Attention-Deficit Hyperactivity Disorder 07.16.2012

7/31/2019 Attention-Deficit Hyperactivity Disorder 07.16.2012

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What does ADHD look like?Jimmy, an 8-year-old boy is undergoing a psycho-educational evaluation. He is very distracted in hisclassroom and has trouble staying in his seat. Histeachers describe him as well-adjusted, with goodself-esteem. He is a good athlete, eats a nutritiousdiet, and has no problems with sleep. His full-scale IQis 87, but there is inconsistency in responses; Jimmyscored much better on the items that were

administered earlier in the session. Parents report thatat home, Jimmy is a good boy but very distractibleand has to be kept on task to get through simplechores or even a meal as a family.


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Cues to the diagnosis Distracted, trouble staying in his seat, BUT well

adjusted with good self-esteem

No mention of oppositional behavior oraggression Home life described as stable IQ testing inconsistency is not subject-specific

but pattern of doing better on earlierquestions

No overall global delay or across-the-boardlow IQ score

No mention of mood or anxiety symptoms


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Jimmy, continued

Parents and teachers administer aVanderbilt, which shows probable AD/HD

diagnosis. Parents would like to startmedication therapy in hopes of improvingJimmys school performance. You elect tostart a stimulant medication.


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Why is this topic confusing?Heres a list of medications used to treat AD/HD by generic name, courtesy ofStahls Prescribers Guide: Armodafinil Amphetamine (d)

Amphetamine (d,l) Atomoxetine Bupropion Chlorpromazine Clonidine Guanfacine Haloperidol Lisdexamfetamine

Methylphenidate (d) Methylphenidate (d,l) Modafinil Reboxitine


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Stimulants: Basic principles They work by blocking reuptake of norepinephrine

and dopamine (amphetamine also facilitatesrelease of these neurotransmitters).

2 basic flavors: Methylphenidate andAmphetamine

Some children respond better to one or the other(individual variation). Family hx can help guideyou where applicable.

All stimulants are schedule 2, with the attendant

hassles: Need signed paper Rx and individual 30-day prescriptions.

Side effects to monitor: Sleep, appetite, growth,and blood pressure.


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Stimulant dosing

Regular formulations: dose twice a day,once in the AM and once ~6 hours later

(usually given at school around lunch time) This is a hassle but often substantially less

costly

Do NOT give the 2nd dose after 2 PM (sleep

disturbance) Once daily (QAM) is much easier, but none of

these are generic yet.


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D,L-MethylphenidateAKA original methylphendate, Ritalin

Starting dose is 5 mg + 5 mg. Go up by 5-

10 mg/week and titrate to effect to maxof 40-60 mg/day. Dose duration 3-4 hours.

FDA approved for kids 6+ with ADHD

Cheapest regimen by far: $18-25 per

month.Older with tried and true data for

efficacy.


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Methylphenidate: longeracting forms

Older long-acting forms: MethylphenidateER/SR.

Duration of action: ~6 hours

Some children may be able to get by withone dose. Otherwise, same dosingschedule as immediate release.

A bit more costly, but generic ($30-40/month).


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Newer methylphenidateformulations

Concerta is a newer extended release form ofmethylphenidate with QAM dosing. Dosing is 18mg QAM to start then up by 9 mg weekly titratingto effect. Its NOT generic, so $220/month.

Focalin is d-methylphenidate(dexmethylphenidate), so twice as potent. It cansometimes work for non-responders to regularmethylphenidate. Dosing is 2.5 twice a day and

up in increments of 2.5 titrating to effect. Durationis about 4 hours, and its about $100/month.Focalin XR is QAM dosing but again, expensive at$215 per month.


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D,L-Amphetamine Usually goes by the name Mixed amphetamine

salts on the boards. You know it as Adderall. FDA approved for children ages 3(!)-12

XR formulation approved for 12-17 Same basic dosing as methylphenidate: Start with 5

and 5, titrate to effect. XR is QAM dosing. Max dose is30-40 mg/day

Sometimes works in patients with inadequateresponse to methylphenidate

Higher street value (and abuse potential?) thanmethylphenidate

Cost: Generic regular form is $80-100/month (?) andAdderall XR is $250-300/month.


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D-Amphetamine Also known as dextroamphetamine,

Dexedrine.

3-4 hour duration of action. Same dosing: 5+5,max 40, titrate to effect weekly (see, this iseasier than you thought, right?)

Cost=$25-$40/month generic Sustained-release has 8 hour duration and is

generic, $90-200/month. Duration is about 8

hours, many children can get by on one dose,but others need an extra immediate-releasedose in the afternoon.


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Lisdexamfetamine

Also known as Vyvanse. And no, I dont knowwhy the generic name has an F instead of a

ph. Prodrug of dextroamphetamine

Long duration 10-12 hrs with QAM dosing.Start 10 mg go up by 10/week to max of 70.

Low abuse potential as it is a prodrug of asustained-release formulation.

Cost: Around $200 per month.


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Back to our caseYou offer Jimmys parents a few different optionsand after weighing the risks and benefits, you andparents decide on long acting form of

dextroamphetamine. Jimmys attention andconcentration improve significantly, and he is doingbetter in school, but parents notice his appetitefalling off. After watching for a few months to see ifhe will outgrow this effect, a significant slow-down inweight gain is noted. Although you feel comfortablewatching for a bit longer (his linear growth hasntchanged), parents are really worried about this andwould like to get him off of the stimulant, but still treathis AD/HD to sustain improvement in schoolpeformance.


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So, now what do you do?

Luckily there are other options.

SNRI (Atomoxetine)

Alpha-2 agonists (clonidine, guanfacine)

Behavioral therapy. In fact, medication +therapy combination is the MOST effective forADHD.

Others medications are out there but arentFDA approved for AD/HD, kids, or both, andtherefore arent used very often.


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Atomoxetine You know this as Strattera Its an SNRI: Serotonin/Norepinephrine Reuptake Inhibitor. Thus, it

works similarly to the SNRI antidepressants, like venlafaxine. This is good to know because its similar to antidepressants in that it

will usually take longer to take effect than the stimulants, so mustbe sure trial is adequate.

Advantage: Can use where stimulants are contraindicated (growthproblems, HTN, cardiac history, others..)

Also doesnt tend to cause the problems with appetite suppressionand sleep disturbance that the stimulants can.

No known abuse potential Dosing: 0.5 mg/kg to start, then can go up to 1.2 mg/kg. Max is 80-

100 mg/day. Its QAM dosing. Not generic. Cost is $220-280 per month.


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Clonidine Binds to all 3 major alpha-2 receptor subtypes, creatively named A,

B, and C. Also binds the Imidazoline receptor (A dirty alpha2agonist)

As a result, it causes a good deal of sedation and hypotension

along with occasional dry mouth and constipation. Advantage: Kids with more aggression symptoms Dosing: Usually twice daily, and unlike stimulants its dosed at

bedtime (sedating). Can also be used p.r.n. foraggression/agitation. Typical range is 0.1-0.4 mg/day.

Kapvay is a newer extended-release formulation of clonidine that isFDA approved for children ages 6-17. It costs $170 a month.

Regular Clonidine is a very old drug (initially marketed for

hypertension) so no incentive to really trial/study it for ADHD, but stillused relatively frequently. Its on the $4 list.


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Guanfacine A cleaner alpha-2 agonist that binds only the alpha-2A

receptor. Thus, fewer side effects in terms of sedation and

hypotension though sedation is still common. Advantageous for aggression or when a stimulant iscontraindicated.

Similar to the situation with clonidine, Intuniv is a newer longacting form that is FDA approved for children 6-17. Youveprobably heard of itTheyre always running that ad withthe mom putting her son on the bus. Intuniv will run about$225 per monthregularguanfacine is on the $4 list.

Dosing- Usually start with 1 mg qhs, go no higher than 2 mgbid (for regular guanfacine, which you might also know asTenex).


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A few others (just for fun) Bupropion (AKA Wellbutrin, Zyban) is not FDA

approved but frequently used for ADHD off-label, more for adults than children.

Efficacious because its an NDRI so increasesthe same neurotransmitter activities thestimulants do.

Modafinil and its cousin Armodafinil (Provigiland Nuvigil, respectively) are very, veryoccasionally used for ADHD again more inadults. They act on the tuberomammarynucleus of the hypothalamus to promotewakefulness.


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Case conclusionAfter a discussion with parents, you elect to startAtomoxetine since they are insured and dont wantJimmy to be sedated. After a week parents callbecause they are frustrated that things haventturned around sooner. You remind them thatAtomoxetine requires a longer trial. 2 months later athis well child visit, Jimmy has improved in school butis still occasionally off-task; despite this, parentswould like Jimmy to stay on atomoxetine to avoidany more stimulant side-effects. You refer them to abehavioral therapist and he continues to improve.


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Sources1. Stahl, Stephen M. The Prescribers Guide: 4th

Edition. Cambridge University Press, 2011

2. Consumer Reports Health Evaluates: Best BuyDrugs for treating Attention-DeficitHyperactivity Disorder. 2012. Online pdf.http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdf

3. Pediatrics Review Education Program Self-Assessment. 2011. American Academy ofPediatrics.
http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdfhttp://www.consumerreports.org/health/resources/pdf/best-buy-drugs/ADHDFinal.pdf


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Attention-Deficit Hyperactivity Disorder 07.16.2012