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Treatment of Attention Deficit/Hyperactivity Disorder

Treatment of Attention Deficit/Hyperactivity Disorder. Lyn Billington Deputy Pharmacy Manager Latrobe Regional Hospital. ADHD. Symptoms are Persistent inattention-becomes a problem at school Hyperactivity - often the most prominent feature Impulsivity

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Treatment of Attention Deficit/Hyperactivity Disorder

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  1. Treatment of Attention Deficit/Hyperactivity Disorder Lyn Billington Deputy Pharmacy Manager Latrobe Regional Hospital Lyn Billington June 2006

  2. ADHD • Symptoms are • Persistent inattention-becomes a problem at school • Hyperactivity - often the most prominent feature • Impulsivity • Accurate diagnosis essential before commencing treatment Lyn Billington June 2006

  3. Course of the condition • In most cases - spontaneous remission • Late adolescence about 50% still show the full syndrome • This falls to about 1/3 by early 20’s • Late 20’s 10% still fully affected. Lyn Billington June 2006

  4. Complications • Academic failure • Truancy • Misconduct • In adult years - more likely to have antisocial personality disorder & substance misuse Lyn Billington June 2006

  5. Etiology • Some studies show genetic causes • Most appear idiopathic • Small number may be related to lead encephalopathy or rare, inherited resistance to thyroid hormones Lyn Billington June 2006

  6. Differential diagnosis • Chaotic upbringing • Foetal alcohol syndrome • Mental retardation • Autism • Children with mania • Children with agitated depression ( however have other symptoms not typical of ADHD) • Children with schizophrenia ( Have other symptoms which rules out ADHD) • Difficult to diagnose in adults Lyn Billington June 2006

  7. Treatment • Medication is not the only treatment. • Parent education & school support are of major importance • Psychostimulants can reduce symptoms Lyn Billington June 2006

  8. Rationale for drug use • Symptom relief • To reduce function impairment in daily life (home, school, peer) • Minimise long term adverse effects on academic performance • Minimise impact on social and emotional development Lyn Billington June 2006

  9. Medication used • Short acting psychostimulants • Dexamphetamine • Methylphenidate Up to 90 % will respond ( to one or the other) Effect is often immediate improvement in impulsive behaviour and task completion Lyn Billington June 2006

  10. Mode of action and Childrens doses • Thought to enhance dopaminergic and noradrenergic transmission • Dose - dexamphetamine2.5-10mg daily increasing by 2.5-5mg/day each week to a maximum of 30mg per day • Dose - methylphenidate 5-10mg/day in two doses increasing by 5-10mg/day each week to a maximum of 40mg /day Lyn Billington June 2006

  11. Short acting stimulants • Rapid absorption – peak response 1-3 hours • Dose titrated according to response • Need to be given more than once daily. • Should not be given after early afternoon to minimise sleep disturbance Lyn Billington June 2006

  12. Methylphenidate also available as • Ritalin LA ®20mg,30mg & 40mg • Concerta®18mg, 36mg & 54mg • Use conventional tables first to establish dose then swap to the long acting formulation • Advantage - once daily dose Lyn Billington June 2006

  13. Adverse effects • Headache • Abdominal discomfort • Appetite suppression • Insomnia • Minor effect on growth – but need to monitor weight and height Lyn Billington June 2006

  14. Atomoxetine (Strattera ®) • May be a useful alternative for children who do not respond to stimulants • Indicated for children > 6 years old • May be useful where diversion of medication is a problem • Monitor liver function Lyn Billington June 2006

  15. Mode of action and dose • Selectively inhibits presynaptic noradrenaline reuptake in the CNS • Dose: < 70 kg Initially 0.5mg/kg/day for 3 days, increasing to 1.2mg/kg/day Lyn Billington June 2006

  16. Adverse effects • Nausea • Vomiting • abdominal pain • decreased appetite • irritability • temper tantrums • Rare- suicidal thoughts and behaviors - monitor Lyn Billington June 2006

  17. Other therapies • Tricyclic antidepressants – not approved for ADHD in Australia. • If used start low - go slow • ECG before commencement (cardiotoxicity) • Consider Imipramine or Nortriptylline Lyn Billington June 2006

  18. Clonidine • No reliable evidence of effectiveness in ADHD • May be useful in children with ADHD who are aggressive and where sleep disturbance is a problem Lyn Billington June 2006

  19. Disadvantages of clonidine • Several weeks for clinical effect • Does not seem to affect inattention symptoms • Risk of causing depression • Monitor BP and pulse during therapy • Avoid sudden cessation Lyn Billington June 2006

  20. Note • Pharmacological treatment for children and adolescents difficult because of the lack of clinical trials in this age group. • Most information extrapolated from adult trials • Care is needed. Lyn Billington June 2006

  21. References • Therapeutic Guidelines - Psychotropic 2003 • The Maudsley 2005-2006 Prescribing Guidelines • Moore & Jefferson Handbook of Medical Psychiatry, 2nd ed • AMH 2006 • Jacobson: Psychiatric Secrets, 2nd ed Lyn Billington June 2006

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