sarah schweiss, pharm.d. ambulatory care resident university of minnesota & duluth clinic...
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ATTENTION DEFICIT HYPERACTIVITY
DISORDER:OVERVIEW OF
MEDICATIONS AND IMPLICATIONS
Sarah Schweiss, Pharm.D.
Ambulatory Care Resident
University of Minnesota & Duluth Clinic
January 18th, 2010
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OBJECTIVES Discuss general information and
consequences of uncontrolled ADHD. Review potential causes, the clinical
presentation, and the diagnosis of ADHD.
Outline pharmacological and non-pharmacological treatment options for ADHD.
Discuss fiction, facts, and controversies surrounding ADHD.
Briefly discuss prescription drug abuse statistics, consequences, and prevention methods.
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GENERAL INFORMATION
3-7% school-age childrenDiagnosis occurs as early as age 3Average age of diagnosis:_____
Up to 60% of children continue to have significant symptoms into adulthood
Males>>Females (3:1) Number of people diagnosed with
ADHD has increased by an average of 3% each year between 1997-2006 (CDC)
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CONSEQUENCES OF UNCONTROLLED ADHD Relationship difficulties Academic failure Social isolation Involvement with deviant peer groups Significantly greater risk of developing:
___________________________________ Low self-esteem
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POTENTIAL CAUSES OF ADHD Currently - no one identified cause
of ADHD Hypothesized to be caused by a
combination of environmental and genetic factors Imbalance between neurotransmitters in
the brain Norepinephrine Dopamine
Genetics Parent with ADHD = _____% chance of
developing ADHD Monozygotic twins have up to a ___%
concordance rateEnvironmental exposures
Maternal smoke or alcohol use
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DIAGNOSIS DSM-IV criteria
Symptoms present prior to age 6 y.o. Must involve 2 environments, e.g., school &
home Patients must meet > 6 symptoms in the
categories of impulsivity, inattention, and/or hyperactivity
Social, academic or occupational functioning is impaired
Other psychiatric illnesses are ruled out
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CLINICAL PRESENTATION OF ADHD:INATTENTION
Lack of attention to details Difficulty sustaining attention and
organizing Avoids tasks Difficulties listening Does not follow through on
instructions Easily distracted Forgetful in daily activities Loses things necessary for activities
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CLINICAL PRESENTATION OF ADHD:HYPERACTIVITY AND IMPULSIVITY
Fidgets and/or squirms Leaves seat when prohibited Runs or climbs excessively at
inappropriate times Difficulties playing quietly Often “on the go” Excessive talking Blurts out answers before completion of
question Interrupts and/or intrudes Difficulty waiting to take turns
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TREATMENT OPTIONS Pharmacological
PsychostimulantsNon-stimulants
Non-pharmacologicalBehavioral InterventionsCounseling/Talk TherapyFocused help with schoolworkTraining for parents
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NON-PHARMACOLOGICAL Behavioral Interventions
Positive reinforcementTime-outResponse CostToken economy
Parent training Family therapy Classroom interventions Contingency management
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OVERVIEW OF MEDICATIONS
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PSYCHOSTIMULANTS Methylphenidate - FDA approved for >6 yo
Immediate Release: Ritalin®, Methylin®, methylphenidate
Intermediate Acting: Ritalin SR®, Methylphenidate SR, Metadate ER, Methylin ER
Sustained Release: Metadate CD, Ritalin LA, Concerta
Dexmethylphenidate (Focalin®) – >6 yo Dextroamphetamine (Dexedrine®,Dextrostat®) >3yo Dextroamphetamine/Amphetamine (Adderall® &
Adderall XR) >3yo Desoxyephedrine/methamphetamine (Desoxyn ®)
>6yo Lisdexamfetamine (Vyvanse ®) >6yo
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HOW DO THEY WORK? Increase norepinephrine and dopamine
in the brain synapse May take __________ for the medication
to begin working Efficacy ranging from 70% to 96%
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DOSING SCHEDULE Dosing schedules differ because
duration of medications vary Immediate Release: Medication effects last
approximately 2-6 hours Usually 2-3 times/day dosing schedule
Intermediate Acting: Medication effects last approximately 6-8 hours Usually twice daily dosing
Sustained Release: Medication effects last approximately 8-12 hours Once daily dosing
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BENEFITS OF PSYCHOSTIMULANTS Increased attention span Decreased hyperactivity Improved impulse control Social benefits Emotional stability Improved motor skills (i.e., handwriting)
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ADVERSE EFFECTS
Common Side Effects Recommendation
Reduced appetite, weight loss
Stomach ache
Insomnia
Headache
Rebound Symptoms
Irritability/jitteriness
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ADVERSE EFFECTS Uncommon to rare
DysphoriaZombie-like stateTics or abnormal movementsHigh blood pressureHallucinations
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PSYCHOSTIMULANTS: PATIENT EDUCATION Empty, labeled bottle for school Keep out of sight & reach from other
children Take with food or milk Start on the weekend while parents able
to observe for any adverse effects Start once a day, then increase to twice
a day (typically breakfast & lunch) Swallow whole, DO NOT CHEW
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DRUG HOLIDAY Important to reassess treatment All children should be given a drug-free
trial every year Historically to allow “catch-up” growth Appropriate times for a drug holiday
WeekendsSummerNOT during holidays or start of the school
year
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PSYCHOSTIMULANT ABUSE POTENTIAL All psychostimulants are controlled substances Methylphenidate, dextromethylphenidate
amphetamine, dextroamphetamine, methamphetamine, and lisdexamfetamine are C-II
WARNING: POTENTIAL FOR ABUSEAmphetamines have a high potential for abuse.
Administration of amphetamines for prolonged periods of time may lead to drug dependence. Particular attention should be paid to the possibility of subjects obtaining amphetamines for non-therapeutic use or distribution to others and the drugs should be prescribed or dispensed sparingly.
Misuse of amphetamines may cause sudden death and serious cardiovascular adverse events. - June 2009
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NON-STIMULANTS Straterra®
(atomoxetine) Tenex®
(guanfacine) Wellbutrin®
(bupropion) Catapres® (clonidine) Risperdal®
(risperdone) Tricyclic
antidepressants desipramine nortriptyline
Zyprexa® (olanzapine)*
Geodon® (ziprasidone)*
Haldol® (haloperidol)*
Straterra® (atomoxetine)*
* = Short-term use (1-4 months)
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NON-STIMULANT – STRATERRA® (ATOMOXETINE) Increases norepinephrine (NOT
DOPAMINE) in the brain synapse Side Effects
Headache InsomniaDry mouthStomach upset
Takes _____________ for max response
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NON-STIMULANT:TENEX® (GUANFACINE) Decreases norepinephrine
May target impulsive behavior Takes ______ to begin working Side effects
**Sedation**Dry mouthLow blood pressure – WARNING: rebound
hypertension if abruptly stoppedSlow heart beatDizziness
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CONTROVERSIES SURROUNDING ADHD
Growth suppression w/ stimulant use ADHD = 2-fold greater risk of substance
abuse Cancer Helps student get straight A’s Decreases seizure threshold Causes Tourette syndrome Herbal/Alternative medications
Pedi-ActivePycnogenol
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ADHD EDUCATIONAL WEBSITES American Academy of Child and
Adolescent Psychiatry – www.aacap.org Attention Deficit Disorder Association –
http://www.add.org/ Parents Helping Parents: Family
Resource Center for Children with Special Needs – http://www.php.com
National Resource Center on ADHD – http://www.help4adhd.org/
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PRESCRIPTION DRUG ABUSE IN TEENS The nonmedical use of prescription drugs
ranks ___ among the most abused class of drugs by adolescents
_________ of teens do not see a great risk in trying prescription pain relievers without a prescription
Rationale behind abusePrescription medications are “safer” Readily availableLess shame attached to using themFewer side effectsLess consequences if parents catch them
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MOST COMMONLY ABUSED PRESCRIPTION MEDICATIONS1. Painkillers – Prescribed to treat pain
codeine, oxycodone, fentanyl, morphine Brand Names: OxyContin, Percocet,
Vicodin/Lortab, Duragesic
2. Depressants – Mainly prescribed to treat anxiety and sleep disorders
Benzodiazepines, barbituates, etc. Brand Names: Klonopin, Soma, Valium,
Xanax
3. Stimulants – Mainly prescribed to treat ADHD
Amphetamines, methylphenidate, etc. Brand Names: Adderall, Concerta, Dexedrine,
Ritalin
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SIGNS AND SYMPTOMS OF PRESCRIPTION DRUG ABUSE Constricted pupils Slurred speech Flushed skin Sweating Lack of appetite Mood swings Personality changes Excessive energy Drowsiness Forgetfulness
Acting secretive Losing interest in
personal appearance
Borrowing $/having extra cash
Skipping classes Poor performance in
school Prescription and
over-the-counter medication signs
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STRATEGIES FOR PREVENTION Open discussion Parent-focused information and training
Monitor teenagers internet use Watch for suspicious behaviorsKeep track of prescription and over-the-
counter medications Education within the school system Pharmacy involvement
Medication guides Age restrictions for purchasing frequently
abused over-the-counter medications Proper training of medical personnel
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ACKNOWLEDGEMENTS
Mark E. Schneiderhan, Pharm.D., BCPPAssociate ProfessorUniversity of Minnesota - DuluthDepartment of Pharmacy Practice and Pharmaceutical Sciences
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REFERENCES1. DiPiro, J. T., et al. Pharmacotherapy : a pathophysiologic
approach. New York : McGraw-Hill, Medical Pub. Division, (2002).
2. Howard, M. M., R. M. Weiler, and J. D. Haddox. "Development and Reliability of Items Measuring the Nonmedical use of Prescription Drugs for the Youth Risk Behavior Survey: Results from an Initial Pilot Test." The Journal of school health 79.11 (2009): 554-60.
3. Salmeron, P. A. "Childhood and Adolescent Attention-Deficit Hyperactivity Disorder: Diagnosis, Clinical Practice Guidelines, and Social Implications." Journal of the American Academy of Nurse Practitioners 21.9 (2009): 488-97.
4. www.CADCA.org5. www.theantidrug.com6. Schneiderhan, Pharm.D., BCPP, Mark E. "Attention Deficit
Hyperactivity Disorder: Pharmacotherapy." University of Minnesota, Duluth, Duluth, MN. 14 Jan. 2010. Lecture.
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?? QUESTIONS ??