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What’s New and What is Our Data
By Roger A. Hofford, M.D. FAAFP, CPE
Associate Professor of Family & Community Medicine
Vi...
Disclosures:
 None
Goals and Objectives:
 Briefly review the diagnosis of ADHD
 Review latest treatment options/algorithms for ADHD
 Revie...
Recent ADHD News Headline
 “Study finds 17% of
college students
misuse ADHD drugs”
 “Stimulant treatment
for ADHD may al...
Recent ADHD News Headline
 “Children with ADHD
more likely to have
eating disorder”
 “Is the Internet giving us
all ADHD...
Recent ADHD News Headline
 “Maternal Chemical
Drug Intolerances:
Potential Risk Factors for
Autism & ADHD” - JABFM
 “Exa...
What is ADHD?
 Most common chronic
neurobehavior/neurodevelopmental childhood
disorder
 Persistent inattention, hyperact...
ADHD DSM-V Criteria
A. Either 1 or 2 or 3
 1) Six (or more) of the following symptoms of
inattention have persisted for a...
ADHD DSM-V Criteria
 Inattention
 a) Often fails to give close attention to details or makes careless mistakes in
school...
ADHD DSM-V Criteria
2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for
at least 6 ...
ADHD DSM-V Criteria
3) Combined – child exhibits six or more symptoms of
Inattention, hyperactivity and impulsivity for gr...
ADHD DSM-V Criteria
 B. Some hyperactive-impulsive or inattentive symptoms that
caused impairment were present before 7 y...
ADHD Incidence (CDC):
 Boys are two times greater than girls
 More likely to be Caucasian or African-American
 May affe...
ADHD Incidence (APA):
 2.5% of U.S. Adults
 5% of U.S. children
Higher incidence of ADHD
 Most likely genetic
 Second-hand smoke
 Premature birth - 2.64 X more likely
 Maternal hyper...
Complications of ADHD Untreated
 Increase risk of injury
 Increased risk of driving offenses
 Increased substance abuse...
Prognosis of ADHD
 Hyperactivity and impulsivity tend to decrease with
age
 Approximately 50% of ADHD children will cont...
Treatment Benefits:
 Better learning and education
 Less accidents
 Less criminal behavior
 Better social interactions...
Associated Comorbidities:
 Increase in other psychiatric comorbidities in a
referred population:
 Anxiety disorder (29%)...
Associated Physical Conditions:
 Tics
 Sleep Apnea
 Sleep disturbances:
 Bedtime resistance
 Difficult sleep onset
 ...
Evaluation:
 Obtain information from multiple sources e.g Conner
or Vanderbilt forms
 Are other neurobehavioral disorder...
Differential Diagnoses:
 Conduct Disorder – stealing, destroying property,
cruelty
 Depression – excessive crying or wor...
Medications that can give
symptoms suggestive of ADHD
 Albuterol
 Steroids
 Antipsychotics
 Antihistamines
 Decongest...
Physical Exam
 HEENT – can patient hear, vision OK
 Pulmonary –
 Cardiac – BP, rate, rhythm, murmurs, extra heart
sound...
Testing (AAP Recommendations):
 Labs: Not routinely recommended if medical history
negative – do not routinely check TSH ...
Testing (AAP Recommendations):
 Neuroimaging – not routinely recommended unless
strong evidence for neurological patholog...
ADHD Treatment Options:
(4-5 year olds)
 Try first treatment with parent- and/or teacher
administrated behavior therapy (...
Behavioral Intervention
 Positive reinforcement
 Time out
 Withdrawal of privileges or rewards
 Token economy
 Routin...
ADHD Treatment Options:
(6-11 year olds)
 FDA – approved medications (best evidence for
stimulants) (AAP strong recommend...
ADHD Treatment Options:
(12-18 year olds)
 FDA – approved medications (best evidence for
stimulants) (AAP strong recommen...
Child with ADHD Diagnosis/Meds
4 y.o thru 17 y.o.
Plan Va. Premier Anthem Coventry Optima INTotal Kaiser CCNC CDC 2011 CDC...
Adults with ADHD Diagnosis/Meds
18 y.o thru 25 y.o.
Plan Va. Premier Anthem Coventry Optima INTotal Kaiser VA MCOs
ADHD MC...
Stimulant Medications: Short acting
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Methylphenidate...
Stimulant Medications: Intermediate acting
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Methylph...
Stimulant Medications: Long-acting
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Methylphenidate
...
Non-Stimulant Medications:
Name Onset of
Action
Duration
of Effect
Dosing Cost (30
days)
Comments
Atomoxetine
(Strattera)
...
Other Second Line Medications:
Medication Indications Dose Costs Comments
Clonidine ER
Catapres***
Kapvay
ADHD+tics;
ADHD+...
Other Second Line Medications:
Medication Indications Dose Costs Comments
Divalproex
Depakote
Depakote ER
ADHD+Aggression ...
Top Chronic Disease Drugs Requiring Prior
Authorization in Virginia (Preliminary Data)
 2. Vyvanse
 4. Strattera
 5. Me...
Algorithm for the Psychopharmacological Management of
Attention Deficit Hyperactivity Disorder (ADHD)
 This algorithm is ...
Algorithm for the Psychopharmacological Management of
Attention Deficit Hyperactivity Disorder (ADHD)
 Stage 2: If patien...
Algorithm for the Psychopharmacological Management of
Attention Deficit Hyperactivity Disorder (ADHD)
 Stage 4 &5: Consid...
Conversion from One Medication
to Another
 Methylphenidate (MPH) – IR to ER: milligram to
milligram
 Mixed amphetamines ...
Conversion from One Medication
to Another
 Stimulant to atomoxetine (Strattera): It takes several
weeks for atomoxetine t...
Conversion from One Medication
to Another
 Short-acting to long-acting alpha agonists:Taper off
short-acting guanfacine(e...
Recent Cochrane Reviews
 “Social skills training for children aged between 5 & 18
with ADHD”
 - There is little evidence...
Recent Cochrane Reviews
 “Tricyclic antidepressants for ADHD (with and w/o
tics) in children and adolescents”
 - TCA’s, ...
Recent Cochrane Reviews
 “Atypical antipsychotic drugs for disruptive behaviour
disorders in children and youths”
 - The...
Diet
 Insufficient evidence for decreasing sugar, increasing
vitamins or using herbs (SORIII)
 Restricting artificial co...
Other Modalities
 Neurofeedback – may improve IQ
 Sleep intervention/hygiene – 2 counseling sessions by
psychologist on ...
Adult ADHD
 Affects 1-6% of adults
 Affects academic performance, interpersonal
relationships, employment, and driving p...
Urine Drug Screens
 Methylphenidate is not usually picked up in the
routine Urine Drug Screens we order
 Be sure to chec...
Thank you!
Attention-Deficity Hyperactivity Disorder
Attention-Deficity Hyperactivity Disorder
Attention-Deficity Hyperactivity Disorder
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Attention-Deficity Hyperactivity Disorder

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Attention-Deficity Hyperactivity Disorder

  1. 1. What’s New and What is Our Data By Roger A. Hofford, M.D. FAAFP, CPE Associate Professor of Family & Community Medicine Virginia Tech Carilion Family Medicine Residency Virginia Commonwealth University Virginia College of Osteopathic Medicine
  2. 2. Disclosures:  None
  3. 3. Goals and Objectives:  Briefly review the diagnosis of ADHD  Review latest treatment options/algorithms for ADHD  Review recent Virginia Medicaid ADHD data and how do we compare with North Carolina and the United States
  4. 4. Recent ADHD News Headline  “Study finds 17% of college students misuse ADHD drugs”  “Stimulant treatment for ADHD may also reduce smoking risk”  “ADHD Medications Don't Lead To Drug Or Alcohol Abuse”  “ADHD drugs 'do not stunt children's growth,' say AAP”  “Can Fish Oil Help Boys With ADHD Pay Attention? Perhaps, but it won't take the place of medication, expert says”
  5. 5. Recent ADHD News Headline  “Children with ADHD more likely to have eating disorder”  “Is the Internet giving us all ADHD?”  “Too Little Behavioral Therapy for Kids with ADHD – CDC”  “Are Antipsychotic meds being overprescribed in ADHD?”  “Intense physical activity is associated with better cognitive control performance in ADHD disorder”  “ADHD Drug Decreases Binge Eating”  “FDA: Daytrana patch may cause permanent depigmentation”
  6. 6. Recent ADHD News Headline  “Maternal Chemical Drug Intolerances: Potential Risk Factors for Autism & ADHD” - JABFM  “Examining the Association Between PTSD & ADHD: A systematic Review & Meta-analysis” – J Cl Psy
  7. 7. What is ADHD?  Most common chronic neurobehavior/neurodevelopmental childhood disorder  Persistent inattention, hyperactivity and/or impulsivity compared to their peer group
  8. 8. ADHD DSM-V Criteria A. Either 1 or 2 or 3  1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
  9. 9. ADHD DSM-V Criteria  Inattention  a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities  b) Often has difficulty sustaining attention in tasks or play activities  c) Often does not seem to listen when spoken to directly  d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)  e) Often has difficulty organizing tasks and activities  f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)  g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)  h) Is often easily distracted by extraneous stimuli  i) Is often forgetful in daily activities
  10. 10. ADHD DSM-V Criteria 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 developmental level:  Hyperactivity  a) Often fidgets with hands or feet or squirms in seat  b) Often leaves seat in classroom or in other situations in which remaining seated is expected  c) 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)  d) Often has difficulty playing or engaging in leisure activities quietly  e) Is often "on the go" or often acts as if "driven by a motor"  f) Often talks excessively  Impulsivity  a) Often blurts out answers before questions have been completed  a) Often has difficulty awaiting turn  b) Often interrupts or intrudes on others (e.g., butts into conversations or games)
  11. 11. ADHD DSM-V Criteria 3) Combined – child exhibits six or more symptoms of Inattention, hyperactivity and impulsivity for greater than six months
  12. 12. ADHD DSM-V Criteria  B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age.  C. Some impairment from the symptoms is present in 2 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 personality disorder).
  13. 13. ADHD Incidence (CDC):  Boys are two times greater than girls  More likely to be Caucasian or African-American  May affect up to 11% of children between the ages of 4 through 17 y.o.  Prevalence is increasing over last 12 years per CDC Surveys: 2003 2007 2011 Virginia 9.3% 10.2% 11.8% United States 7.8% 9.5% 11%
  14. 14. ADHD Incidence (APA):  2.5% of U.S. Adults  5% of U.S. children
  15. 15. Higher incidence of ADHD  Most likely genetic  Second-hand smoke  Premature birth - 2.64 X more likely  Maternal hyperthyroidism  Maternal smoking – 2.4 – 3.0 X  Maternal excessive alcohol use – 2.5X  Childhood traumatic brain injury requiring hospitalization – 20%  Childhood lead exposure in 3rd quartile lead level – OR 2.3
  16. 16. Complications of ADHD Untreated  Increase risk of injury  Increased risk of driving offenses  Increased substance abuse  Increased cigarette use/abuse
  17. 17. Prognosis of ADHD  Hyperactivity and impulsivity tend to decrease with age  Approximately 50% of ADHD children will continue into adulthood with ADHD symptoms  Increased risk of suicide in adulthood  Increased risk of obesity in adulthood
  18. 18. Treatment Benefits:  Better learning and education  Less accidents  Less criminal behavior  Better social interactions  Better employment opportunities
  19. 19. Associated Comorbidities:  Increase in other psychiatric comorbidities in a referred population:  Anxiety disorder (29%)  Conduct disorder (15%)  Depression (15%)  Bipolar (7%)
  20. 20. Associated Physical Conditions:  Tics  Sleep Apnea  Sleep disturbances:  Bedtime resistance  Difficult sleep onset  Hard to wake up in the AM  Increased night time awakenings  Less sleep time  Loud snoring at 2-3 y.o – increase risk of ADHD  ADHD & Enuresis 40% in 6-12 y.o.
  21. 21. Evaluation:  Obtain information from multiple sources e.g Conner or Vanderbilt forms  Are other neurobehavioral disorders present?  Are developmental disorders in speech, learning, hearing present?  Home situation?  School situation?
  22. 22. Differential Diagnoses:  Conduct Disorder – stealing, destroying property, cruelty  Depression – excessive crying or worrying; recurrent thoughts of death/suicide  Oppositional Defiant Disorder – argues, intentionally defies rules, loses temper frequently  Hx of sexual abuse – inappropriate sexual behavior  Tourette Syndrome – repetitive sounds or motor tics  Learning disorder – ADHD sx in a particular setting
  23. 23. Medications that can give symptoms suggestive of ADHD  Albuterol  Steroids  Antipsychotics  Antihistamines  Decongestants  Anticonvulsants
  24. 24. Physical Exam  HEENT – can patient hear, vision OK  Pulmonary –  Cardiac – BP, rate, rhythm, murmurs, extra heart sounds  Neuro exam
  25. 25. Testing (AAP Recommendations):  Labs: Not routinely recommended if medical history negative – do not routinely check TSH or lead levels  Neuropsych testing: Not routinely recommended unless history suggests it (low general cognitive ability, low language or math ability). If classic ADHD sxs, do not need to do neuropsych testing  EKG:  - AAP does not recommend routine EKG testing (Quality Evidence D)  - AHA recommends (Level C recommendation)
  26. 26. Testing (AAP Recommendations):  Neuroimaging – not routinely recommended unless strong evidence for neurological pathology. Soft neurological findings are not an indication.  EEG: not routinely recommended unless history suggest reason for doing
  27. 27. ADHD Treatment Options: (4-5 year olds)  Try first treatment with parent- and/or teacher administrated behavior therapy (AAP Strong Recommendation -Evidence Quality A)  If no improvement and moderate-severe dysfunction consider methylphenidate (AAP Recommendation – Evidence Quality B)
  28. 28. Behavioral Intervention  Positive reinforcement  Time out  Withdrawal of privileges or rewards  Token economy  Routines  504 Education Plan  IEP
  29. 29. ADHD Treatment Options: (6-11 year olds)  FDA – approved medications (best evidence for stimulants) (AAP strong recommendation, Evidence Quality A)  Parent- and/or teacher-based behavioral therapy (AAP recommendation, Evidence Quality B)
  30. 30. ADHD Treatment Options: (12-18 year olds)  FDA – approved medications (best evidence for stimulants) (AAP strong recommendation, Evidence Quality A)  Parent- and/or teacher-based behavioral therapy (AAP recommendation, Evidence Quality C)
  31. 31. Child with ADHD Diagnosis/Meds 4 y.o thru 17 y.o. Plan Va. Premier Anthem Coventry Optima INTotal Kaiser CCNC CDC 2011 CDC 2011 VA MCOs VA National ADHD MCO Data 4 thru 17 Child with ADHD DX 11,794 12,428 1,772 5,487 1,745 59 11.1-13% 11% 33,285 Child rx ADHD meds 13,460 15,165 1,233 10,649 1,687 49 65,121 42,243 ADHD_Meds/DX 114.13% 122.02% 69.58% 194.08% 96.68% 83.05% 126.91% No. Child in plan 116,231 148,989 20,252 94,913 39,391 2,069 920,040 421,845 Percent Rx/No in plan 11.58% 10.18% 6.09% 11.22% 4.28% 2.37% 7.08% 6.60% 6.10% 10.01%
  32. 32. Adults with ADHD Diagnosis/Meds 18 y.o thru 25 y.o. Plan Va. Premier Anthem Coventry Optima INTotal Kaiser VA MCOs ADHD MCO Data 18 thru 25 College age with ADHD Dx 629 1,050 80 298 114 6 2177 College age rx ADHD med 1081 1,269 81 962 123 6 3522 ADHD_Meds/DX 171.86% 120.86% 101.25% 322.82% 107.89% 100.00% 161.78% No. College age in plan 24,463 17,096 2,908 15,158 5,404 347 65376 Percent Rx/No in plan 4.42% 7.42% 2.79% 6.35% 2.28% 1.73% 5.39%
  33. 33. Stimulant Medications: Short acting Name Onset of Action Duration of Effect Dosing Cost (30 days) Comments Methylphenidate (Ritalin) (Methylin) 20-30 minutes 3-6 hrs BID- TID $76 $84 $536 Take 30 min before meals; Avoid in cardiac conditions Dexmethylphenidate (Focalin) 30 minutes 3-6 hrs BID $67 $78 Take with/after meals Mixed amphetamine Salts (Adderal) 30 minutes 5-7 hrs Qd <5yo; >5yo BID- TID $142 $295 Take with/after meals Dextroamphetamine (Dexedrine) 20-60 minutes 4-6 hrs Qd <5yo; >5yo BID- TID $142 $318-342 Take with/after meals
  34. 34. Stimulant Medications: Intermediate acting Name Onset of Action Duration of Effect Dosing Cost (30 days) Comments Methylphenidate (Ritalin- SR) (Metadate-ER) 60-90 minutes 3-8 hrs (highly variable) Daily; ½ dose in early afterno on $NA $88 $108 Take with/after meals; may need to add short- acting in afternoon Dextroamphetamine (Dexedrine Spansules) 60-90 minutes 6-10 hrs (highly variable) Daily $147 $338 Take with/after meals; may need to add short- acting in afternoon
  35. 35. Stimulant Medications: Long-acting Name Onset of Action Duration of Effect Dosing Cost (30 days) Comments Methylphenidate (Ritalin LA) (Methadate CD) Concerta Daytrana Patch Aptensio(just FDA approved) 1.8 hrs 90 min 30-60 min 3 hours 60 min 7-9 hrs 7-9 hrs 10-12 hrs 10-12 hrs 12 hrs Daily $130-135 $213 $206 $208-265 $251 $195 Take with food/after meal; Avoid using in patients with structural heart disease Dexmethylphenidate (Focalin XR) 30 min 12 hrs Daily $227-253 Avoid taking with antacids Mixed amphetamine Salts (Adderal XR) 30 min ~8 hrs Daily $157 $214 Take with food/after meals Lisdesamfetamine (Vyvanse) 2 hours 10 hrs Daily $199 Avoid using in patients with structural heart disease
  36. 36. Non-Stimulant Medications: Name Onset of Action Duration of Effect Dosing Cost (30 days) Comments Atomoxetine (Strattera) Slow onset- weeks ~24 hrs 0.5 mg/kg up to 1.2 mg/kg $303 Not for child <6 y/o.; some med interaction CYP2D6 – liver; If worried about substance abuse Buproprion Wellbutrin Wellbutrin SR Wellbutrin XL Indications: Intolerant of ADHD meds; Has depression, aggression, irritabilty; smoking cessation IR: BID SR: BID XL:Daily – titrate to XL using IR/SR $29-34 $102-123 $74-207 (284-396) Lowers sz threshold; Black Box warnings; Avoid bedtime dosing Side Effects
  37. 37. Other Second Line Medications: Medication Indications Dose Costs Comments Clonidine ER Catapres*** Kapvay ADHD+tics; ADHD+ PTSD; ADHD+Insomnia ADHD+ODD ADHD+Aggression Start 0.05 mg qHS, Not prn; Can be used BID in severe cases $114 $75-200 $158 Sedation – improves w/ time; Watch BP; Baseline EKG; Do not stop abruptly Guanfacine ER Tenex *** Intuniv ADHD+tics; ADHD+ PTSD; ADHD+Insomnia ADHD+ODD ADHD+Aggression Start 0.5 mg qHS Start 0.5 mg qHS Start 1 mg qAM $250 $78-230 $291 Sedation; Baseline EKG; Watch BP Risperidone Risperdal ADHD+tics ADHD+aggression ADHD+ mood swings ADHD severe insomnia Start 0.5 mg qHS $78-102 $219-330 Side effects; Be careful if using fluoxetine & sertraline – increases risperidone levels
  38. 38. Other Second Line Medications: Medication Indications Dose Costs Comments Divalproex Depakote Depakote ER ADHD+Aggression Start 10-15 mg/kg/day in divided dose $36-92.99 $45-145 $88-130 Use if > 10 yo; caution in liver ds. Desipramine Norpramin ADHD+tics; ADHD+ PTSD; ADHD+Insomnia ADHD+ODD ADHD+Aggression Start 10 mg PO qd $37-145 $54-122 Sedation; Baseline EKG; Trazodone ADHD+insomnia ADHD+aggression Start 25 mg qHS $35-48 Monitor BP and heart rate
  39. 39. Top Chronic Disease Drugs Requiring Prior Authorization in Virginia (Preliminary Data)  2. Vyvanse  4. Strattera  5. Methylphenidate  10. Amphetamine
  40. 40. Algorithm for the Psychopharmacological Management of Attention Deficit Hyperactivity Disorder (ADHD)  This algorithm is intended for new patients who have never been on ADHD medications in their lifetime.   Stage 1: Long-acting preferred if school age to avoid dosing in school. Either methylphenidate or mixed amphetamine. Twice daily dosing is useful if late evening behavior problems. Titrate dose every one to three weeks until maximum effective dose reached or goals reached at lower dose or side effects prevent further dosing increases.   Atomoxetine (Strattera) (prior authorization) should be considered Stage 1 if patient has comorbid anxiety or tic disorder or household concerns for substance abuse. If atomoxetine (Strattera) is used, give at least 6 weeks to see if effective.
  41. 41. Algorithm for the Psychopharmacological Management of Attention Deficit Hyperactivity Disorder (ADHD)  Stage 2: If patient fails on one of the above either methylphenidate or mixed amphetamine, try the other class before moving to one of the medications below.   Stage 3: If patient fails on mixed amphetamines and methylphenidate, physician should request prior authorization for amoxetine (Strattera) or lisdexametafine (Vyvanse). Failing on medication would be due to significant side effects such decreased appetite, weight loss, and/or decreased sleep that does not respond to time.
  42. 42. Algorithm for the Psychopharmacological Management of Attention Deficit Hyperactivity Disorder (ADHD)  Stage 4 &5: Consider re-evaluating ADHD diagnosis or other co-morbidities present before going to this stage; If ADHD confirmed consider behavioral therapy before add- on medication for Stage 3 or 4 medications. Often necessary to use add-on medication if co-morbid aggression or to reduce side effects of tics or insomnia   If discontinuing an add-on medication, titrate dose downward over 1-2 week period to avoid sudden drop in blood pressure.
  43. 43. Conversion from One Medication to Another  Methylphenidate (MPH) – IR to ER: milligram to milligram  Mixed amphetamines (Adderal) – IR to ER: milligram to milligram  Switching from MPH to mixed amphetamines (Adderal): reduce mixed amphetamine milligram by 50%  Switching from MPH to Concerta: Increase Concerta dose by ~20% (e.g MPH 10-15 mg to Concerta 18 mg)
  44. 44. Conversion from One Medication to Another  Stimulant to atomoxetine (Strattera): It takes several weeks for atomoxetine to start working – start at recommended starting dose; Therefore, slowly taper off stimulant over several weeks as it takes several weeks for atomoxetine to work.  Dexmethylphenidate (Focalin) IR to XR: milligram to milligram  Oral methylphenidate to patch: milligram to milligram is NOT equivalent
  45. 45. Conversion from One Medication to Another  Short-acting to long-acting alpha agonists:Taper off short-acting guanfacine(e.g. Tenex) completely before starting long-acting guanfacine (e.g. Intuniv) then start long –acting at starting dose
  46. 46. Recent Cochrane Reviews  “Social skills training for children aged between 5 & 18 with ADHD”  - There is little evidence to support or refute social skills training (11 randomized trials) December 2011  “Family therapy for ADHD in children”  - Further research needed to determine effectiveness. (2 studies)March 2010;
  47. 47. Recent Cochrane Reviews  “Tricyclic antidepressants for ADHD (with and w/o tics) in children and adolescents”  - TCA’s, particularly desipramine, had a beneficial effect in the short term for core symptoms. Mild increases in BP and pulse rate. (RCT=6) September 2014  “Medications for ADHD in children with tics”  - MPH, clonidine, guanfacine, desipramine and atomaxetine appear to reduce ADHD symptoms in children with tics. (RCT=8) April 2011
  48. 48. Recent Cochrane Reviews  “Atypical antipsychotic drugs for disruptive behaviour disorders in children and youths”  - There is some limited evidence of efficacy of risperidone reducing aggression and conduct problems in children aged 5 to 18 (RCT=8) September 2012  - There is no evidence so far to support the use of quetiapine (Seroquel) as of September 2012
  49. 49. Diet  Insufficient evidence for decreasing sugar, increasing vitamins or using herbs (SORIII)  Restricting artificial color dyes (Level 2 Evidence)  Omega-3 fatty acid supplement – modest effect
  50. 50. Other Modalities  Neurofeedback – may improve IQ  Sleep intervention/hygiene – 2 counseling sessions by psychologist on sleep hygiene –BMJ 2015 (LOE 1B-)  Family-centered Care – using collaborative care team March 2015 publication  Exercise
  51. 51. Adult ADHD  Affects 1-6% of adults  Affects academic performance, interpersonal relationships, employment, and driving performance  Not many studies in adults  Cochrane Review: good high quality evidence for immediate-release methylphenidate (Ritalin) and suggest side effects are not serious. (RCT=11) September 2014
  52. 52. Urine Drug Screens  Methylphenidate is not usually picked up in the routine Urine Drug Screens we order  Be sure to check the Virginia PMP database
  53. 53. Thank you!

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