attention deficit/ hyperactivity disorder j. hancey, phd, md dept. of psychiatry ohsu
TRANSCRIPT
Cognitive Features of ADHD
• Inattention, distractibility, loss of focus, wandering from task to task
• Task incompletion
• Difficulties with
priorities
Behavioral Features of ADHD
• Impulsivity• Thrill-seeking behavior• Risk taking behavior• Irritability
Developmental Features of ADHD:
Children
Adolescents
Adults DisorganizationImpatienceInattentivenessImpulsivityBoredomIrritabilityDistractibleShift activitiesAggressiveLow frustration toleranceMotor hyperactivity
ADHD: “an equal opportunity destroyer”
Impairments:-academic/occupational
-3 fewer years of education than controls-social functioning-substance abuse-health/injury
-4x serious injury rate, 3x MVA rate-self-esteem-sexual behavior-criminality (estimates: 25-57% of inmates)
-the Colorado experience (recidivisim cut from 60% to 11%
The Risk of Substance Abuse: Declines with Treatment
Biederman J, et al. Pediatrics, 1999; 104:e20
--between ages 15-27 = 47% (vs 15%)--65% lifetime
Differential: BAD vs ADHD
• Symptomatic: episodic vs chronic• Decreased need for sleep vs insomnia• Hypersexuality• Grandiosity• Elated mood
Co-morbidity
• OCD• Tourette’s Syndrome
– a PANDAS phenomenon?
• Learning Disabilities• Conduct Disorder• Sleep disturbances: DFA, morning sedation• Drug/etOH abuse• ODD, CD, ASPD
Sleep Disorders in ADHD
• Sleep disorders common with ADHD at all ages– Sleep walking, talking– DFA (10-15% in young children; 50% at 12.4
years; 75% by age 30– Restlessness– Fractured sleep architecture– enuresis
Corkum, et al. J Am Acad Child Adolesc Psychiatry 1999,38.1285
Sleep Disorders in ADHD (cont)
• 75% of adolescents and adults with ADHD
are “nightowls”—difficulty shutting down• Once asleep, they experience multiple
awakenings or toss and turn• Significant difficulty awakening and feeling
mentally alert• Intrusion of drowsiness when bored
Medications
• Start with stimulant medications– 80% of patients will respond to stimulants, but
often at lower than recommended doses– stimulants address the underlying problem of
hypoarousal– dosage correlates with no known factors--age,
sex, body weight, sx severity--must be individualized
Extended Release Stimulant Options• Concerta: 22% immediate / 78% delayed• Metadate CD: 30% / 70%• Ritalin LA: 50% / 50%• Adderall XR: 50% / 50%• Vyvanse: dextroamphetamine linked to lysine
Absorption may be impaired by citric and ascorbic acid. Avoid citrus fruit, all fruit juices, most carbonated beverages, breakfast bars, high vitamin cereals and vitamin C one hour before and after dose.
A simple acid-base reaction may precipitate out the stimulant, thusprecluding absorption.
Long-acting MethylphenidateMedications
Concerta® [package insert]. Moutain View, CA: Alza Corporation; 2001. OROS® is a registered trademark of ALZA Corporation.Metadate® CD [package insert]. Rochester, NY: Celltech Pharmaceuticals, Inc; 2002. Diffucaps® is a registered trademark of Eurand.Ritalin® LA [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2002. SODAS™ is a trademark of Elan Corporation, Plc.
Products Concerta® Metadate® CD Ritalin® LA
OROS® Diffucaps® SODAS™
Dose 18 mg 27 mg 36 mg 54 mg 20 mg 20 mg 30 mg 40 mg
Immediaterelease 4 mg 6 mg 8 mg 12 mg 6 mg 10 mg 15 mg 20 mg
30% 50%
Sustained/2nd release 14 mg 21 mg 28 mg 42 mg 14 mg 10 mg15 mg 20 mg
78% 70% 50%
22%
FormulationTechnology
Ritalin® LA 40 mg
Metadate® CD 60 mg (3 x 20 mg)
Concerta® 54 mg
Time (h)
0 5 10 150
5
10
15
20
Mea
n d,l
-met
hyl
ph
enid
ate
pla
sma
leve
ls (
ng
/mL
)
Comparison of Extended-release Methylphenidate Dosage Forms
Ritalin® 20 mg BID
Gonzalez MA, et al. Int J Clin Pharmacol Ther. 2002;40:175-184.
Data on file, Novartis Pharmaceuticals.
Stimulants
• Newer products are refined formulations,
not new drugs.
Absorption impaired by citric and ascorbic acid. Avoid citrus fruit, all fruit juices, most carbonated beverages, breakfast bars,
high vitamin cereals and vitamin C one hour before and after dose.
A simple acid-base reaction precipitates out the stimulant, thusprecluding absorption.
Adderall®
• Blend of four different salts of amphetamine• Available generically as MAS
• available as an XR formulation– Duration of action above baseline about 7.5-8 hrs– May need bid dosing in adults
Metadate® CD (methylphenidate HCl, USP) Extended-Release Capsules for ADHD
Biphasic Release: Diffucaps®* Bead-Delivery System
Metadate is a registered trademark of Celltech Pharma, Ltd.*Diffucaps is a registered trademark of Eurand.
Focalin®: dex-methylphenidate
• The dextro isomer of methylphenidate
• Dose at ½ the dosage of the racemic mixture
Non stimulants with reported efficacy
• Desipramine• Bupropion• Modafanil/armodafanil• Guanfacine/clonidine• Atomoxetine • Duloxetine
Lisdexamfetamine: Vyvanse®
• Dextroamphetamine linked to lysine side-chain
• Activated when lysine cleaved off by enzyme on RBC’s
• Duration: 12-14 hours
Drug Choice Considerations
• Duration of action
• Intra-day dosing
• Compliance is generally poor due to forgetfulness
Dependence, Addiction and Abuse
• Dependence?--you betcha!• Drug addiction?--No. Washes out daily,
without withdrawal.• Drug abuse?--possible, but rare. People
usually feel worse if overdosed. Report feeling like a “zombie” or “too amped”:
• Diversion: a huge issue<0.1% will take excess meds >5x in their lifetime