It Ain t Always About Pain. MNA Pharmacology Summit Tupelo, Mississippi Sueanne Davidson DNP FNP-BC

Transcription

1 It Ain t Always About Pain MNA Pharmacology Summit Tupelo, Mississippi Sueanne Davidson DNP FNP-BC

2 ADHD

3 ADHD ADD, ADHD, Hyperkinetic disorder - It gets confusing Condition has been known for over 100 years but different labels have been used In 1994, the DSM changed the name from ADD (Attention Deficit Disorder) to ADHD because of advances in research 2013 DSM updated diagnostic criteria

4 Types of ADHD Inattentive Hyperactive/Impulsive Combined (Hyperactive/Impulsive and Inattentive) ** Most common

5 ADHD In children hyperactivity usually predominates Adolescents often display oppositional and restless behavior Adults have more problems with attention

6 Overview Complex disorder of higher brain functioning Symptoms- Inattention, Impulsivity and Hyperactivity Must occur before age 12 Must continue at least 6 months Must cause significant impairment in social, academic or occupational functioning Must create problems in multiple settings (home and school) ** need two different informants

7 ADHD Serious Public Health Problem Large estimated prevalence- 12 million U.S adults ages have ADHD (CDC 2010) School age children 11% affected with 75% continuing to exhibit symptoms into adulthood Significant impairment- school performance, socialization, and occupational functioning Chronic condition requiring long term intervention

8 Screening Tools/Rating Scales NICHQ Vanderbilt Assessment Scale (Parent and teacher informant) ages 6-12 SNAP-IV Teacher and Parent Rating Scale- ages 6-18 Wender Utah Rating Scale - Adults

9 ADHD American Academy of Family Physicians survey estimated that 1/25 adults in US have ADHD Adults with ADHD had it in childhood regardless if diagnosis was made Adults with ADHD consistently have problems with interpersonal relationships/employment

10 Symptoms of ADHD in Adults Impatient/problems with driving Easily bored Short attention span are you listening to what I said Inner restlessness of thought and activity Fidgety Forgetful, losing things Chronically late/poor time managers Procrastinating, trouble starting a task Difficulty getting organized/managing money Many ideas at the same time Easily distracted/ Impulsive decisions/moody

11 Heredity Family Aggregation of Disorder Parent is ADHD 20-54% offspring will have ADHD 25-35% of Siblings 78-92% of Identical Twins 15-20% of Mothers 25-30% of Fathers Variation in ADHD symptoms is genetically influenced-

12 Heredity Heredity not a factor? These contribute to risk of ADHD to varying degrees Difficult pregnancies/deliveries/low birth weight Prefrontal lobe injury Prenatal ETOH/Tobacco use/abuse High lead levels Not supported by research- excessive TV viewing, poor parenting, family chaos or poverty

13 Overview ADHD Complex disorder of higher brain functioninginattention, motor over-activity and difficulty inhibiting behaviors Symptoms- Inattention, Impulsivity and hyperactivity Must occur before age 12 Continue at least 6 months Create problems in multiple settings

14 Types of ADHD Inattentive

15 ADHD Inattentive Type Symptoms for six months Lack of attention to detail Poor listener Failure to follow through tasks Lack of sustained attention Disorganized Loses things necessary Easily distracted Forgetful

16 Hyperactive/Impulsive Type

17 Hyperactive/Impulsive Type Hyperactive/Impulsive On the go Inappropriate running and/or climbing Leaves seat often Fidget/Squirms Difficulty with quiet activities Talks excessively Blurts answers Intrusive Can t wait turn

18 Disorders that may Accompany ADHD Learning Disabilities (25-35%) Anxiety or Mood Disorders (33%) Bipolar Disorder Tourette Syndrome (tics) rare Oppositional Defiant Disorder (33%) Conduct Disorder (20-40%)

19 Other ADHD like conditions Chronic Stress Psychological disorders- Depression/Anxiety Substance Abuse

20 Key Public Health Concerns Safety of Pharmacological interventionshealth risk and benefits Effectiveness of current interventions to reduce impairment associated with ADHD Access to diagnosis and appropriate interventions for individuals and families affected by disorder***

21 ADHD Prevalence

22 Increased identification and treatment Greater media interest Heightened consumer awareness Availability of effective treatments Less social stigma Understanding ADHD as biochemical disorder and not an out of control child disorder

23 Brain scans reveal ADHD differences Functional Imaging- views brain while it works Static imaging reveals Lobe reduction in ADHD individuals

24 ADHD Medication Stimulants Nonstimulants

25 ADHD Medication Current guidelines American Academy of Child and Adolescent Psychiatry- Use long acting Initiation of drug therapy Dosing Schedule

26 5 P s of Drug delivery system Pills- IR Methylphenidate and Amphetamines Pump- Like tube of toothpaste (Concerta) Pellet- Dissolve at different times Patch- Dermal delivery system (Daytrana) Prodrug- Amphetamine (Vyvance) nonabusable

27 ADHD Medications Stimulants- Methylphenidates and Amphetamines Nonstimulants- Nor epinephrine reuptake inhibitors, Alpha agonists, Trycyclic Antidepressants

28 Stimulants Pharmacodynamics- Dopamine agonist indirectly release and prevent reuptake of Dopamine, Nor Epinephrine and Serotonin in presynaptic nerve endings.

29 Stimulant effect on Neurotransmitters

30 What s the deal with MAO and MAOI s Monoamine Oxidase A- enzyme responsible for breakdown of Dopamine, Nor Epinephrine and Serotonin Monoamine Oxidase B- enzyme responsible for breakdown of Dopamine(more potent than MAO- A) and phenyl ethylamine (PEA)- has actions similar to amphetamines itself (thought to be involved with feelings of lust, confidence, obsession and sexuality Amphetamines in high doses can inhibit these enzymes leading to increased Dopamine..ect.

31 Genes and ADHD Dopamine transporter (DAT1) gene- thought to be involved with Dopamine and Norepinephrine transporters DBH gene- thought to create a chemical that converts Dopamine and Norepinephrine Dopamine receptor D4 (DRD4) gene- associated with dopamine receptors in the brain and sensitivity to dopamine

32 Stimulants Pharmacodynamics Dopamine,Norepinephrine and Serotonin nerve fibers connect these regions of the brain to the prefrontal cortex to coordinate thinking, feeling, and responding to external stimuli. Stimulants increase these neurotransmitters therefore improving communication

33 Mesolimbic Reward Pathway

34 Stimulants Pharmacokinetics- Rapid onset of action. Plasma levels peak 1-4 hours, half life 1-12 hours depending on immediate/extended release Metabolized in Liver/Excreted In Kidney

35 Stimulants Pharmacotherapeutics- Precautions/Contraindications- Heart, MAOI s, Pregnancy category C/Breastfeeding, glaucoma, drug interactions ( Coumadin & anticonvulsants) Adverse reactions- Insomnia, weight loss growth retardation***, irritability, blurred vision, headaches and paradoxical drowsiness

36 Methylphenidate Instant Release-Regular tablets- Ritalin, Methylin (chew tabs or solution). Available 5, 10, 20mg tablets* last 2-5 hours. Problem with peaks and valleys. Dosing inconvenience Adults mg/d in2-3 divided doses-max 60mg/d in divided doses Children > 6yrs 5mg bid before breakfast/lunch. Max 60mg/day in divided doses

37 Methylphenidate Intermediate acting extended release tablets- ( Ritalin SR, Methylin ER, Metadate ER, Metadate CD ) Ritalin SR- 20mg 1x/day in am lasts up to 8 hours(duration of effect corresponds to total daily Ritalin IR dose). Advantage- Instant release converted to sustained release by keeping same dosage, convenient and less peak/valley Disadvantage- takes 2-3 hrs before peak effect

38 Methylphenidate Long acting extended release- Capsule (Ritalin LA), Tablet (Concerta) Ritalin LA- 20, 30, 40 mg ER capsule 1x/day am Can open capsule and sprinkle med in applesauce Advantage- Provides ½ IR and ½ ER beads, (school/work issue solved) lasts up to 8 hrs, less insomnia and no conversion

39 Methylphenidate Concerta- 18mg 1x/day children & adolescents, 18-36mg 1x/day adults. Conversion 5mg IR BID/TID = 18mg q am 10mg IR BID/TID= 36mg q am 15mg IR BID/TID= 54mg q am 20mg IR BID/TID = 72mg q am Disadvantage-Do not crush, chew or divide Concerta- 22% IR, 78% ER over hours provides smooth drug release

40 Methylphenidate Quillivant - Liquid 20% IR, 80% ER Reconstituted = 25mg/5ml Ages 6 and greater- 20mg/day in am max is 60mg/day May give with or without food Onset of action within 45 minutes and lasts 12 hours

41 Methylphenidate Daytrana cm- reaches peak concentration 2hrs 12.5= 10mg delivered over 9 hrs Patches provide a much lower first pass effect Use if difficulty swallowing meds Alternate sites Hips and remove after 9hours Dermal Irritant

42 Abuse Potential High potential for abuse and addiction Crushed, snorted or injected = effect almost identical to cocaine One of top ten stolen Rx drugs in US Street names- Kiddie coke, Vitamin R and the R ball

43 Pearls Methylphenidates Ritalin IR- Abuse potential increases Ritalin = Abdominal pain in children Generic form is Cheap Concerta with smoother effect than Adderall XR Methylphenidate has best track record

44 Dexmethylphenidates Focalin, Dexedrine, Focalin XR, Vyvance, Focalin tablets- usually BID dosing Peds mg/day (start 2.5mgBID) Adults mg/day 4-6 hour duration of effect Can titrate 2.5mg/week for peds and 10mg/week for adults

45 Dexmethylphenidates Focalin XR- dose 1x/day in am lasts 12 hours Available 5mg, 10, 15, 20, 25, 30, 35, 40mg capsules Max 30mg/day peds, 40mg/day adults New to Methylphenidates- 5mg/day peds, 10mg/day adults On Methylphenidates- initiate with ½ current total daily dose Effects last up to 12 hours/2 distinct peaks 4 hours apart

46 Dexmethylphenidates Vyvance- 1x/day in am (lasts hours) Comes in 20mg, 30, 40, 50, 60 and 70mg Capsules Dosing Adults and Peds- 30mg q am Can titrate increments 10mg/week Max dose 70mg/day Prodrug- inactive requires vivo conversion

47 Pearls Dexmethylphenidates Propensity for abuse much less than Ritalin Take with or without food Can sprinkle Focalin XR and Vyvance over applesauce /dissolve Vyvance in water V yvance first non- abusable amphetamine ever invented Lack of worsening sleep quality with Vyvance Vyvance- Longest acting stimulant available**

48 Mixed Amphetamine Salts Adderall IR, Adderall XR Capsule Adderall IR tablet- 5mg, 7.5, 10, 12.5, 15, 20, and 30mg 5mg/day or BID- increase by 5mg/weekly with max 40mg/day Dose in am and additional dose at intervals 4-6hrs

49 Mixed Amphetamine Salts Adderall XR Capsules- 5mg, 10, 15, 20, 25, 30mg ( 2 beads- ½ immediately ½ 4 hrs later) Children- 10mg q am titrate up 5-10mg/week max dose 30mg/day Adolescents-10mg/day may increase to 20mg/day after 1 week Adults- 20mg/day adjust weekly- usual 60mg/day Can change from IR dose to XR dose at the same total daily dose taken once daily

50 Pearls Mixed Amphetamine Salts Studies suggest Adderall slightly more potent and longer period of efficacy especially at lower doses than Methylphenidates See more weight loss with Adderall than methylphenidate or atomoxetine Can take with or without food May see more aggression with Adderall in children and teens Watch Adderall with Ultram-Seizures/SSRI s

51 Non stimulant Strattera Pharmacodynamics /MOA- Selective inhibition of the pre-synaptic Nor epinephrine Transporters Pharmacokinetics Well absorbed. Maximum plasma concentration 1-2 hrs after dosing. Up to 24 hour symptom relief Metabolized by liver/excreted in kidney

52 Non stimulants Strattera- (Atomoxetine) 10mg, 18, 25, 40, 60, 80, 100mg First line treatment for adults with ADHD Children/ Teens < 154 lbs mg/lb. body weight- Increase to 0.6mg/lb. body weight- max 1.4mg/kg Adults > 154 lbs- 40mg q day or 20mg BID *May take 6-8 weeks to see effects Smooth delivery Side effects- Dry mouth, headache, nausea, decreased appetite, sexual dysfunction

53 Pearls Strattera Unique Medicaid approval < 12 yrs old* Less abuse potential than stimulants Offers 24 hr coverage Preferred over Amphetamines in patients with Psychiatric disorders & ADHD Take with or without food Can use with TICs as does not effect Dopamine Can refill over the phone- non scheduled drug Good choice if Depression or Anxiety with ADHD

54 Pearls Strattera Black Box warning- Children/Teens increase risk of suicidal thoughts or actions Can d/c without tapering in Adults Long term use has been shown to affect memory Monitor liver- may increase enzymes Swallow capsule whole do not open, crush/chew $$$$ Under patent till 2017 Headache and nausea most frequent complaint

55 Non stimulant Tenex/Intuniv Pharmacodynamics/MOA- Alpha 2 Adrenergic Agonist Stimulates alpha 2 Nor epinephrine receptors concentrated heavily in Prefrontal cortex Affecting post-synaptic alpha 2 receptors Pharmacokinetics- Well absorbed from GI Significant first pass effect

56 Non Stimulant Tenex/ Intuniv Pharmacotherapeutics- Contraindicated in recent MI, Coronary Insufficiency or Renal Impairment Side Effects- low BP, HR, Fainting, dizziness Sleepiness**, and nausea Guanfacine IR (Tenex)- safety and efficacy <12 not established. Take at HS Guanfacine ER (Intuniv) 1mg, 2, 3, 4mg- Max 4mg/day mg/kg/Day Take at am

57 Pearls Intuniv Not a scheduled drug/category B Avoid high fat meal- will raise blood levels Do not crush pill Mainly used as adjunctive therapy to treat Insomnia and behavioral problems/anger issues Taper dose decrements of 1mg q 3-7 days

58 Antidepressants TCA Antidepressants - used as both primary and adjunctive therapy in children/adults who fail response to stimulants. Desipramine and Nortryptyline affects Nor epinephrine reuptake Avoid in Cardiac Disease/Conduction abnormalities

59 Stimulants How do I prescribe DEA Schedule II drug/ Refills prohibited Pharmacy requires new original prescription every month DEA office of Diversion Control Code of Federal Regulations Section

60 Code of Federal Regulations Section Schedule II refilling prohibited May issue multiple Rx. authorizing patient to receive up to 90 day supply Each Rx for legitimate medical purpose by practitioner acting in usual course of practice Written instructions on each Rx. as to earliest date Pharmacist may fill Provider concludes giving multiple Rx. does not create undue risk of diversion/abuse Issuing multiple Rx. is permissible under state law Use sound medical judgment in determining how often to see patient when 90 day Rx. given

61 Bureau of Narcotics suggestions for Nurse Practitioners Apply for access to the Mississippi Prescription Monitoring Program (PMP) Be familiar with Practitoner s Manual on DEA Diversion Control website