AD/HD Across the Lifespan. Michael F. Finkel MD, FAAN. Department of Neurology. Medical and Surgical Specialists Naples, Florida.

Transcription

1 AD/HD Across the Lifespan Michael F. Finkel MD, FAAN. Department of Neurology. Medical and Surgical Specialists Naples, Florida.

2 Worldwide Prevalence of ADHD Is 3% to 7% Studies of ADHD prevalence United States (Shaffer et al 1996) Tennessee (Wolraich et al 1996) Mannheim, Germany (Esser et al 1990) London, England (Esser et al 1990) Germany (Baumgaertel et al 1995) Iowa (Lindgren et al 1990) Pittsburgh, Pa (Costello et al 1988) US inner city (Newcorn et al 1989) Ontario (Szatmari et al 1989) New Zealand (Anderson et al 1997) Goldman, et al. JAMA.1998;279: Prevalence of ADHD (%) in school-age children

3 Tip of the Iceberg Issues With ADHD Related Life impairment for the Child / Adolescent School Functioning Social Functioning Home Functioning (mornings, evenings, bedtime)

4 ADHD: An Enduring Disorder During School Before School Continuous ADHD Symptoms After School Evening/ Bedtime

5 ADHD: A Continuous Disorder Impairments Family School Social Self Symptoms Hyperactivity Impulsivity Interferes with routines at dinner, bedtime Destructive Runs around room, disturbs other children Blurts out answers Other kids don t invite to social events Doesn t wait turn Feels rejected Low self esteem Frequently gets into trouble Inattention Parent reports inattention; homework is a nightmare Gets behind in school work Kids report cheating in games Thinks of self as unintelligent

6 ADHD Is Associated with Increased Medical Costs Medical cost (1995 national avg dollars) $4500 $4000 $3500 $3000 $2500 $2000 $1500 $1000 $500 $0 $4306 ADHD $1944 Non-ADHD Overall medical costs P<0.001 % total cohort ADHD (n=309) Non-ADHD (n=3810) 26% 18% Inpatient hospital admission 41% 33% Outpatient hospital admission 81% 74% Emergency admission N=4119 P<0.001 P<0.006 P< to 1995 Leibson CL, et al. JAMA. 2001;285:60-66.

7 VYVANSE (LISDEXAMFETAMINE) Developed to reduce diversion, abuse, and addiction. Protodrug : Lysine molecule attached to dexamphetamine must be cleave to activate the drug in the GI tract. Enzymatic activation is rate related and this slower process allows effect to last up to 12 hours.

8 VYVANSE (LISDEXAMFETAMINE) Dose Equivalents (per SHIRE) Adderall XR 10 mg = Vyvanse 30 mg Adderall XR 20 mg = Vyvanse 50 mg Adderall XR 30 mg = Vyvanse 70 mg

9 Increased Traffic Violations and Motor Vehicle Accidents in Adolescents and Adults with ADHD P=0.004 ADHD n=25 Control n=23 P=0.07 Subjects (%) P=0.07 P= Traffic violations Speeding violations Drunk driving License suspended Driver-caused accidents Barkley RA, et al. Pediatrics. 1996;98:

10 Earlier Initiation of Smoking with ADHD Smoking probability ADHD n=128 Control n= to 17-year-old boys P< Age Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44.

11 Increased Lifetime Substance Abuse in Untreated Adults with ADHD Lifetime rate of substance abuse in referred ADHD adults (%) ADHD (n=239) 55% Control (n=268) P< % 0 Biederman, et al. Biol Psychiatry. 1998;44:

12 Pharmacotherapy Significantly Reduces Substance Abuse in Adults with ADHD 40 Effect of pharmacotherapy 32% % of study population % P< % 0 Unmedicated ADHD (n=19) Medicated ADHD (n=56) Control (N=137) Biederman J, et al. Pediatrics. 1999;104:e20-e24.

13 Formulating the complete diagnosis

14 Associated Disorders Only in 30% of cases is ADHD presented in a unique form. The remaining 70% could present other psychiatric disorders of critical prognosis. Anxiety disorders (difficulty in responding adecuately to the demands of the surroundings) 25% 40-60% Conduct disorders (agressive behaviour that often leads to minor offenses) 30% 40-70% Mood disorders (depression) Learning disabilities (high rate of grade retention and academic failure)

15 Does the child have specific attentional disabilities? AD/HD Hyperactive Impulsive AD/HD Inattentive AD/HD Combined

16 Does the child have specific learning disabilities? In symbol recognition? In production and/or understanding of language? In motor coordination?

17 Does The Child Have Comorbid Mental Health Disorders? Mood Disorders Internalizing (Anxiety) Disorders Obsessive Compulsive Disorders Behavioral Disorders

18 Does The Child Have Comorbid Medical Disorders? Migraines Epilepsy Tics Limb Movement Disorders Enuresis Stutter

19 Is The Family Under Pressure? Financial Crisis Medical Illness And Death Parental Relationship Problems Substance Abuse

20 Arrange The Diagnosis Grouping To Formulate The Treatment Plan Diagnoses Relating To Attentional Disabilities Diagnoses Relating To Learning Disabilities Diagnoses Relating To Comorbid Mental Health Orders Diagnoses Relating To Comorbid Medical Conditions Family Stressors That Will Affect Treatment

21 Mechanism of Action

22 Schematic diagram of Concerta TM use of OROS technology g g gy

23 Ritalin LA: Extended-release Delivery via SODAS Technology SODAS is a trademark of Elan Corporation, Plc

24 Ritalin LA: Optimized PK Profile for Rapid Onset and School-day Duration Same rapid onset as Ritalin 50/50 bimodal release mimics Ritalin BID dosing Times displayed in clocks are for illustrative purposes only. Approaching pre-dose levels. Data on file.

25 METADATE (Methylphenidate HCI, USP) g

26 Comparison of Extended-release Methylphenidate Dosage Forms Mean d,l-methylphenidate plasma levels (ng/ml) Ritalin 20 mg BID Concerta 54 mg Metadate CD 60 mg (3 x 20 mg) Ritalin LA 40 mg Time (h) Gonzalez MA, et al. Int J Clin Pharmacol Ther. 2002;40: Data on file, Novartis Pharmaceuticals.

27 ADDERALL XR: The Science Behind Optimal Dosing

28 A Norepinephrine Reuptake Inhibitor (NRI)

29 Daytrana Patch Delivery System Newly released methylphenidate delivery system. Worn on alternating thighs for 9 hours daily. Effects last 12 hours. Parents/patients can leave on or take off earlier. Smooth release of medication. Sizes: 10, 15, 20, 30 mg