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2/18/2015
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PSYCHOPHARMACOLOGICAL TREATMENT OF ADHD AND COMMON CO-MORBID DISORDERSMolly Butler, PMHNP-BCAssistant Professor in Psychiatry
Outline
Diagnosing ADHD Treatment Recommendations Psychopharmacological Interventions Stimulants and Non-Stimulants
Treatment Strategies Case Studies
Diagnosing ADHD
DSM Definition
18 official symptoms
6/9 symptoms of inattentiveness or hyperactivity/impulsivity for under 17 yo, only 5 in 17yo and older
Lasting at least 6 months Maladaptive and exceeding norm for age
Begins prior to age 12 Causes clinically significant impairment in two or more settings
Not better accounted for by another disorder
Inattentive Symptoms
Fails to give close attention to details or makes careless mistakes Difficulty sustaining attention in tasks or play activities Doesnt seem to listen when spoken to directly Doesnt follow through on instructions and fails to complete tasks Difficulty organizing Avoids, dislikes or reluctant to engage in tasks that require
sustained mental effort Loses things Easily distracted Forgetful
Hyperactive/Impulsive Symptoms
Fidgets Leaves seat when expected
to remain seated Runs or climbs excessively Difficulty playing or
engaging in leisure activities quietly
Often on the go or acts as if driven by a motor
Talks excessively
Blurts our answers before questions have been completed
Has difficulty waiting turn Interrupts or intrudes on
others
Hyperactivity Impulsivity
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Whats New in DSM-V
Autism Spectrum Disorder is not in exclusion criteria Specifiers:
Severity: mild, moderate, severe Presentations: predominately inattentive,
hyperactive/ impulsive or combined type Broader areas of defined impairment Developmentally appropriate descriptions
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Rule Out Organic Causes
Hyperthyroidism Seizures Lead toxicity Food or food additive sensitivity Sleep apnea Substance abuse
Differential Diagnosis
Depression
Anxiety Disorders (PTSD)
Bipolar Disorder
Autism Spectrum Disorder
ODD/ CD
Substance Use
Intellectual Disability
Speech and/or language disorder
Sudden life changes (divorce, death, move)
Typical development
Differential: Symptoms Specific to Depression
Depressed mood Anorexia/ Weight loss SI Excessive Guilt Psychomotor retardation Mutism Fatigue
Differential: Symptoms Specific to Anxiety
Phobias Worries Stress induced onset Obsessions Compulsions Perfectionism Somatic complaints Posttraumatic play
Differential: Symptoms Specific to Bipolar Disorder
Positive family history
Prolonged rages/ explosive irritability
Episodic
Euphoria- giddy or silly
Grandiosity
Risky acts without concern for safety
Decreased need for sleep
Nearly continuous need for 1 or more less hours per night than avg child without feeling tired
Pressured speech
So much or so fast they cant be understood or interrupted
Racing thoughts
Unintelligible, rapid changes in thought pattern, flight of ideas, sentence fragments
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Differential: Symptoms Specific to Autism Spectrum Disorder
Impaired nonverbal and verbal communication Restricted Interests Stereotyped/ repetitive movements Inflexible adherence to routine/ rituals Lack of: Fantasy play Social relatedness Imaginative play
Treatment
Treatment Guidelines
NIMH multimodal treatment study of ADHD (MTA Cooperative Group 1999, 2004) 579 children ages 7-9 with ADHD treated for 14 months
1) Monthly medication management with stimulant by specialist only2) Behavioral management only (35 group sessions, therapist visited school
multiple times to work with staff, summer camp)3) Combined group: meds plus behavioral management4) Routine community care/ treatment as usual (TAU)
-PCP visits 1-2 times / year
RESULTS: Medication only and combined groups were superior to behavioral therapy alone and routine community care
Follow-Up to MTA
Superiority persisted for med and combination treatment over behavioral management and TAU Effect size was 50% smaller after 24 months
Med only groups dosages were significantly higher than combination at 24 months
PsychopharmacologicalInterventions
Neurochemical Factors
Sustaining focus and attention
Mediating energy levels
Motivation
Interest
Dopamine Norepinephrine
Verbal fluency
Serial learning Vigilance for executive
functioning Sustaining and focusing
attention Prioritizing behavior
Modulating behavior based on social cues
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How Medications Treat Symptoms
Increase in norepinephrine increases strength of signals to the prefrontal
cortex Increase in dopamine
increase in saliency, decreases noise from extraneous stimuli
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Whats out there?
Methylphenidates Amphetamines
Atomoxetine (Strattera) Alpha-2 Agonists Bupropion (Wellbutrin) TCAsModafinil (Provigil)
Stimulants Non-Stimulants
Stimulants
Stimulants Compared to other pharm options:
most studied, commonly used and effective first line agents
In RCTs, effect sizes for stimulant treatment of ADHD are usually large for teacher ratings (0.8) and for parent ratings (0.5)
70% of children will respond to 1st trial 90% will respond to 1st or 2nd trial Compared to placebo, stimulants:
Reduce hyperactivity and disruptive behavior Improve parent-child interaction Improve problem solving with peers Reduce aggressive and antisocial behavior
Stimulant Medications
Methylphenidate
Ritalin
Methylin
Focalin
Ritalin SR
Metadate ER
Methylin SR
Ritalin LA
Metdate CD
Focalin XR
Daytrana
Quillivant XR
Concerta
Amphetamine/ dextroamphetamine
Adderall
Dexedrine
Dexedrine Spansules
Dextro Stat
Adderall XR
Vyvanse
Methylphenidates Amphetamines
How stimulants work
d,l- methylphenidate and d-amphetamine Release DA from presynaptic DA terminalsBlock DA transporter (so blocks reuptake)May reverse dopamine out of nerve terminal
l-amphetamineSimilar effect on both DA and NE
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Immediate Release Methylphenidate
Immediate release tablets Ritalin, D,L-Methylphenidate, Methylin and Focalin
In quick, out quick: Behavioral effects in 30 minutes Peak plasma levels in 90 minutes Half-life 3 hours 3-5 hour duration TID dosing
IR Methylphenidate Dosing
Ritalin, D,L-Methylphenidate, Methylin Typically start 5 mg q am for children and 10 for adults May increase dose q 3 days- 1 week Add noon and afternoon doses first Max dose: 20mg TID (60 mg total)
Focalin Start 2.5 mg Increase q 7 days Max: 20 mg total daily dose
Most common uses in my practice: Initiating treatment in young or small children Appetite disruption with longer acting formulas Adjunctive to longer acting formulas in am or afternoon
Longer Acting Methylphenidate
Sustained release, long acting capsules, tablet or liquid and transdermal patch
All methylphenidate BUT differ in number, rate and shape of methylphenidate pulses into blood stream
Methylphenidate, Single Pulse, Sustained Release
older sustained release tablets Ritalin SR, Metadate ER, Methylin SR FDA approved ages 6-15 Immediate release tablet coated with wax matrix Slower onset, lower serum concentrations Peak in 5 hours 6-8 hours duration Rarely used: BID Often need immediate release in morning to compensate
Long Acting Methylphenidate Capsules
Sustained Release Capsules Ritalin LA, Metadate CD, Focalin XR
Ritalin LA and Focalin XR Beads inside capsule contain half dose as immediate
release and half as delayed releaseMimics total dose given in immediate form about 4
hours apart
Long Acting Dosing
Ritalin LA > 5 hours duration Start 10 mg q am May increase in weekly increments of 10 mg Max 60 mg daily
Focalin XR Duration 12-16 hours Peaks at 1-2 and 6-7 hours Start 5 mg po q am Increase by 5 mg q week Max 40 mg daily After first peak 45% higher in women
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Metadate CD
Ages 6-15 30% as immediate release and 70% delayed release Peaks 1-2 and 4-5 6-8 hours duration Start: 10 mg po q amMax: 60 mg po q am
Methylphenidate ER (Concerta)
Complex-release formulation Tablet coated with immediate release methylphenidate Osmotic pump releases rest of drug over 10-12 hours
Produces ascending serum concentration Similar to TID immediate release dosing with less variation Start 18 mg po q am May increase by 18 mg q week Ages 6-12: max is 54 mg daily 13 and up: max is 72 mg daily Disadvantage: may not be as effective in am as dual pumps in early
morning Also approved for comorbid ODD and LD
Wont take a pill?
Methylin Chewable Tabs or Oral SolutionComparable to immediate release
Daytrana Transdermal Patch Apply in morning and take off 9 hours laterNo symptom reduction in first 2 hours Plasma levels peak at 7-9 hours Duration is 11.5 hours Start with 10 mg/9 hr patch, may increase to next size patch q7 days;
Max: 30 mg/9 hr patch q day Produces higher plasma levels than dose equivalents of other preparations Tics more common and mild skin reactions are common
Wont take a pill?
Quillivant XR methylphenidate ER oral solution ages 6 and older initial dose: 20 mg once a day max dose: 60 mg once a day may increase daily dose by 10-20 mg at weekly
intervals
IR Amphetamines
Adderall, Dextrostat generic, Dexedrine only medication with FDA approval down to age 3
4-6 hour duration Plasma levels peak at 3 hours Start 5 q am Max 40 mg daily in split doses q 4-6 hours Titration and clinical indication same as immediate
release forms of Methylphenidate
Long-Acting Amphetamine
Adderall XR capsules (d, l-amphetamine) Dual pulse with 1/2 immediate- and extended- release beads (just
like Ritalin LA and Focalin XR) 6-8 hours duration Peak in 7 hours Start 5 or 10 mg q am Increase by 5-10 mg/day at weekly intervals as needed Max typically 30 mg daily
Dexedrine Spansules (d- amphetamine) Peaks in 4 hours 6-8 hours duration Max 60 mg po q am
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lisdexamfetamine dimesylate (Vyvanse)
Prodrug of Dextroamphetamine After oral administration it is rapidly absorbed in GI tract and
converted to active form, dextroamphetamine Reduces risk for abuse
Ages 6-12, adults Can be swallowed whole or opened up and mixed with water,
ice cream, applesauce or yogurt Full 12 hour duration More steady levels Start 30 mg
but available in 20 mg capsule Increase by 10-20 mg q week Max: 70 mg daily
Standard Warning on Stimulants
Sudden death associated with cardiac abnormalities or other serious heart problems
Baseline ECG/ echo and collaboration with cardiologist or PCP Hx of heart defects or heart disease Reports of murmur, syncope, chest pain, HTN or arrhythmias Family hx of heart disease < 40 years old Rates of unexpected sudden death on stimulants 0.19-0.5 in 100,000 patient-
years and 1.3- 1.6 in 100,000 patient-years in general population
Caution in adults with preexisting heart conditions and HTN Use with caution in:
patients or patients with family members with history of SUDs patients with psychotic or bipolar disorders patients with tics or Tourettes
Stimulant Side Effects
Decreased appetite and weight loss Slowed growth rate (poorly documented) Headache Abdominal pain Delayed sleep onset New onset tics Rebound crankiness and tearfulness
(immediate release) Overstimulation Nervousness Picking at skin/ nail biting Behavioral changes
Irritability Aggression Depressed mood
Sudden death
Adverse cardiac events Angina
Tachycardia
Palpitations
HTN
Tactile and visual hallucinations
Seizures
Activation of hypomania or mania
Common Rare but Serious
Monitoring patients on stimulants
Height/ Weight BP HR Rating Scales
Stimulant Clinical Pearls
May have greater effect on behavior than attention sxs If no improvement in target symptoms when dose is increased, drop back down Wont cause addiction in those with ADHD
Actually a protective factor for SUDs If causes or increases nail biting, chewing or picking at skin consider baseline
obsessive/ anxiety features If causes aggression and irritability consider comorbid process Little evidence of tolerance to stimulant effect
But may need to increase with growth Take with food
Appetite suppression Absorption and bioavailability may increase after meal
Immediate release Can crush or break in half
Capsules Can open up and sprinkle
Stimulant Nonresponders
Pt factors: Is it really ADHD? Is there a comorbid diagnosis? Are side effects interfering w response? Is the patient compliant?
Medication factors: Is patient over- or underdosed? Is there a time of day when med is not effective? Are drug interactions effecting the response?
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Stimulant Nonresponders
Family Factors: Are there increased family stressors that contribute to
diminished stimulant tx response? Is there a parent with undiagnosed ADHD or other
psychiatric illness adding to family stress? Do care givers disagree on giving patient the med?
Nonstimulants
Nonstimulants
Atomoxetine, Clonidine, Guanfacine, Buproprion, TCAs and Modafinil
Typically used when: Inadequate response to stimulants
Monotherapy Adjunct treatment
Unable to tolerate stimulants Tic disorder Patient or family history of SUDs Caregiver preference Comorbid disorders
Atomoxetine (Strattera)
First drug approved for treatment of ADHD Approved for ages 6+
Selective NE reuptake blocker causes increase in NE and DA levels in prefrontal cortex
Peak plasma concentrations 1 hour without food and 3 hours with food
Half-life 5 hours but duration of action is much longer than half-life so may dose once daily
Hepatic metabolism in cytochrome P4502D6
Atomoxetine (Strattera)
Dosing: Children < 70 kg: start 0.5 mg/kg/day; after 3 days
increase to 1.2mg/kg/day. Max: 1.4 mg/kg/day or 100 mg daily, whichever is less
Adults and children >70 kg: start 40 mg; after 3 days increase to 80. May increase to max of 100 if needed after 2-4 weeks
Drug interactions: Not within 14 days of MAOIs Decrease dose of atomoxetine with CYP450 2D6 inhibitors
(fluoxetine and paroxetine) Co-administration with albuterol may increase HR and BP
Atomoxetine: Adverse Events
2 FDA warnings: Black Box Warning for suicidality
September 2005- Eli Lilly study- 5 / 1,800 spontaneously reported suicidal ideation compared to 0 reports in placebo group
Warning for liver injury December 2004, reports of severe liver injury and jaundice in two patients d/c in patients with jaundice, dark urine or lab findings of liver injury
Side effects: GI upset and decreased appetite, drowsiness, increased HR (6-9
bpm), increased BP (2-4 mm Hg), insomnia, dizziness, anxiety, irritability, dry mouth, dysmenorrhea, sweating, sexual dysfunction, urinary hesitancy or retention
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Atomoxetine
What to do about SEs:Wait Lower dose Split dose Change medication
Monitor: Ht and wt BP and pulse
Alpha-2 Agonists: Guanfacine and Clonidine
Large number of alpha 2 adrenergic receptors in prefrontal cortex that mediate ADHD sxs These meds stimulate postsynaptic receptors to increase the
strength of NE signals FDA-approved for use of HTN in adults since early 1970s
IR guanfacine and clonidine NOT FDA approved for ADHD Grew in popularity for C/A psychiatry in 1990s
Extended release versions approved by FDA for monotherapy or stimulant augmentation Clonidine Hydrochloride extended Release (Kapvay) Guanfacine XR (Intuniv)
Alpha-2 Agonists: Clonidine and Guanfacine
Studies suggest benefits for behavioral target sxs of: Aggression Hyperactivity Hyperarousal (anxiety/ PTSD) Impulsivity Sleep disturbance
Fewer benefits for attentional and cognitive sxs of ADHD Additional uses:
Adjunct therapy in ADHD Treatment of rebound symptoms with stimulants Comorbid tic disorder ADHD and/or Aggression with CD ADHD sxs in Autism Spectrum Disorder or Fragile X
Clonidine (Catapres) Data
Small controlled study by Hunt and Colleagues in 1985: Only 10 children Results: reduction in hyperactivity and aggression
Improvements averaged 22.9% on parent ratings in 5 published studies on ADHD
Conner and colleagues 2000: Pilot study comparing methylphenidate, clonidine and the
combination in 24 children with ADHD and either ODD or CD All groups improved Clonidine alone effect size of 0.56 (moderate effect size) in ADHD
sxs in children with comorbid conduct disorders, developmental delay and tic disorders
Guanfacine (Tenex) Data
Selective alpha-2A receptor agonist so has a reduced SE profile compared to clonidine
Two open label trials with 23 children (Chappell et al., 1995; Hunt et al. 1995): No efficacy or safety data available
Short Acting Alpha-2 Agonists
Dosing: Clonidine (Catapres)
0.1 mg strength tablet Start tab at bedtime May increase by 0.05 mg q 4-6 days Max typically 0.2- 0.3 mg total daily dosing QID dosing for optimal benefit
Guanfacine (Tenex) 1 mg strength Start tab at bedtime May increase by 0.5 mg q 4-6 days Max typically 3 mg total daily dosing Dose TID less sedating than clonidine
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Guanfacine XR (Intuniv)
FDA approved in 2009 for tx of ADHD ages 6-17 2 clinical trials N= 345/324 8/9 weeks Double-blind, placebo-controlled, parallel-group, fixed
dose design Increased by 1 mg/week No patients under 55 lbs
Guanfacine XR (Intuniv) Clinical Trials
ADHD sxs evaluated weekly with ADHD Rating Scale-IV Mean reductions in ADHD-RS at endpoint were statistically sig
greater for intuniv Placebo adjusted changes from baseline were statistically sig
for all dosages Improvements seen at 0.05-0.8mg/kg/day Additional benefit at 0.12mg/kg/day if tolerated No differences in gender response Most effective in 6-12 yo
Only 25% were 13-17 Fixed doses may have been too low (avg was 0.01-0.04 mg/kg)
Guanfacine XR (Intuniv)
Dont substitute for IR guanfacine on mg-mg basis d/c IR then start intuniv
Start 1mg once daily and increase by no more than 1 mg/day/week
Max dosage: 4 mg/day Should be slowly tapered (by 1 mg q 3-7 days) due
to risk of rebound hypertension and tachycardia Should re-titrate if miss two consecutive doses
Clonidine HCL Extended Release (Kapvay)
Approved 2010 for tx of ADHD monotherapy and was first to be approved for adjunctive therapy with a stimulant
Two phase III trials which demonstrated improvements in core sxs at 5 weeks for ages 6-17
SEs (incident >5% and 2x placebo) included: somnolence, fatigue, upper respiratory tract infection, irritability, sore
throat, insomnia, nightmares, emotional disorder, constipation, nasal congestion, increased body temperature, drug mouth and ear pain
Clonidine HCL Extended Release (Kapvay)
Maintenance past 5 weeks not yet evaluated Start 0.1mg and increase weekly as needed to 0.4
mg daily BID dosing
Alpha-2 Agonists in General
Side Effects: sedation, dizziness, orthostatic hypotension, dry mouth,
bradycardia, irritability, sleep disturbance, syncope
Caution: Documented sudden unexpected deaths in children
taking clonidine Rebound HYPERtension associated with missed doses Rare disinhibition
Monitoring BP, pulse
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Buproprion (Wellbutrin)
NDRI (Norepinephrine Dopamine Reuptake Inhibitor) antidepressant
Preparations: Wellbutrin SR/XL, Budeprion, Zyban and Alplenzin
Has been reported to be effective for ADHD symptoms in some placebo-controlled trials (Casat et al., 1989, Clay et al., 1988, Simeon et al., 1986)
Conners et al., 1986: multisite, DB, placebo-controlled trial. Teachers reported improvement in ADHD symptoms but parents did not
Not first line
Buproprion (Wellbutrin)
FDA Black Box Warning for suicidality Dosing:
300-450 mg/ day immediate release OR
300 mg /day SR SR form in C/A is metabolized more rapidly than adults- dose BID. No info on XL and Alplenzin form in C/A Contraindicated: seizure DO (risk is dose dependent) and eating DO Side Effects:
Decreased seizure threshold Rare induction of mania Dry mouth, constipation, weight loss, anorexia Insomnia, dizziness, HA, agitation, tremor
Tricyclic Antidepressants (TCAs)
Not Approved for tx of ADHD d/t potentially serious CV events Most are NE reuptake inhibitors Imipramine (Tofranil)
Some studies have found comparable effects but more dropouts with IMI vs Methylphenidate (Rapoport et al., 1974; Werry et al., 1980) SEs including sedation Tolerance to therapeutic effects in 6-10 weeks
Nortriptyline (Pamelor) Superior to placebo but no head to head studies with methylphenidate
Dosing: 2 mg/kg/day max 5 mg/kg/day (antidepressant dose) TCA SEs: cardiac tachyarrhythmias, drowsiness, anticholenergic SEs and
seizures/ EEG changes Monitoring:
ECG at baseline and at stable dose Draw levels Possible drug interactions
Modafinil (Provigil)
Non-stimulant w/o cardiovascular effects indicated for narcolepsy MOA not fully understood Alters balance of GABA and glutamate
Biederman and Colleagues, 2005: Large RCT, DB, PC study 425 mg daily Improvement in ADHD core sxs at home and school
Equivalent to 6 cups of coffee (600 mg caffeine) on alertness and performance tests in sleep deprived healthy adults (Wesensten et al., 2002)
SEs: insomnia, HA, decreased appetite Manufacturer withdrew application for ADHD indication in children
d/t report of Stevens-Johnson Syndrome and visual hallucinations
FDA Approved Drugs for Adult ADHD Stimulants
Adderall XR Vyvanse Quillivant XR Focalin XR Concerta
Non-Stimulant Strattera
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Treatment Strategies
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How do we decide what to use?
Practice Parameters recommend oral stimulants as first line: AACAP practice parameters for ADHD (Plizka and AACAP Work Group
on Quality Issues 2007) An international consensus statement (Kuthcher et al., 2004) American Academy of Pediatrics (2001) The Texas Childrens Medication Algorithm Project: Revision of the
Algorithm for Phamacotherapy of ADHD (Plizka et al., 2006) AACAP practice parameters say to start with long acting formulation
of stimulant except with small or young child when long acting is not available in low- enough dose, then use immediate release formulation Start with atomoxetine when indicated Practice guidelines DO NOT require a treatment failure or adverse event
before allowing trial of another agent
The Texas Childrens Medication Algorithm Project: Revision of the Algorithm for Phamacotherapy of ADHD (Plizka et al., 2006)
Algorithms for ADHD with no significant comorbid disorder and with comorbid: Anxiety MDD Tic Disorder Aggression
Algorithm for ADHD with No Comorbid Condition
Stage 0: Diagnostic assessment Non medication treatment alternatives
Stage 1: Methylphenidate or Amphetamine
Stage 2: Stimulant not used in stage 1
Change in formulations (immediate to long acting) not considered stage change Proceed to stage 3 when one Methylphenidate and one Amphetamine have been used
Stage 3: Atomoxetine
Stage 4: Bupropion or TCA
Stage 5: Agent not used in stage 4
Stage 6: Alpha 2 agonist (clonidine or guanfacine)
When to Use Adjunctive Pharmacotherapy
Initial insomnia due to stimulant effect or ADHD sxs: Exogenous Melatonin
OTC Natural hormone that regulates circadian rhythms As a drug can synchronize circadian clock to environmental cycle 1.5-9 mg at bedtime
Antihistamine Benadryl 25-50 mg Hydroxyzine (Vistaril) Anticholinergic SEs
Alpha-2 agonists Clondine up to 0.2 mg q hs
Typically an interrupted and not restful sleep Tenex up to 2 mg q hs
Adjunctive Therapy for Initial Insomnia Cont
Antidepressants with sedation as major SE Trazodone (Desyrel)
Serotonin 2 reuptake inhibitor 25-100 mg q hs 10% risk of priapism
Mirtazapine (Remeron) Alpha 2 agonist and SNRI 7.5- 30 mg q hs Low doses= most sedating Increased appetite and wt gain
Additional Indications for Adjunctive Pharmacotherapies
Partial response Add alpha 2 agonist or atomoxetine to stimulant
Breakthrough symptoms Add am or afternoon immediate release formulation to long
acting formulation
Rebound Symptoms Irritability, whining, crankiness, tearfulness Typically when stimulant wears off in afternoon or evening alpha 2 agonists another dose of stimulant
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Stimulants + Alpha 2 Agonists
Frequently used as adjunct therapies Kapvay and Intuniv both have FDA approval for adjunctive therapy 4 reported deaths of children on methylphenidate and clonidine IR
All had additional risk factors Daviss and Colleagues, 2008:
16 week MC, DB trial 122 children with ADHD 4 groups: Clonidine, methylphenidate, both or placebo Clonidine: 0.6 mg/ day Methylphenidate: 60 mg/day Monitored ECGs and vital signs More incidents of bradycardia in children on clonidine (17.5% versus 3.4%) No other group differences in ECG or CV outcomes No suggestion of interaction between clonidine and methylphenidate on CV
outcomes
Managing a Client in the Ideal World
Monitor by direct contact, phone or e-mail Target sxs SEs Taking as prescribed Missed doses
Teacher input at least twice per school year Weekly contact with initial dose adjustments then
monthly for first few months then less frequent if stable
Annual discontinuation trial (usually summer)
Real World: ADHD Rarely Seen Without Comorbid Disorders
2/3 of children with ADHD also meet criteria for other psychiatric disorders
50% have ODD or CD 50% have learning disorders 25-30% have an anxiety disorders 2% have Tourettes
Much higher with ADHD than random population sample or with other disorders
Increased risk for mood disorders 10-30% of children develop depression Up to 20% may have bipolar do
Other disorders increase the impairment associated with ADHD
Treatment of ADHD with Comorbid Disorders
What is causing the most impairment? Use Texas Childrens Medication Algorithms for
ADHD with comorbid disorders AnxietyMDD Tic disoder aggression
http://www.dshs.state.tx.us/mhprograms/adhdpage.shtm
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Case Studies
Case Study #1 Pt is a 9 y/o boy seen with GM for review of ADHD and
conduct disorder Current Meds:
Ritalin 10 mg q am and with lunch.
He is now in 4th grade where they go to school for an extra 45 mins daily (8-3:45). He does well most of the day but, during last two classes he is having trouble with talking excessively, not being prepared for class and not getting classwork done. He is also not bringing home necessary supplies for homework and is still working on it as late as 9pm q night.
Tolerating Ritalin without SEs. No change in sleep or appetite. No additional meds
Case Study #2 Pt is a 15 yo fm seen for f/u of anxiety and depression. She is seen
with and without mom today. Current Meds:
Zoloft 200 mg Anxiety sxs are now well managed on current med regimen. Now, pt
and mom report difficulty focusing, inability to sit down and complete work and distractability. Pt reports that she wants to do her work but she can't. Her grades have been dropping significantly due to incomplete work and lack of organization. She also reports sad mood and passive SI without plan or intent. She denies current SI/HI and recent SIB. She reports low energy and hypersomnia (>10 hours nightly). She denies use of drugs or ETOH and most recent UDS was negative. Mom gave provider several NICHQ Vanderbilt Assessment Scales completed by parents and teachers. One teacher and both parents were elevated for inattentive ADHD sxs.
Case Study #3
Pt is an 8 yo boy who presents with mom and PGM. Current Meds:
Adderall XR 10 mg po q am Family reports a favorable response to Adderall XR 10 mg which was
started 3 weeks ago. Mom reports that he is much more calm and that he has been "wonderful". Teacher reported that his school work has improved, behavior is good, no longer squirming or getting out of seat and has had good manners. Family is concerned that pt is agitated, hyper-emotional and angry in the late afternoon and early evenings when medication is wearing off. Overall mood is "happy.
Some decrease in appetite but still eating well. No sleep disturbance. No tics or additional SEs noted.
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Case Study #4 Pt is an 11 yo ca f seen for f/u for ADHD and adjustment d/o r/t family discord,
neglect and variable involvement of bio-mom. Current Meds:
Tenex 0.5 mg TIDConcerta 18 mg
Pt has been taking Concerta 18 mg X 2 weeks. GM reports that pt c/o chest pain, agitation, nervousness, "not feeling like herself" and anger on Concerta. GM reports that pt was given EKG by PCP due to c/o chest pain on Vyvanse and it was wnl. No reports of syncope. Vital signs wnl.
She continues to be hyperactive, impulsive and defiant. This is problematic at home, school and church. Current wt. 132 lbs, 60 kg
Past medication trials: Vyvanse Adderall XR Concerta Focalin XR
Pt c/o several SEs on all stimulants.
References
Barkley, Russell A (2000). Taking Charge of ADHD: The complete, authoritative guide for parents (Revised ed.). New York: Guildord Press.
Barkley R, Murphey K (2005). Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. New York: Guliford Press. .
Findling, Robert L. (2008). Clinical Manuel of Child and Adolescent Psychopharmacology (4th ed.). Arlington: American Psychiatric Publishing, Inc.
Green, Wayne H. (2007). Child and Adolescent Clinical Psychopharmacology. Philadelphia: Lippincott, Williams and Wilkins.
Kolevzon A, Stewart D (2004). Psychiatry Pearls: The Pearls Series. United States: Hanley & Belfus, Inc.
Lewis (2007). Lewiss Child and Adolescent Psychiatry: A Comprehensive Textbook (4th ed.). Philadelphia: Lippincott, Williams and Wilkins.
Sadock B, Sadock V. (2003). Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Philadelphia: Lippincott, Williams and Wilkins.
Stahl, Stephen M. (2000). Essential Psychopharmacology: Neuroscientific Basis and Practical Applications (2nd ed.). Cambridge: Cambridge University Press. S
Stahl, Stephen M. (2008). Everything You Wanted to Know About ADHD But Forgot You Wanted to Ask. Carlsbad, California: NEI Press.
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