Psychopharmacology for Treatment of ADHD and ADHD with other co-existing psychiatric condition

Transcription

1 Psychopharmacology for Treatment of ADHD and ADHD with other co-existing psychiatric condition Presented by Cat Dang, D.O Medical Director - Insightful Minds, Inc.

2 Objectives Evaluation process Pharmacology options for ADHD: Stimulants Non-stimulants Pharmacology options for ADHD with co-existing psychiatric conditions: ODD/CD Anxiety Depression Bipolar Learning Disabilities

3 Common Statements I hate movies. I can t sit there for more than 20 minutes. My mind is on something else. I m the class clown. My friends used to call me Monkey. I can t remember to do anything. I m the post-it note queen. I hate reading. By the time I finish the paragraph, I can t remember what the first sentence was about. I always misplace things. I lost two wallets this week.

4 Background Attention Deficit Hyperactivity Disorder (ADHD or ADD)

5 Epidemiology of ADHD Affects 5 to 7 % of prepubertal elementary school children As of 2015 it is estimated to affect about 51.1 million people globally More prevalent in boys than in girls (up to 9:1) Symptoms of ADHD are often present by age 3 years, but the diagnosis is generally not made until the child is in a structured school setting

6 Evaluation Considerations Examination / Confirmation The continuous performance task helps to confirm inattention and impulsivity (TOVA, IVA) Brain mapping (QEEG, SPECT Scan) Rating Scales: Connors, Vanderbilt, Adult ADHD Rating Scale Differential Diagnosis Vision Deficits Hearing Deficits Learning Disabilities Developmental Delays Neurological Abnormalities (absence seizure) Endocrine Disorders: hypothyroidism, anemia, lead poisoning Sleep Disorders: obstructive sleep apnea, narcolepsy, periodic limb movement disorders

7 Course and Prognosis Remission is unlikely before the age of 12 60% - 80% persist into adolescent years When remission does occur, it is usually between the ages of 12 and 20 Most patients with the disorder undergo partial remission but are vulnerable to antisocial behavior, substance use disorders, and mood disorders In about 15 to 20 % of cases, symptoms persist into adulthood

8 At Risk Outcomes Poor academic performance Low self esteem Poor social and interpersonal relationships High risk for injuries, MVA High rates of substance abuse Employment difficulties High risk for teen pregnancy, incarcerations

9 Treatment Options Attention Deficit Hyperactivity Disorder (ADHD or ADD)

10 Medication Treatment Options Methylphenidate class FDA approved for children 6 years old and older Mechanism of Action: reduce the breakdown of dopamine and norepinephrine in prefrontal cortex Dexmethylphenidate (Focalin) D-Isomer of methylphenidate

11 Medication Treatment Options Methylphenidate class: Long acting formulations Aptensio XR (extended release capsule) Contempla XR ODT(extended release oral disintegrating tablet )

12 Medication Treatment Options Amphetamine Salts (Adderall) FDA approved for children 3 years old and older Mechanism of Action: reduces breakdown of dopamine and norepinephrine in prefrontal cortex increases release of dopamine and norepinephrine in prefrontal cortex Dextroamphetamine (Dexedrine) D-Isomer of Amphetamine Salt Milder efficacy Milder side effects

13 Medication Treatment Options Other short-acting variants: Evekeo (amphetamine derivative tablet) Adzenys XR ODT (amphetamine XR oral-disintegrating tablet) Dyanavel XR (amphetamine extended release oral suspension) Zenzedi (dextroamphetamine tablet)

14 Medication Treatment Options Long-acting Variants: Mydayis (amphetamine extended release capsule)

15 Efficacy of Stimulants MTA study (Multimodal Treatment of ADHD) in 1999 Largest study involving 579 children with ADHD ages 7 to 9.9 years old over 14-month treatment 4 study groups: Medication management: 74% on methylphenidate; 10% on dextroamphetamine Behavioral Treatment: parent training, child-focused treatment, school intervention Combined treatment: medication and behavioral management Community Care: parents were given a list of community mental health resources and made whatever treatment arrangements they preferred

16 Efficacy of Stimulants Medication management, and medication with behavioral treatment were the most effective For many children with combined ADHD, medication alone is likely to be effective when care is taken to determine the optimal medication/dose for each child, and when ongoing effectiveness of medication is carefully monitored Intensive and well-conducted behavioral treatment can also be an effective option for treating children with ADHD, but can be hard for parents to implement Children treated by community physicians may be routinely undermedicated Children treated by community physicians are often put on nonstimulant medications and/or combinations of medications that are not necessary 10% of children were on multiple medications More than 16 % were treated with an antidepressant

17 Efficacy of Long-acting Stimulants Daytrana patch: 12-month trial on children with ADHD ages 6-12 years old Side effects: mild loss of appetite, headache 80% effective, without clinically significant change in growth Suggestive use for patients with substance abuse potential Vyvanse: 11-month trial on children with ADHD ages 6-12 years old More consistent plasma level of medication Effective and well tolerated without serious side effects Suggestive use for patients with substance abuse potential

18 Common Side Effects of Stimulants Common Side Effects of Stimulants Headache Stomachache Nausea Decreased appetite Insomnia Irritability Rebound symptoms

19 Serious Side Effects of Stimulants Motor tics: can transiently occur in 15-30% of children taking stimulants Growth suppression: Past studies suggested that "long-term use of the drugs could stunt children's growth. More recent studies suggest that children eventually do reach normal height and weight. Treated children with ADHD tend to grow at a slower rate but catch up during adolescence and adulthood. Drug holidays Psychosis: visual hallucinations, paranoia Cardiovascular side effects: cardiac arrhythmia, sudden death in children with underlying heart problems

20 Medication Treatment Options Strattera (Atomoxetine) Non-stimulant Increases norepinephrine level Less rebound, less insomnia Less abuse potential Takes 3-7 weeks for max effect Some side effects: headache, sedation, irritability, mania, black box warning for suicidal thinking, liver enzyme abnormality

21 Medication Treatment Options Adrenergic Agents Adrenergic Agents: Clonidine and Guanfacine, Intuniv, Kapvay Effective for hyperactive symptoms Less effective for inattention symptoms Guanfacine: 30% improvement for inattention Some side effects: sedation, hypotension, rebound hypertension Antidepressants Antidepressants: Wellbutrin Not indicated in children Increases levels of dopamine and norepinephrine Some side effects: lower seizure threshold, weight loss or decreased appetite, dry mouth, black box warning for suicidal thinking

22 Medication Treatment Options Other Medications The following medications are not FDA approved at this time: Effexor Cymbalta Tricyclic antidepressants: Amitriptyline, Desipramine, Imipramine, Nortriptyline Provigil

23 Medication Treatment Options Genetic Testing: result for a teenage girl

24 Medication Treatment Options Genetic Testing: result for a 30 year old female

25 Monitoring Medication Treatment Physical Exam Blood pressure Pulse Weight Height EKG Feedback from teachers about school performance Feedback from family members TOVA/IVA test while on medication

26 Special Considerations ADHD and Comorbid Psychiatric Conditions

27 ADHD and Comorbid Psychiatric Conditions» Illustration from Joseph Biederman and Stephen Faraone, Harvard Mahoney Neuroscience Institute Letter, Winter 1996 Volume 5 Number 1

28 ADHD and ODD/CD Most common co-morbid disorder is Oppositional Defiant Disorder (ODD) 54-57% of ADHD children get diagnosed with ODD by 7 years of age ODD is precursor for Conduct Disorder (CD) CD in children: 20-50% CD in adolescents: 44-50% CD in adulthood: up to 26%

29 Treatment: ADHD and ODD/CD Stimulants: preferably long-acting forms to avoid abuse Daytrana patch Concerta Vyvanse Alpha-agonists: Clonidine, Kapvay, Clonidine transdermal patch Tenex, Intuniv Mood Stabilizers Atypical Antipsychotics: Risperdal, Abilify, Zyprexa, Seroquel Anticonvulsants: Depakote, Tegretol, Trileptal Lithium

30 Treatment: ADHD and Anxiety Co-existing Anxiety: up to 25% Strattera Antidepressants: Effexor, Pristiq, Cymbalta Combination of Stimulants and Anxiolytic Medications Be aware stimulants may increase anxiety

31 Treatment: ADHD and Depression Co-existing Depression: 26% in children, 14% in adulthood Wellbutrin Antidepressants: Effexor, Pristiq, Cymbalta, etc Combination of Stimulants and Antidepressants

32 Treatment: ADHD and Bipolar Disorder Co-existing Bipolar: 10-20% Combination of Alpha-Agonists and Mood stabilizers Combination of Stimulants and Mood Stabilizers Monitor side effects related to stimulants: irritability, insomnia, psychosis

33 ADHD and Tic disorders Childhood motor tic disorder: 18% By mid-adolescent years: 2% By adulthood: less than 1 % Tourrette s Disorder (motor and vocal tics): less than 0.4% Treatment: alpha-agonist If severe: add atypical antipsychotics (Geodon, Abilify, Risperdal)

34 ADHD and Learning Disabilities 19-26% have one learning disability Reading disorders: 16-39% Spelling disorders: 24-27% Math Disorders: 13-33% Speech and language disorders: 30% Treatment: Psycho-education testing to determine area of deficits, IEP, 504 Accommodations, Behavioral Intervention

35 Psychosocial Interventions and Other Treatment Options Social skills groups: increase self-esteem Training for parents: positive reinforcement, setting routines and limits. Behavioral interventions (organizational skills): ADD Coaching, physical activities Nutrition: omega-3 fatty acid supplements, reduced sugar consumption, reduced caffeine consumption Neurofeedback Individualized Education Program: 504 accommodations Colleges can provide accommodation through Disability Office Career coach

36 References Sadock B, Sadock V. Kaplan & Sadock s Synopsis of Psychiatry, Ninth Edition. Lippincott Williams & Wilkins 2003; 43: American Psychiatric Association: Diagnostic Criteria from DSM-IV-TR. Washington D.C. 2000: Donnelly & Sons Company. WebMD, LLC. Web Oct [ American Academy of Pediatrics. Web. Oct [ Wikipedia: The Free Encyclopedia. Wikimedia Foundation, Inc. Web. Oct [ Medscape. WebMD, LLC. Web. Sept [ MentalHelp.net. CenterSite, LLC. Web. Sept [ Center for Disease Control. Web. Sept [ Psychiatric Times. UBM Medica LLC. Web. Sept [