPOtension, orthostais, fainting) -- DO NOT stop abruptly (rebound hypertension) - Sedation & Drowsiness ## Footnote These are used in HTN

Question 31

What are some **side effects** for the **centrally-acting alpha-2 adrenergic receptor agonist** used for **ADHD**?

Answer 31

- Dry mouth - Somnolence - Fatigue - Dizziness - Constipation - Decreased HR - Hypotension

Question 32

What are some **additional notes** for the **centrally-acting alpha-2 adrenergic receptor agonist** used for **ADHD**?

Answer 32

- **MUST** be taperd to reduce the risk of rebound hypertension - DO NOT substitute IR forms for ER forms