Attention deficit hyperactivity disorder: overview of medications and implications

1. Attention deficit hyperactivity disorder:overview of medications and implications Sarah Schweiss, Pharm.D. Ambulatory Care Resident University of Minnesota & Duluth Clinic January 18th, 2010

2. 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.

3. General information • 3-7% school-age children • Diagnosis occurs as early as age 3 • Average 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)

4. Consequences of uncontrolled adhd • Relationship difficulties • Academic failure • Social isolation • Involvement with deviant peer groups • Significantly greater risk of developing: • ___________________________________ • Low self-esteem

5. 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 rate • Environmental exposures • Maternal smoke or alcohol use

6. 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

7. 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

8. 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

9. Treatment options • Pharmacological • Psychostimulants • Non-stimulants • Non-pharmacological • Behavioral Interventions • Counseling/Talk Therapy • Focused help with schoolwork • Training for parents

10. Non-pharmacological • Behavioral Interventions • Positive reinforcement • Time-out • Response Cost • Token economy • Parent training • Family therapy • Classroom interventions • Contingency management

11. Overview of medications

12. 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

13. 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%

14. 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

15. Benefits of psychostimulants • Increased attention span • Decreased hyperactivity • Improved impulse control • Social benefits • Emotional stability • Improved motor skills (i.e., handwriting)

16. Adverse effects

17. Adverse effects • Uncommon to rare • Dysphoria • Zombie-like state • Tics or abnormal movements • High blood pressure • Hallucinations

18. 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

19. 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 • Weekends • Summer • NOT during holidays or start of the school year

20. Psychostimulant abuse potential • All psychostimulants are controlled substances • Methylphenidate, dextromethylphenidate amphetamine, dextroamphetamine, methamphetamine, and lisdexamfetamine are C-II WARNING: POTENTIAL FOR ABUSE Amphetamines 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

21. 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)

22. Non-stimulant – Straterra® (atomoxetine) • Increases norepinephrine (NOT DOPAMINE) in the brain synapse • Side Effects • Headache • Insomnia • Dry mouth • Stomach upset • Takes _____________ for max response

23. Non-stimulant:Tenex® (guanfacine) • Decreases norepinephrine • May target impulsive behavior • Takes ______ to begin working • Side effects • **Sedation** • Dry mouth • Low blood pressure – WARNING: rebound hypertension if abruptly stopped • Slow heart beat • Dizziness

24. 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-Active • Pycnogenol

25. 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/

26. 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 abuse • Prescription medications are “safer” • Readily available • Less shame attached to using them • Fewer side effects • Less consequences if parents catch them

27. Most commonly abused prescription medications • Painkillers – Prescribed to treat pain • codeine, oxycodone, fentanyl, morphine • Brand Names: OxyContin, Percocet, Vicodin/Lortab, Duragesic • Depressants – Mainly prescribed to treat anxiety and sleep disorders • Benzodiazepines, barbituates, etc. • Brand Names: Klonopin, Soma, Valium, Xanax • Stimulants – Mainly prescribed to treat ADHD • Amphetamines, methylphenidate, etc. • Brand Names: Adderall, Concerta, Dexedrine, Ritalin

28. 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

30. Strategies for prevention • Open discussion • Parent-focused information and training • Monitor teenagers internet use • Watch for suspicious behaviors • Keep 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

31. acknowledgements Mark E. Schneiderhan, Pharm.D., BCPP Associate Professor University of Minnesota - Duluth Department of Pharmacy Practice and Pharmaceutical Sciences

32. References • DiPiro, J. T., et al. Pharmacotherapy : a pathophysiologic approach.  New York : McGraw-Hill, Medical Pub. Division, (2002). • 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. • 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. • www.CADCA.org • www.theantidrug.com • Schneiderhan, Pharm.D., BCPP, Mark E. "Attention Deficit Hyperactivity Disorder: Pharmacotherapy." University of Minnesota, Duluth, Duluth, MN. 14 Jan. 2010. Lecture.

33. ?? questions ??