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CNS 2b Knebel
ADHD
| Question | Answer |
|---|---|
| ADHD overview? | Neurodevelopmental disorder with significant impairment in executive function (i.e., impulse control and/or attention) *one of the most studied and diagnosed psychiatric disorders in children *accounts for 3-50% of child psychiatric outpatient visits *thought to be due to central dopaminergic and noradreneric dysfunction *decrease DA--> Hyperactiviity *decreased NE activity--> difficulty with concentration |
| ADHD risk factors? | Very low birth weight (less than 1,500 grams) Conveys a 2-3 fold risk for ADHD Smoking during pregnancy -Hx of child abuse, neglect, multiple foster placements; -Neurotoxin exposure (Lead), infections (encephalitis), or alcohol exposure in utero; First-degree biological relatives (accounted for in 50-92% of cases |
| Classifying Behavioral Symptoms--> 1. Hyperactivity? | -Moves about constantly, including in situations in which it is not appropriate; or excessively fidgets, taps, or talks -Extreme restlessness or wearing others out with constant activity |
| Classifying Behavioral Symptoms--> 2. Impuslivity? | -The act of making hasty actions that occur in the moment without first thinking about them and that may have a high potential for harm -Desire for immediate rewards or inability to delay gratification |
| Classifying Behavioral Symptoms--> 3. Inattention? | -Wanders off task, lacks persistence, has difficulty sustaining focus, and is disorganized -Not due to defiance or lack of comprehension |
| Hyperactivity refers to? | excessive motor activity (such as a child running about) when it is not appropriate, or excessive fidgeting, tapping, or talkativeness |
| In adults, hyperactivity may manifest as? | Extreme restlessness or wearing others out with their activity |
| Impulsivity refers to? | hasty actions that occur in the moment without forethought and that have high potential for harm to the individual. May manifest as: -darting into the street w/o looking -social intrusiveness -decisions w/o consideration of long-term consequences) -may reflect a desire for immediate reward/inability to delay gratification |
| Hallmarks of inattention behavior include? | Academic underachieving; wandering off task; lacking persistence difficulty sustaining focus; being disorganized |
| ADHD subtypes include? | Predominantly inattentive type; predominantly Hyperactive-Impulsive type; Combined type; Not otherwise specified |
| Classifying Diagnostic Criteria: we really want to look at? | Age 12-16: > 6 Age 17: >5 Symptoms present by age 12 regardless of diagnosis age Present in two or more settings Assigned as mild, moderate, or severe |
| ADHD Additional Criteria/ High points include: | **Symptoms must be present before age 12** includes adults and older adolescents (>17yo); Clear evidence of interference w/ development (social, academic or occupation functioning); Not better accounted for by another psychiatric or medical disorder; Impariemtn from symptoms in > 2 settings**; Individuals: >17 yrs only need 5 symptoms; No exclusion for Autism Spectrum disorder |
| ADHD: Additional Diagnostic Considerations: mainly look at? | Comorbidity (only around 25% of patients have ADHD alone) Conduct disorders Mood disorders Anxiety disorders Alcohol/substance use *Associated features may include low frustration tolerance, irritability, anxiety, or mood lability Possible bipolar disorder? Other neurodevelopmental d/o |
| ADHD Clinical Course: (Symptom progression/Expression) in Preschool? | Difficulties in daycare or school, including problems with peer relationships, learning, and a higher risk of injuries Impulsivity/hyperactivity prominence **Self-esteem development between Preschool and ages 5-9 |
| ADHD Clinical Course: (Symptom progression/Expression) in 5-9? | Boys: 2x more likely to be diagnosed, display more hyperactive behaviors, which are easily observable and potentially disruptive |
| ADHD Clinical Course: (Symptom progression/Expression) in Adults? | Multiple co-morbid conditions *30 – 70% will continue ADHD symptoms into adulthood = concentration difficulties at work |
| Main ADHD Scoring Scale to know is the Conner's assessment tool, which states? | One of the most commonly used measures of child behavior problems 27 diagnostic questions scored from 1-3 Easy administration, scoring and interpretation Large normative samples- provides t-scores based on age and sex |
| Other ADHD Scoring Scales that are used in their assessment of pts includes? | -ADHD Rating Scales (ADHD-RS-IV and 5) -Adult ADHD Self Report Scale (ASRS) -Vanderbilt |
| Main consequences/Prognosis of ADHD? | -Poor academic performance -Language or learning problem (25-35%) |
| Multimodal Treatment of ADHD (MTA) Results at 14 month? | All groups showed improvement Medication management > behavioral therapy The medication management and combined treatment groups showed significantly greater reduction in core ADHD symptoms and impairment |
| Multimodal Treatment of ADHD (MTA) Results at 8 year? | Sustained improvement is achievable, but not normalization. Children with behavioral, socio-economic, intellect advantage, or best response to treatment have the best prognosis |
| Multimodal Treatment of ADHD (MTA) bottom line Results | Medication therapy is effective, especially when combined with behavioral therapy, but does not result in achievement of normalization even though response is predictable |
| American Academy of Pediatrics Guideline updates: Diagnostic Key action Statement (KAS) (1) | The primary care clinician (PCC) should initiate ADHD evaluation for children who present with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity (grade B). |
| American Academy of Pediatrics Guideline updates: Diagnostic Key action Statement (KAS) (2) | Diagnosis requires meeting DSM-V criteria, including symptoms and impairment in more than 1 setting per multiple informants (grade B). |
| American Academy of Pediatrics Guideline updates: Diagnostic Key action Statement (KAS) (3) | Evaluation should include screening for comorbid emotional, behavioral, developmental, and physical conditions (eg, tics, sleep apnea) (grade B). |
| American Academy of Pediatrics Guideline updates: Diagnostic Key action Statement (KAS) (4) | Each case should be managed by the principles of the chronic care model in the medical home (grade B) |
| American Academy of Pediatrics Guideline updates: Diagnostic Key action Statement (KAS) (5) Age-specific guidelines | a) 4 to 6 Years: Behavior management (PTBM) and/or behavioral classroom interventions (grade A). Methylphenidate may be considered if behavioral interventions are ineffective or unavailable (grade B) (b) 6 to 12 Years: FDA- approved medications + behavioral therapy and/or behavioral classroom intervention (grade A). (c) 12 to 18 Years: Appropriate medication management +/- behavioral therapy (grade A) |
| American Academy of Pediatrics Guideline updates: Diagnostic Key action Statement (KAS) (6) | Dose titration of medications to achieve maximum benefits with tolerable adverse effects (grade B). |
| American Academy of Pediatrics Guideline updates: Diagnostic Key action Statement (KAS) (7) | Initiate treatment of comorbid conditions/make appropriate referrals (grade C). |
| APA guideline summary Diagnostics include? | Evaluate those with academic or behavioral problems Diagnosis requires meeting DSM-V criteria Screen for comorbid conditions Chronic care is key |
| APA guideline summary Tx includes? | 4-6: Behavioral therapy first 6-12: Pharmacotherapy + Behavioral 12-18: Pharmacotherapy +/- Behavioral Titrate Medications Refer/treat comorbid conditions |
| Non-pharmacologic Therapy Overview inlcudes? | Family-focused interventions (education, support groups, Parent management training) School-focused interventions (Classroom modifications, Tutoring, calendars or electronic organization devices Child-focused interventions (education about ADHD, Psychosocial therapy) |
| ADHD Tx considerations includes? (RED and bolded) | Duration of desired coverage; Ability to swallow pills or capsules; avoiding administration at school *time of day when the target symptoms occur *coexisting mood, pshycotic or behaviorla conditions *AE (kids 6-12--> lo |
| Pharmacotherapy options for stimulants includes? | Methylphenidate Amphetamines |
| Pharmacotherapy options for non-stimulants includes? | *Atomoxetine *Alpha agonists *Clonidine *Guanfacine -TCA; Bupropion; Modafinil; mood stabilizers |
| Pharmacotherapy options: CNS stimulants are ____ ____. Non-stmimulants are ____ and _____ line | 1st line; 2nd/3rd *Amphetamines and methylphenidate group >90% response rate when used correctly *Atomoxetine, bupropion, clonidine, guanfacine |
| Classifying behavioral symptoms: *Hyperactivity (stimulants, alpha agonists, NRTI--> | Moves about constantly, including in situations in which it is not appropriate; or excessively fidgets, taps, or talks Extreme restlessness or wearing others out with constant activity |
| Classifying behavioral symptoms: Impulsivity (stimulants alpha agonists)--> | The act of making hasty actions that occur in the moment without first thinking about them and that may have a high potential for harm Desire for immediate rewards or inability to delay gratification |
| Classifying behavioral symptoms: Inattention (stimulants)--> | Wanders off task, lacks persistence, has difficulty sustaining focus, and is disorganized Not due to defiance or lack of comprehension |
| Overarching Tx considerations: | Fundamentally, the pharmacodynamics and clinical effects of MPH are the same as that of amphetamine Generally, MPH = amphetamine in clinical effectiveness *nonresponse or intolerable side effect with one stimulant does not preclude a good response to the other |
| Methylphenidate available dosage forms include? | Concerta Focalin XR Aptensio XR Daytrana Quillivant XR Quillichew ER Comtempla XR-ODT |
| Methylphenidate agents MOA? | inhibits the reuptake of DA and NE; Does NOT promote DA release from synaptic vesicles |
| Concerta drug information? | Osmotic Controlled Release Oral Delivery System” – OROS Semi-permeable membrane (*compartments--> GHOST tablets--> body isnt alwasy going to be breaking it down) *instead of 3x a day, only once a day based on plasma concentration |
| Concerta dosing info? | Dosage form: “Osmotic Controlled Release Oral Delivery System” – OROS DOA: 8-12 hours; 1 hour initial plateau, followed by a gradual increase over 5 to 9 hours Dosing: 18 – 54 mg once daily |
| Daytrana drug info? | Adhesive-based matrix transdermal system (MTS) (only TRANSDERMAL DOSAGE form available) *Patch applied to outside of hip 2h prior to needed effect (remove after 9h); **2-fold absorption when exposed to heat (HEAT will cause absorption to increase--> may need to adjust dose) OD concerns: -60% of the MPH content remains in the patch after use -Keep out of reach of children |
| Jornay drug info? | **Only Methylphenidate product to be given at NIGHT** **doesn't release until 12h after taking -Dual delayed and extended release layers -fatty meals do not affect absorption -beads can be removed from capsule and sprinkled over food DOA: Onset: 12 hours, Peak: 14-16 hours, Duration: 12 hours Dosing: Starting: 20 mg; Adult Max: 100 mg |
| Remember Methylphenidate Formulation Drugs | Concerta Focalin XR Aptensio-XR Daytrana Quillivant XR Quillichew ER Cotempla XR-ODT Journay PM |
| What are your amphetamines? | Adderall Adzenys XR-ODT Adzenys ER Dyanavel XR Mydayis Evekeo Vyvanse AAADME V |
| Amphetamines MOA? | Blocks reuptake of NE/DA in presynaptic neurons and promote neurotransmitter release |
| _______ are More pharmacologically active in CNS 4x greater impact on dopamine Affects concentration and motivation Half-life: 9-11 hours | Dextroamphetamine |
| Less pharmacologically active in CNS More cardiovascular effects and wakefulness Linked to greater NE effects Half-life: 11-14 hours | Levoamphetamine |
| Prodrug that is covalently linked to l-lysine Converted to dextroamphetamine via first-pass metabolism | Vyvanse (Lisdexamfetamine) *hydrolyzation is rate limited and contributes to the longer duration of response |
| Vyvanse (Lisdexamfetamine is indicated for? | children > 6 years, adults, and for binge-eating disorder |
| how is Vyvanse supplied? | as capsules and chewable tablets |
| T/F: Vyvanse capsules can be broken and sprinkled on food and mixed with fluids | True |
| What is the dosage form of Vyvanse? | Capsule and a chewable tablet |
| Dosing of Vyvanse? | Starting: 30 mg, Increase by 10/20mg/week, mMx: 70 mg/day |
| Mydayis is approved for? | patients > 13 years *<12yo increased SE |
| Drug facts about Mydayis? | Mixed amphetamine salts, triple bead delivery (allows for 16h drug delivery) One IR bead, 2 ER beads (First releases after ingestion, Second in proximal small intestine, Third in the distal colon) Beads can be removed from capsule and sprinkled over food |
| Brand name for Amphetamine/ Dextroamphetamine? | Adderall® Adderall ®XR |
| Brand name for Dextroamphetamine sulfate? | Dexedrin® Procentra® Zenzedi |
| Brand name for Lisdexamphetamine dimesylate? | Vyvanse |
| Brand name for Methylphenidate? | Concerta® Daytrana® Metadate CD® Metadate ER® Methylin® Quillivant XR® Ritalin® Ritalin SR® Ritalin LA® Aptensio XR® |
| Brand name for Dexmethylphenidate? | Focalin Focalin XR |
| Common SE of Stimulants and how you manage each: Reduced appetite/ Weight loss? | High-calorie meal when stimulant effects are low (breakfast, dinner) |
| Common SE of Stimulants and how you manage each: GI? | Give on full stomach, lower dose if possible |
| Common SE of Stimulants and how you manage each: Insomnia? | Dose earlier in day, lower last dose of day or give earlier, consider sedating med at bedtime |
| Common SE of Stimulants and how you manage each: HA? | Divide dose, give with food, give analgesic |
| Common SE of Stimulants and how you manage each: Rebound Symptoms? | Longer-acting stimulant trial, atomoxetine, antidepressant |
| Common SE of Stimulants and how you manage each: Irritability, jitteriness? | Assess for co-morbid condition, reduce dose, consider mood stabilizer or atypical antipsychotic |
| What are some uncommon ADRs and management: Dysphoria? | Reduce dose, reassess diagnosis, alternate tx |
| What are some uncommon ADRs and management: Zombie-like state? | Reduce dose or change stimulant |
| What are some uncommon ADRs and management: Tics/abnormal movement? | Reduce dose, consider alternative therapy |
| What are some uncommon ADRs and management: increased BP or HR? | Reduce dose, change stimulant |
| What are some uncommon ADRs and management: Hallucinations? | D/C stimulant, reassess diagnosis, mood stabilizer or antipsychotic may be considered |
| What are some uncommon ADRs and management: Risk for sudden cardiac death? | Risk no greater in clinical trials than general population – assess risk of cardiac structural abnormality and family history – if concern, cardiac echo |
| Simulants come with cardiac concerns such as? | Chronotropic and pressor effects *Monitor pulse and blood pressure during initiation of treatment and periods of dose adjustment 6 BPM and 5 mmHg on average |
| Whe is the only time routine ECG is indicated for stimulants? | those with pre-existing heart conditions; *consider if either a family or personal history |
| What are the contraindications to stimulant usage? | -Advanced arteriosclerosis -Symptomatic cardiovascular disease -Mod-Severe HTN Hyperthyroidism -Glaucoma -Hyperthyroidism -Agitated states/Other psychiatric comorbidities -History of drug abuse -MAOI use during or within 14 days -Severe motor tics or tic disorders |
| Stimulant dosing strategies include: | 1. Low-dose immediate release or controlled release stimulant used initially 2. Dose-response effects seen in short period of time 3. IR dosage forms should be given at least twice daily 4. IR preferred for patients weighing < 16 kg due to limited low-dose availability of long-acting stimulants 5. Avoid giving controlled release dose too late in morning, may give an after-school immediate release dose 6. Late afternoon symptoms may require longer-acting formulation 7. Don't combine AMP and MPH |
| Frequency of stimulant medication is based upon the type of? | ADHD |
| Child with inattentive type may need medication when? | only on school days |
| Child with peer relationship difficulties may need medication ___ | daily |
| Child who participates in after-school activities may require? | XR formulations/more frequent dosing |
| Which stimulants must be swallowed whole? | Single-pulse SR such as: -Ritalin SR -Metadate ER -Methylin ER |
| These medications can be BID dosing and may be sprinkled into soft foods | Dexedrine Spansules Ritalin LA Focalin XR Adderall XR Metadate CD **Do not take with antacids/ drugs that decrease gastric acidity *High-fat meal may delay onset & increase [peak] |
| Can you open/chew the concerta OROS capsule? | No -will have a ghose capsule in stool |
| What stimulant is a good for pts who cannot take oral meds? | Daytrana patch *Must be applied 2 hours before desired effect needed *Effects last 2-3 hours after patch removed |
| Disadvantage of OROS Concerta? | Children with decreased GI absorption/ intestinal resection may not fully benefit *do not open or chew *Ghost capsule in stool |
| This stimulant is given OVERNIGHT and helps with tolerability/adherence? | Jornay |
| MOA of Atomoxetine? | Selective norepinephrine reuptake inhibitor |
| Dosing of Atomoxetine? | Children/adolescents up to 70 kg - 0.5 mg/kg, increased after a minimum of 3 days to a target total daily dose of approximately 1.2 mg/kg QD or BID. >70kg and adults – 40 mg, increased after a minimum of 3 days to a target total daily dose of approximately 80 mg QD or BID No data showing increased benefit with doses >100 mg |
| CI of Atomoxetine includes? SE? | Mainly Liver dysfunction -Liver toxicity - |
| What is the BBW for Atomoxetine? | Suicidal ideation |
| Atomoxetine dosing for children/adolenscents up to 70 kg? | 0.5mg/kg |
| Atomoxetine dosing for > 70kg and adults? | 40 mg |
| Atomoxetine doses greater than 100mg show no _____ _____ | increased benefit |
| Maximum effect may take how many weeks for Atomoxetine? | 2-4 weeks |
| What are my non-stimulant alpha agonists? | Clonidine (Kapvav) and Guanfacine (Intuniv) |
| Dosing for Clonidine (Kapvav) is? | Half life: 12 hours 0.05-0.4 mg BID |
| Dosing for Guanfacine (Intuniv) is? | Half life: 18 hours 1-7 mg QD |
| Difference in dosing b/w Clonidine and Guanfacine is? | Clonidine is dosed BID due to a shorter 1/2 life; Guanfacine is dosed once daily due to a longer 1/2 life |
| SE of both Clonidine and Guanfacine include? | hypotension, bradycardia, dry mouth, sedation, night terrors, cardiac (EKG) |
| Alpha Agonists require a gradual dose taper due to? | rebound tachycardia |
| Brand name for Atomoxetine? MOA? | Strattera NE reuptake inhibitor |
| Brand name for Bupropion? MOA? | -Wellbutrin® Zyban® Wellbutrin XL® -DA & NE reuptake inhibitor |
| Brand name for Clonidine? MOA? | Catapres® CatapressTTS-1,2,3® Kapvay® Nexiclon XR® -Centrally acting alpha-2 adrenergic agonist |
| Brand names for Guanfacine? MOA? | Tenex® Intuniv® -Centrally acting alpha-2 adrenergic agonist |
| When should 2nd gen antipsychotics be used? | only in the presence of other psychiatric disorders |
| When would you use atomoxetine? | reserved for 2nd line tx if failure of stimulatns or concern for abuse |
| When would you use alpha-agonists? | 2nd for those unresponsive to or unable to tolerate stomach upset or insomnia with stimulant medications |
| Methylphenidate and Amphetamines place in therapy for ADHD is? | 1st line therapy |
Created by:
Xander635
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