adhd: an overview and approach to management€¦ · adhd: an overview and approach to management...
TRANSCRIPT
ADHD: An Overview and
Approach to Management
Carrie P. Peek, M.D., Ed.M.
Department of Neurology
Boston Children’s Hospital
Disclosure
• I have no financial relationship with a
commercial entity producing health-care
related products and/or services
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Objectives
• To review diagnosis of ADHD in the
primary care setting
• To review important considerations in the
pharmacological management of ADHD
• To explore the integrated care model for
ADHD management
Case: Kevin
• 8 year old male presents for evaluation of
current medication treatment
• Diagnosed at 7 years with ADHD, using
structured questionnaires
Kevin
• Height 125 cm, Weight 24 kg, BMI 15.4
(39th percentile)
• Currently taking 10 mg regular (short-
acting) methylphenidate (MPH) at 7:30 AM
– for the past 2 months
– approx. 0.5 mg/kg/day dosing
Kevin
• Teacher reports that he is in good
behavioral control and well-focused in the
mornings.
• He eats lunch well.
• But by 2 pm, he begins to have attention
problems.
Kevin
• You discuss medication options including
switching to:
– twice daily dosing of MPH
– once daily extended release MPH formulation
• Decide collectively to switch to MPH LA 20
mg daily at 7:30 AM
Kevin
• Teacher now reports “He’s wired” around
10:00 AM, several hours after am dose
• Stops eating lunch
• However, he is “more like himself” (and
back in behavioral control) in afternoons
Kevin
• You discuss medication options including:
– switch stimulant formulation (given MPH response)
– switch to non-stimulant (if this effect is concerning…)
• Begin alternate MPH (Ritalin SR 20 mg)
– No longer “wired”
– His appetite improves at lunch.
– In behavioral control and focused through school
– But parents now want an appointment immediately…he is blinking “incessantly”
Kevin
• Kevin presents to your office at 2 PM for a
follow-up visit.
• He is attentive and cooperative.
• Height 126 cm, weight 24 kg, BMI 15.2
(39th percentile)
• On exam, he blinks very rapidly every
fifteen seconds; parents say this has been
new in the last two weeks.
What would you do?
Kevin
• Kevin was switched to an amphetamine
class stimulant.
• He returns for a 1 month follow-up visit.
• His attention has significantly improved,
and he no longer has tics.
Introduction
• ADHD is a clinical syndrome that starts in
childhood with symptoms of inattention,
hyperactivity, and/or impulsivity.
• These symptoms affect the child’s overall
functioning cognitively, academically,
behaviorally, emotionally, and socially.
Epidemiology
• Prevalence estimates reported vary widely
• Recent meta-analysis showed that overall
prevalence of ADHD in children and
adolescents is 5.9-7.1 % (Willcutt 2012)
• More common in boys than girls
Epidemiology
• Prevalence in boys: 13.2%
• Prevalence in girls: 5.6 %
• Male-to-female ratio is 4:1 for predominantly
hyperactive type
• Male-to-female ratio is 2:1 for the predominantly
inattentive type
• Prevalence of ADHD increases with age
Pathogenesis
• Results of twin studies estimate the
heritability to be 76%.
• ADHD has been associated with markers
at chromosomes 4, 5, 6, 8, 11, 16, and 17
• Genes with statistically significant evidence
of association with ADHD:– dopamine 4 and 5 receptors
– dopamine transporter
– dopamine beta-hydroxylase
– serotonin transporter gene
DSM-5 ADHD Diagnostic
Criteria• A persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with
functioning or development, as characterized in
(1) and/or (2):
– (1) Six or more symptoms of inattention
– (2) Six or more symptoms of hyperactivity-
impulsivity
– Symptoms for at least 6 months to a degree that is
inconsistent with developmental level and that
negatively impacts directly on social and
academic/occupational activities
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DSM-5 Updates
• Several inattentive or hyperactive-impulsive symptoms were
present prior to age 12 years.
• Specify whether:
– Combined presentation
– Predominantly inattentive presentation
– Predominantly hyperactive/impulsive presentation
ADHD Diagnosis
• Obtain information from home and school settings before the
office visit
• Questionnaires such as Vanderbilt or Conners’ Rating Scales
can be used alone or in combination
– http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-
assessment-scales
ADHD Diagnosis
• Clinical interview
• Structured questionnaires
• Medical evaluation
• Neurological examination
ADHD Diagnosis
• Continuous performance tasks
– Gordon Diagnostic System
– Normed for 4 years of age to adult
ADHD Management
• Pharmacotherapy as a first-line treatment
of ADHD is strongly supported in the
literature
• MTA study showed that medication alone
or medication combined with behavioral
therapy had better outcomes compared to
behavioral therapy alone.
ADHD Medication
Considerations• When do you want medication effect?
• Does this change from day to day? Month
to month?
• Are there special situations?
• Start med trial on the weekends to see
how the child responds.
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ADHD Medication
Considerations
• Response and side effects can vary across the day
– Time limited response with short acting stimulant
– Peak tension/jitteriness
• Response and side effects can occur simultaneously
– Positive response and low appetite
ADHD and Tics Considerations
• Important to inquire about any (even transient) tics before starting
• Important to inquire again… if there is a history of tics if tics emerge “for the first time” on medication
• Tics may wax/wane independently
• Change in stimulant formulation may be sufficient to address common side effects including tics
ADHD Formulations
• Choice should be based on child’s needs and
profile
• Can remain within the stimulant class if:
• there is a detectable response
• side effects are in the mild range, or transient or
intermittent (but a concern)
Methylphenidate
• Primarily acts by releasing amines from
storage sites
• Also blocks re-uptake and inhibits
monoamine oxidase
• Readily absorbed across gut
• Poorly bound to protein
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Methylphenidate
• Peak level 1-2 hours
• Duration of Action 3-4 hours
• Both of these have wide variability
• 90% metabolites are not effective
• Side effects related to dopamine
stimulation, and rate of change of
dopamine stimulation
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Methylphenidate
• Total daily dose of regular formulation methylphenidate: 0.5-1.5 mg/kg/day
• Start low, move as indicated by response
• Monitor response in multiple ways (at home and at school)
• Important dosing safety issue: The methylphenidate derivatives do not have equivalent durations of action or dosing.
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Methylphenidate
• Wax matrix preparations– (1st generation long acting)
• OROS-based presentation
• Bead dispersal systems
• Transdermal patch
• Dextro-isomer (available as pills or bead dispersal system)
• Ritalin SR, Metadate ER
• Concerta
• Ritalin LA
• Daytrana
• Focalin, Focalin XR
Amphetamine
• Releases amines from storage sites
• Also blocks reuptake and inhibits
monoamine oxidase
• Easily absorbed across gut
• Poorly bound to protein
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Amphetamine
• Peak in 2 hours
• Duration 2-3 hours
• Both of these are variable
• Metabolites all inactive
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Amphetamine
• Dextroamphetamine pills
and spansules: latter are
wax-matrix based
technology
• Prodrug (lisdexamfetamine)
• Racemic mixture of D- and
L-isomers: bead dispersal
• Dextroamphetamine, Dexedrine Spansule
• Vyvanse
• Adderall,
Adderall XR
Amphetamine
• Total daily dosing of short-acting amphetamine derivatives: 0.25 - 0.75 mg/kg/day
• Start low, move as indicated by response
• Monitor response in multiple ways (at home and at school)
• Important dosing safety issue: The amphetamine derivatives do not have equivalent durations of action or dosing.
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Non-stimulant medications
• Consider if at least one stimulant from
each class of stimulants has either failed
to show efficacy or side effects are
moderate-marked or are clinically
concerning
Atomoxetine (Strattera)
• Selective Norepinephrine Reuptake Inhibitor
• Consider starting with 0.5 mg/kg/day
• Increase every 1-2 weeks, towards 1.2 mg/kg/day (max 100mg)
• BID dosing will likely improve tolerability, may improve efficacy
• Patience while awaiting clinical response– in 1-3 months vs. weeks with stimulant class
medications
Alpha-adrenergics
• First agents to receive FDA approval for adjunctive therapy to stimulant medications and monotherapy indication
– Clonidine extended release (Kapvay)
– Guanfacine extended release (Intuniv)
Alpha-adrenergics
• May be optimal choice for tics or
significant impulsivity in a younger child
• Clonidine
– Reduce NE release
– Monitor for sedation (less with patch
formulation)
• Guanfacine
– Modulate: prefrontal increase NE activity
– Less sedating vs clonidine
side effects
can occur alongside
response in ADHD
Tics may occur during
ADHD treatment
Shared Care
• Care coordination is essential for effective
care and management of children with
chronic health conditions.
• Shared care involves collaboration of
families, PCP’s, and subspecialists.
– Ex. Shared care algorithm for ADHD
developed at BCH in collaboration with the
department of neurology
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BCH Neurology Consultation
• 617.355.8348, for either advice or urgent
appointment
• Expected call back time to referring MD is less
than 30 minutes
• Can get appointments same day or next day for
urgent patients
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Thank You