adhd presentation

ADHDDiagnosis &

Pharmacological Management

Lori Dewey, MSN, PMHCNS-BC

September 2014

Objectives

Understand the screening and diagnosis of ADHD

Develop knowledge of common medications used to treat ADHD in adults

Know the indications, dosage ranges, mechanisms of actions, monitoring, and contraindications of medications used to treat ADHD

ADHD Defined

ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination these

– http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/

Inattentive Symptoms

Fails to give close attention to details or makes careless mistakes in schoolwork

Has difficulty keeping attention during tasks or play Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish

schoolwork, chores, or duties in the workplace Has difficulty organizing tasks and activities Avoids or dislikes tasks that require sustained mental

effort (such as schoolwork) Often loses toys, assignments, pencils, books, or tools

needed for tasks or activities Is easily distracted Is often forgetful in daily activities

Hyperactivity Symptoms(More likely in children)

Fidgets with hands or feet or squirms in seat

Leaves seat when remaining seated is expected

Runs about or climbs in inappropriate situations

Has difficulty playing quietly

Is often "on the go," acts as if "driven by a motor," talks excessively

Impulsivity Symptoms

Blurts out answers before questions have been completed

Has difficulty awaiting turn

Interrupts or intrudes on others (butts into conversations or games)

– http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/

Diagnosis

Screening tool:

– Adult ADHD Self-Report Scale (ASRS-v1.1)

http://www.help4adhd.org/documents/adultadhdselfreportscale-asrs-v1-1.pdf

DSM IV Criteria

A. Either (1) or (2)1) Six or more of the following symptoms of inattention have persisted for at least six months to a

degree that is maladaptive and inconsistent with the developmental level:

Inattention

often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

often has difficulty sustaining attention in tasks or play activities often does not seem to listen when spoken to directly often does not follow through on instructions and fails to finish schoolwork, chores, or duties in

the workplace (not due to oppositional behaviour or failure of comprehension) often has difficulty organizing tasks and activities often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such

as schoolwork or homework) often loses things necessary for tasks or activites at school or at home (e.g. toys, pencils, books,

assignments) is often easily distracted by extraneous stimuli if often forgetful in daily activities

DSM IV Criteria Cont.

2) Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with the developmental level:

Hyperactivity often fidgets with hands or feet or squirms in seat often leaves seat in classroom or in other situations in which remaining

seated is expected often runs about or climbs excessively in situations in which it is

inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

often has difficulty playing or engaging in leisure activities quietly often talks excessively is often 'on the go' or often acts as if 'driven by a motor'Impulsivity often has difficulty awaiting turn in games or group situations often blurts out answers to questions before they have been completed often interrupts or intrudes on others, e.g. butts into other children's games

DSM IV Criteria Cont.

B. Some hyperactivity - impulsive or inattentive symptoms that cause impairment were present before the age of 7 years.

C. Some impairment from the symptoms is present in more than two or more settings (e.g. at school or work or at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified: ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not

met for the past six months ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but

Criterion 1A is not met for the past six months.

Treatment

Behavioral and cognitive therapies

– Focused on reducing impulsivity and reinforcing positive long-term habits

Pharmacological management

– Stimulants

– Non-stimulants

Treatment

Stimulants:

– Adderall and Adderall XR

– Vyvanse

– Ritalin and Ritalin LA

– Daytrana

– Concerta

– Focalin and Focalin XR

Non-stimulants:

– Strattera

– Wellbutrin

– Tenex

– Intuniv – no adult dosing available

– Clonidine

– Kapvay – no adult dosing available

Stimulants

Monitor mood symptoms:

– Depression

– Anxiety

– Agitation

– Psychosis

– Emotional lability

– Exacerbation of bipolar sx

Stimulants

Monitor LFTs

Short acting stimulants have a higher potential for abuse and more street value than longer acting stimulants

All stimulants carry a black box warning of potential drug dependence and abuse

Collaborate care with other providers/specialists for ptwith CV diseases/disorders, HTN, seizure disorders, liver impairment, etc

Caution with drugs that inhibit metabolism of stimulants

– Especially Prozac

Stimulants

Adderall XR, Ritalin LA, Focalin, and Vivanse may be opened up and sprinkled on food

Vyvanse capsule may be dissolved in water

Adderall

Adderall (dextroamphetamine/amphatimine)

– Dosage forms: 5, 7.5, 10, 12.5, 15, 20, 30mg

– 5-40 mg/day PO divided qd-tid

– Start 5 mg po qam or bid

– Increase 5 mg/day qwk

– Dose 4-6 hours apart

– Doses >40 mg rarely more effective

Adderall

BLACK BOX WARNING: HIGH ABUSE POTENTIAL, DEPENDENCY

– SERIOUS CARDIOVASCULAR ADVERSE EVENTS & SUDDEN DEATH REPORTED WITH MISUSE

Adderall

^^ dopamine & norepinephrine in the presynaptic neuron

– More robust in it’s action

– ^^ incidence of side effects

– Highly abused

– Works well at low doses

– Good for someone with no hx of mood disorders or substance abuse

Adderall

Caution with: cardiovascluar disease, HTN, arrhythmias, drug abuse hx, psychosis, bipolar, depression, Tourettes/tics, seizures

May cause dysthymia

Side effects are dose dependent

^^ GI effects if taken on an empty stomach

Avoid abrupt withdrawal

Adderall

Common side effects:

– Loss of appetite/weight loss

– Dry mouth

– Difficulty sleeping

– Headaches

– Abdominal pain, nausea, vomiting

– Temporary increases in blood pressure

– Emotional changes

– Increased heart rate

Adderall XR

Adderall XR (dextroamphetamine/amphatimine)

– Dosage forms: 5, 10, 15, 20, 25, 30mg ER

– Start 20 mg i po qam

– Increase 10 mg/day q week

– Maximum dose: 60 mg/day

– 6-10 hour duration

– May augment with IR

Adderall XR

BLACK BOX WARNING: HIGH ABUSE POTENTIAL, DEPENDENCY

– SERIOUS CARDIOVASCULAR ADVERSE EVENTS & SUDDEN DEATH REPORTED WITH MISUSE

Adderall XR

Caution with:

cardiovascluar disease/arrhythmias

HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Avoid abrupt withdrawal

Adderall XR



– Dry mouth


– Headaches





Vyvanse

Vyvanse (lisdexamfetamine)

– Dosage forms: 20, 30, 40, 50, 60, 70 mg

– 30 mg po qam

– Increase 10-20 mg/day q week

– Maximum dose: 70 mg/qd

– Use lowest effective dose

– Molecules dissolve in the stomach. Less street value

– Difficult to get insurance to cover

Vyvanse

Caution with: cardiovascluar disease/arrhythmias

HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Vyvanse



– Dry mouth


– Headaches





– Hyperhydrosis

Ritalin

Ritalin (methylphenidate)

– Dosage forms: 5, 10, 20 mg

– Start 5-10 mg po bid


– May be dosed bid-qid

– Duration: 3-5 hours

– Give 30-45 min before meals

– Last dose before 6 pm

Ritalin

BLACK BOX WARNING: DRUG DEPENDENCE

Ritalin

Avoid use within 14 days of MAOI


HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Ritalin



– Dry mouth


– Headaches





Ritalin LA

Ritalin LA (methylphenidate)

– Dosage forms: 10, 20, 30, 40 mg ER

– Start 20mg po qam




– Do not crush or chew

Ritalin LA


Ritalin LA



HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Ritalin LA



– Dry mouth


– Headaches





Daytrana

Daytrana (methylphenidate transdermal)– Dosage forms: 10, 15, 20, 30/9 h patch

– Apply 1 patch qd x 9h. Off 15h

– Start 10mg/9h patch qd x 9h off x 15 h

– Increase next size patch q week

– Maximum dose: 30 mg/9 h patch qd

– Apply 2 h before desired effect

– Drug effects may persist 5 hours after removal

– Use same titration when converting from po

– Do not alter/cut patch

Daytrana


HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Daytrana



– Dry mouth


– Headaches





– ALT/AST elevation

Concerta

Concerta (methylphenidate) – long acting ritalin

– Dosage forms: 18, 27, 36, 54 ER

– Dose: 18-72 mg po qam

– Start 18-36 mg po qd

– Increase by 18 mg/day q wk

– Maximum dose: 72 mg/day. May be dosed bid in some cases


– Do not cut, crush or chew

– Dissolves in stomach in layers

– Less potent effect. Only effects dopamine. More tolerable in ptwith emotional problems

Concerta


– CHRONIC ABUSE MAY LEAD TO MARKED TOLERANCE AND PSYCHOLOGICAL DEPENDENCE

Concerta



HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Concerta



– Dry mouth


– Headaches





Focalin

Focalin (dexmethylphenidate)

– Pure molecule of ritalin

– Dosage forms: 2.5, 5, 10 mg

– Start 2.5 mg po bid

– Increase 5-10 mg/day q week


– Difficult to get insurance to cover

– To convert from methylphenidate:

Start at 50% of current methylphenidate daily dose

Focalin


Focalin


HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Focalin



– Dry mouth


– Headaches





Focalin XR

Focalin XR (dexmethylphenidate)

– Dosage forms: 5, 10, 15, 20, 25, 30, 35, 40 mg ER

– Start 10 mg po q am

– Increase 10mg/day q week


– To convert from IR form use same same daily dose. To convert from methylphenidate start at 50% of current methylphenidate daily dose

– Do not crush/cut/chew

Focalin XR


Focalin XR


HTN

drug abuse hx

psychosis

bipolar

Tourettes/tics

seizures

Focalin XR



– Dry mouth


– Headaches





Strattera

Strattera (atomoxetine)

– NON STIMULANT

– May take up to 4-6 weeks to see results

– Dosage forms: 10, 18, 25, 40, 60, 80, 100 mg

– Start 40 mg po qam x 3 days

– Increase to 80 mg/day

– May increase to 100 mg/day after 2 weeks if needed


– Requires slower titration if pt is poor CYP2D6 metabolizer or on strong CYP2D6 inhibitor

– Norepinephrine reuptake inhibitor

– Doses >40 mg/day may be divided bid

– Dosing accd to weight= 0.5-1.4 mg/kg/day

Strattera

Avoid use within 14 days of MAOI cardiovascluar disease/arrhythmias

HTN/hypotension

tachycardia

hepatic impairment

depression

bipolar

Strattera

Common side effects:– Headache

– Dizziness

– Loss of appetite/weight loss/dry mouth

– Difficulty sleeping/somulance/fatigue

– Abdominal pain, nausea, vomiting/constipation

– Erectile dysfxn/decreased libido/ejaculatory dysfxn

– Urinary hesitancy/retention

– Dysmenorrhea

– Diaphoresis


– Increased heart rate/BP

Wellbutrin

Wellbutrin (buproprion)

– NON STIMULANT

– ADHD: 100 mg po tid

– Dosage forms: 75, 100 mg

– Start 100 mg po bid

– Increase after 3 days

– Maximum dose: 150 mg/dose up to 450 mg/day

– ADHD responds to high doses

Wellbutrin


– Seizure Disorder/decreased seizure threshold

– Appetite disturbance

– Head injury

– HTN

– Bipolar

– Hepatic/renal impairment

– Bulemia – may cause e-lyte imbalance

Wellbutrin

Common side effects:– Agitation/anxiety

– Headache/dizziness

– Nausea/constipation/appetite decrease/weight loss/abd. pain/diarrhea

– Tremor

– Diaphoresis

– Abnormal dreams/insomnia

– Tinnitus

– Palpatations

Wellbutrin SR

Wellbutrin SR (bupropion)

– NON STIMULANT

– Dosage forms:100, 150, 200 mg ER

– Start 100 mg po qam


– Divide dose bid



Wellbutrin SR




– Head injury

– HTN

– Bipolar


Wellbutrin SR




– Tremor

– Diaphoresis


– Tinnitus

– Palpatations

Wellbutrin XL

Wellbutrin XL (bupropion)

– NON STIMULANT

– Dosage forms: 150, 300 mg ER

– Start 150 mg po qam

– Increase after 7 days to 300 mg



Wellbutrin XL




– Head injury

– HTN

– Bipolar


Wellbutrin XL




– Tremor

– Diaphoresis


– Tinnitus

– Palpatations

Tenex

Tenex (guanfacine)

– NON STIMULANT – OFF LABEL

– Dosage forms: 1, 2 mg

– Start: 0.5 mg po q evening

– Increase 0.5 mg/day q week

– Given bid-qid


Tenex

Caution with:

– Elderly

– Hepatic impairment

– Renal impairment

– Cardiovascular disease

– Hypotension

– Avoid abrupt withdrawal – may cause withdrawal sx & rebound HTN

Tenex


– Somnolence

– Hypotension

– Dizziness

– Constipation

– Fatigue

– Headache

– Impotence

Intuniv

Intuniv (guanfacine) – long acting tenex

– 24 hr release

– Dosage forms: 1, 2, 3, 4 mg ER

– Weight dose – 0.05-0.12 mg/kg/day

– Start 1 mg po qd x 1 week then 2 mg po qd

– Hypotension & ^^ HR common

– NO DOSAGE RANGE FOR USE IN ADULTS

Clonidine

Clonidine


– Dosage forms: 0.1, 0.2, 0.3 mg

– Start: .025-.05 mg po q evening

– Increase 0.025-.05 mg/day q week

– Given bid-qid

– Maximum dose: 0.3 mg/day

Clonidine

Caution with:

– Elderly

– Hepatic impairment

– Renal impairment

– Cardiovascular disease

– Hypotension

– Avoid abrupt withdrawal – may cause withdrawal sx & rebound HTN

Clonidine


– Somnolence

– Hypotension

– Dizziness

– Constipation

– Fatigue

– Headache

– Sexual dysfxn

Kapvay

Kapvay (clonidine)


– Dosage forms: 0.1, 0.2, mg ER

– Start: 0.1 mg po q evening

– Increase 0.1mg/day q week

– Given qd-bid

– Maximum dose: 0.4mg/day

– Must taper dose when discontinuing

– NO DOSAGE RANGE FOR USE IN ADULTS

adhd presentation

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