2013 Virtual AD/HD Conference 1

Transcription

1 Medication for & Coexisting Conditions Part 2 Dr. Kenny Handelman Child, Adolescent & Adult Psychiatrist Halton Healthcare Adjunct Professor of Psychiatry, University of Western Ontario Overview: Overview of Symptoms Treatment Treatment Targets First Line Medications Stimulants Non-stimulants Treatment Algorithms Second/Third Line Medications Treating with Coexisting (comorbid) Conditions Generations of Medication Short Actings Long Actings Advantages of long acting medications Generic Medicines Be Careful! Generic Concerta Generic Strattera Generic Adderall/Adderall XR others... Issues: Is it the same? % of blood concentration They DO NOT account for the time release mechanism Can you control what you get? Not necessarily Insurance coverage, What Pharmacy carries How the doctor writes the Rx: NO SUBSTITUTION Abuse /Diversion Potential Warnings Discussion: Cardiovascular (Suicide Risk) Psychosis/Agitation 2013 Virtual AD/HD Conference 1

2 Buproprion (Wellbutrin) An Antidepressant Also marketed as a smoking cessation medication (Zyban) Works predominantly on dopamine Some studies that it helps adults with Doses up to 400 mg/day Careful risk of seizures at above 450 mg/day Canadian context max recommended of 300 mg/day Seizure risk: With overdose Increased risk if have an eating disorder anorexia or bulimia Buproprion cont d Side effects: Can include dopamine type of side effects i.e. decrease sleep, increased energy (can lead to agitation ), mildly lower appetite Dosing: generally in 2013, doctors use the XL formulation Wellbutrin XL 150 mg/day Consider titrating up to 300 mg/day Other considerations: A good option if there is depression + May be a good option if someone is also working on smoking cessation treatment Desipramine Tricyclic Antidepressant Data that it works in Bad side effect profile Including: Anti-cholinergic side effects: dry mouth, blurry vision, constipation, urinary retention, etc. ***Very dangerous in overdose*** Risk of cardiac arrhythmias need cardiac monitoring I recommend only using if working with a specialist with experience with TCA s Modafinil (Provigil, Allertec) Indicated for the treatment of fatigue related to: Narcolepsy, Shift work disorder, fatigue with Obstructive Sleep Apnea despite proper use of CPAP Several studies showing benefit in child/teen, but concerns with dermatological toxicity Small trial in adults with Not FDA approved for Dose: 200 mg/day Common Side effects: insomnia, headache, nausea, nervousness and hypertension Side effects in kids/teens: Decreased appetite, weight loss and serious dermatological reactions Many CYP isoenzyme drug interactions be careful here Atypical Antipsychotics/Second Generation Antipsychotics Include: (listed alphabetically) Aripiprazole Abilify Olanzapine Zyprexa Quetiapine Seroquel Risperidone Risperdal Ziprazidone Geodon Are used for: Schizophrenia Bipolar Mania Bipolar - depression Treatment refractory depression Autism spectrum agitation/aggression Conduct in youth Oppositional Defiant in youth? Do Atypicals have a role in? Not unless there is a comorbidity that merits use Each has side effects As these are mood stabilizers what about people with severe agitation/poor emotional control and? Be cautious of metabolic side effects Risk of elevating cholesterol Risk of elevating Triglycerides Risk of raising blood sugar (diabetes risk) 2013 Virtual AD/HD Conference 2

3 Guanfacine Alpha 2 agonist Guanfacine XR = Intuniv Approved for mono-therapy or combination therapy (with a stimulant) in 6-17 years old No clear data for adult May lower BP Be careful with rebound hypertension Clonidine Alpha 2 agonist Clonidine XR = Kapvay Approved for mono-therapy or combination therapy (with a stimulant) in 6-17 years old No clear data for adult May lower BP Be careful with rebound hypertension ***Sedation is more likely to be an issue than with Guanfacine NCS: If you have X the prevalence of is. and Co-Existing Conditions 9.4% 22.6% 21.2% Major Depression Chronic Dysthymia Bipolar NCS: If you have X the prevalence of is. National Comorbidity Survey Replication: Mood s in Adult N= % 11.9% 11.1% Adult Major Depression 18.6% Dysthymia 12.8% Bipolar 19.4% Any Mood 38.3% Active Substance Abuse Generalized Anxiety Panic 2013 Virtual AD/HD Conference 3

4 N=3199 National Comorbidity Survey Replication: Anxiety s in Adult Adult Generalized Anxiety 8% Any Anxiety 47% Panic 8.9% PTSD 11.9% Agoraphobia 4% Obsessivecompulsive 2.7% Social Phobia 29.3% Case Presentation: Diagnostic Prioritization for Pharmacotherapy Alcohol and substance abuse Mood disorders Bipolar and MDD Anxiety disorders Obsessive-compulsive disorder, generalized anxiety disorder, panic Order of treatment also considers the severity of the concurrent disorders. Goodman D. Treatment and assessment of in adults. In: Biederman J, ed. Across the Life Span: From Research to Clinical Practice An Evidence-Based Understanding. Hasbrouck Heights, NJ: Veritas Institute for Medical Education, Inc Which To Treat First? + Anxiety Texas Algorithm Assessment/ Family Consultation/ Treatment Planning Non-med treatments Atomoxetine Both and Anxiety improve Methylphenidate or Amphetamine No response or Anxiety Continuation No response or Anxiety improves/ not Anxiety Methylphenidate or Amphetamine Atomoxetine Add SSRI Pliszka et al. J Am Acad Child Adolesc Psychiatry 2006;45: Depression and Bipolar and Bond et al, 2012, Annals of Clinical Psychiatry;24(1):23-37; The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid attention-deficit/hyperactivity disorder Bond et al, 2012, Annals of Clinical Psychiatry;24(1):23-37; The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid attention-deficit/hyperactivity disorder 2013 Virtual AD/HD Conference 4

5 Take Away Messages: Work with your healthcare provider to find the best treatment for yourself (or your loved one) Keep medication treatment in context i.e. therapy, coaching, lifestyle efforts (sleep, exercise, diet, supplements can make a big difference too!) Aim for great symptom control Watch for partial response aim to optimize Think of the different medication options first line and beyond Ensure your treatment is address co-existing conditions as well Questions? ***Use this information to help to advocate for the best treatment you can get*** 2013 Virtual AD/HD Conference 5