Attention deficit hyperactivity disorder: overview of medications and implications

ATTENTION DEFICIT HYPERACTIVITY

DISORDER:OVERVIEW OF

MEDICATIONS AND IMPLICATIONS

Sarah Schweiss, Pharm.D.Ambulatory Care Resident

University of Minnesota & Duluth ClinicJanuary 18th, 2010

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.

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)

CONSEQUENCES OF UNCONTROLLED ADHD Relationship difficulties Academic failure Social isolation Involvement with deviant peer groups Significantly greater risk of developing:

___________________________________ Low self-esteem

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

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

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

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

TREATMENT OPTIONS Pharmacological

PsychostimulantsNon-stimulants

Non-pharmacologicalBehavioral InterventionsCounseling/Talk TherapyFocused help with schoolworkTraining for parents

NON-PHARMACOLOGICAL Behavioral Interventions

Positive reinforcementTime-outResponse CostToken economy

Parent training Family therapy Classroom interventions Contingency management

OVERVIEW OF MEDICATIONS

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

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%

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

BENEFITS OF PSYCHOSTIMULANTS Increased attention span Decreased hyperactivity Improved impulse control Social benefits Emotional stability Improved motor skills (i.e., handwriting)

ADVERSE EFFECTSCommon Side Effects Recommendation

Reduced appetite, weight loss

Stomach ache

Insomnia

Headache

Rebound Symptoms

Irritability/jitteriness

ADVERSE EFFECTS Uncommon to rare

DysphoriaZombie-like stateTics or abnormal movementsHigh blood pressureHallucinations

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

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

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

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)

NON-STIMULANT – STRATERRA® (ATOMOXETINE) Increases norepinephrine (NOT

DOPAMINE) in the brain synapse Side Effects

Headache InsomniaDry mouthStomach upset

Takes _____________ for max response

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

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

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/

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

MOST COMMONLY ABUSED PRESCRIPTION MEDICATIONS1. Painkillers – Prescribed to treat pain

codeine, oxycodone, fentanyl, morphine Brand Names: OxyContin, Percocet,

Vicodin/Lortab, Duragesic2. 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

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

STRATEGIES FOR PREVENTION Open discussion Parent-focused information and training

Monitor teenagers internet useWatch for suspicious behaviorsKeep track of prescription and over-the-

counter medications Education within the school system Pharmacy involvement

Medication guidesAge restrictions for purchasing frequently

abused over-the-counter medicationsProper training of medical personnel

ACKNOWLEDGEMENTS

Mark E. Schneiderhan, Pharm.D., BCPPAssociate ProfessorUniversity of Minnesota - DuluthDepartment of Pharmacy Practice and Pharmaceutical Sciences

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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