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ADHD presentation

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ADHD presentation

  1. 1. ADHD Diagnosis & Pharmacological Management Lori Dewey, MSN, PMHCNS-BC September 2014
  2. 2. 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
  3. 3. ADHD Defined  ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination these – http://www.ncbi.nlm.nih.gov/pubmedhealth/P MH0002518/
  4. 4. 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
  5. 5. 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
  6. 6. 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/
  7. 7. Diagnosis  Screening tool: – Adult ADHD Self-Report Scale (ASRS- v1.1) http://www.help4adhd.org/documents/adulta dhdselfreportscale-asrs-v1-1.pdf
  8. 8. 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
  9. 9. 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
  10. 10. 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.
  11. 11. Treatment  Behavioral and cognitive therapies – Focused on reducing impulsivity and reinforcing positive long-term habits  Pharmacological management – Stimulants – Non-stimulants
  12. 12. 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
  13. 13. Stimulants  Monitor mood symptoms: – Depression – Anxiety – Agitation – Psychosis – Emotional lability – Exacerbation of bipolar sx
  14. 14. 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 pt with CV diseases/disorders, HTN, seizure disorders, liver impairment, etc  Caution with drugs that inhibit metabolism of stimulants – Especially Prozac
  15. 15. Stimulants  Adderall XR, Ritalin LA, Focalin, and Vivanse may be opened up and sprinkled on food  Vyvanse capsule may be dissolved in water
  16. 16. 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
  17. 17. Adderall  BLACK BOX WARNING: HIGH ABUSE POTENTIAL, DEPENDENCY – SERIOUS CARDIOVASCULAR ADVERSE EVENTS & SUDDEN DEATH REPORTED WITH MISUSE
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. Adderall XR  BLACK BOX WARNING: HIGH ABUSE POTENTIAL, DEPENDENCY – SERIOUS CARDIOVASCULAR ADVERSE EVENTS & SUDDEN DEATH REPORTED WITH MISUSE
  23. 23. Adderall XR  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures  Avoid abrupt withdrawal
  24. 24. Adderall XR  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
  25. 25. 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
  26. 26. Vyvanse  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures
  27. 27. Vyvanse  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 – Hyperhydrosis
  28. 28. Ritalin  Ritalin (methylphenidate) – Dosage forms: 5, 10, 20 mg – Start 5-10 mg po bid – Increase 10 mg/day q week – May be dosed bid-qid – Duration: 3-5 hours – Give 30-45 min before meals – Last dose before 6 pm
  29. 29. Ritalin  BLACK BOX WARNING: DRUG DEPENDENCE
  30. 30. Ritalin  Avoid use within 14 days of MAOI  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures
  31. 31. Ritalin  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
  32. 32. Ritalin LA  Ritalin LA (methylphenidate) – Dosage forms: 10, 20, 30, 40 mg ER – Start 20mg po qam – Increase 10 mg/day q week – Maximum dose: 60 mg/qd – Duration: 8-20 hours – Do not crush or chew
  33. 33. Ritalin LA  BLACK BOX WARNING: DRUG DEPENDENCE
  34. 34. Ritalin LA  Avoid use within 14 days of MAOI  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures
  35. 35. Ritalin LA  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
  36. 36. 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
  37. 37. Daytrana  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures
  38. 38. Daytrana  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 – ALT/AST elevation
  39. 39. 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 – Duration: 8-12 hours – Do not cut, crush or chew – Dissolves in stomach in layers – Less potent effect. Only effects dopamine. More tolerable in pt with emotional problems
  40. 40. Concerta  BLACK BOX WARNING: DRUG DEPENDENCE – CHRONIC ABUSE MAY LEAD TO MARKED TOLERANCE AND PSYCHOLOGICAL DEPENDENCE
  41. 41. Concerta  Avoid use within 14 days of MAOI  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures
  42. 42. Concerta  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
  43. 43. 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 – Maximum dose: 20 mg/day – Difficult to get insurance to cover – To convert from methylphenidate:  Start at 50% of current methylphenidate daily dose
  44. 44. Focalin  BLACK BOX WARNING: DRUG DEPENDENCE
  45. 45. Focalin  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures
  46. 46. Focalin  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
  47. 47. 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 – Maximum dose: 40 mg/day – 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
  48. 48. Focalin XR  BLACK BOX WARNING: DRUG DEPENDENCE
  49. 49. Focalin XR  Caution with:  cardiovascluar disease/arrhythmias  HTN  drug abuse hx  psychosis  bipolar  Tourettes/tics  seizures
  50. 50. Focalin XR  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
  51. 51. 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 – Maximum dose: 100 mg/qd – 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
  52. 52. Strattera  Avoid use within 14 days of MAOI  cardiovascluar disease/arrhythmias  HTN/hypotension  tachycardia  hepatic impairment  depression  bipolar
  53. 53. 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 – Emotional changes – Increased heart rate/BP
  54. 54. 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
  55. 55. Wellbutrin  Avoid use within 14 days of MAOI – Seizure Disorder/decreased seizure threshold – Appetite disturbance – Head injury – HTN – Bipolar – Hepatic/renal impairment – Bulemia – may cause e-lyte imbalance
  56. 56. Wellbutrin  Common side effects: – Agitation/anxiety – Headache/dizziness – Nausea/constipation/appetite decrease/weight loss/abd. pain/diarrhea – Tremor – Diaphoresis – Abnormal dreams/insomnia – Tinnitus – Palpatations
  57. 57. Wellbutrin SR  Wellbutrin SR (bupropion) – NON STIMULANT – Dosage forms:100, 150, 200 mg ER – Start 100 mg po qam – Increase 100 mg/day q week – Divide dose bid – Maximum dose: 400 mg/day – Do not cut, crush or chew
  58. 58. Wellbutrin SR  Avoid use within 14 days of MAOI – Seizure Disorder/decreased seizure threshold – Appetite disturbance – Head injury – HTN – Bipolar – Hepatic/renal impairment
  59. 59. Wellbutrin SR  Common side effects: – Agitation/anxiety – Headache/dizziness – Nausea/constipation/appetite decrease/weight loss/abd. pain/diarrhea – Tremor – Diaphoresis – Abnormal dreams/insomnia – Tinnitus – Palpatations
  60. 60. 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 – Maximum dose: 450 mg/day – Do not cut, crush or chew
  61. 61. Wellbutrin XL  Avoid use within 14 days of MAOI – Seizure Disorder/decreased seizure threshold – Appetite disturbance – Head injury – HTN – Bipolar – Hepatic/renal impairment
  62. 62. Wellbutrin XL  Common side effects: – Agitation/anxiety – Headache/dizziness – Nausea/constipation/appetite decrease/weight loss/abd. pain/diarrhea – Tremor – Diaphoresis – Abnormal dreams/insomnia – Tinnitus – Palpatations
  63. 63. 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 – Maximum dose: 4 mg/day
  64. 64. Tenex  Caution with: – Elderly – Hepatic impairment – Renal impairment – Cardiovascular disease – Hypotension – Avoid abrupt withdrawal – may cause withdrawal sx & rebound HTN
  65. 65. Tenex  Common side effects: – Somnolence – Hypotension – Dizziness – Constipation – Fatigue – Headache – Impotence
  66. 66. 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
  67. 67. Clonidine  Clonidine – NON STIMULANT – OFF LABEL – 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
  68. 68. Clonidine  Caution with: – Elderly – Hepatic impairment – Renal impairment – Cardiovascular disease – Hypotension – Avoid abrupt withdrawal – may cause withdrawal sx & rebound HTN
  69. 69. Clonidine  Common side effects: – Somnolence – Hypotension – Dizziness – Constipation – Fatigue – Headache – Sexual dysfxn
  70. 70. Kapvay  Kapvay (clonidine) – NON STIMULANT – OFF LABEL – 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

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