Trouble shooting medication adjustment and side effect management in children with ADHD

Transcription

1 Trouble shooting medication adjustment and side effect management in children with ADHD Drs. Joanna Holland and Sarah Manos 44 th Annual Dalhousie Spring Refresher April 5, 2018

2 Disclosure We have no disclosures Our wait list is long

3 What we can and can not do WE CAN. We have more time We ve seen lots of children with ADHD We can be a resource to you WE CANNOT. See referrals as quickly as we would like Get special access to psychology and psychoeducational assessments Ensure extra resources at school

4 Objectives Describe the approach to monitoring children with ADHD Be comfortable adjusting ADHD medications to improve efficacy Have an approach to the management of common side effects of ADHD medications

5 Case 1 Jimmy 8 year old boy (grade 2) is referred to pediatric clinic with concerns that he has trouble following instructions in school and is falling behind academically. He is also disruptive to other children in the class and parents are frustrated by his behaviour at home. He is otherwise healthy.

6 Case 1 - Jimmy Diagnosis Thorough history and physical examination: establish the symptoms (inattention, hyperactivity/impulsivity) and degree of impairment Obtain information from multiple environments (home and school) Rating scales helpful Rule out other causes of symptoms-and consider common comorbidities that may need further assessment

7 Case 1 - Jimmy Diagnosed with ADHD combined type with no comorbidities. Psychoeducation is provided: information about what ADHD is Best treated with a multimodal approach of psychosocial interventions and medication Resources and recommendations given How do you discuss medication with families and decide which medication to start with?

8 Starting Medication May consider other interventions first...but medication is not a last resort Review risks of untreated ADHD Any trial of medication is just that... a trial Monitor both efficacy (reduction in ADHD symptoms) and side effects Tell me about anything that could be a side effect

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10 Different classes of medications Stimulants - Amphetamine-based psychostimulants - Methylphenidate-based psychostimulants Non psychostimulants - Selective norepinephrine reuptake inhibitor - Selective alpha 2A adrenergic receptor agonist

11 Choosing which medication to start with Long acting is first line Always a trial Start low and titrate to reach goal of best effective dose,balancing side effects Timing of symptoms/duration of action required? Can child swallow pills? Affordability - Do they have a drug plan? Are there comorbidities and/or contraindications? Patient preference/previous experience of family members? Risk of diversion/abuse?

12 Contraindications to Psychostimulants Treatment with MAO inhibitors and up to 14 days after discontinuation Symptomatic cardiovascular disease Glaucoma Pheochromocytoma Advanced arteriosclerosis Untreated hyperthyroidism Known hypersensitivity or allergy to the products Acute psychiatric conditions such as mania or psychosis Moderate to severe hypertension

13 Drug interactions to watch for SSRIs/SNRIs may increase risk of serotonin syndrome Methylphenidate may increase the level of phenytoin, primidone and phenobarbital Inhibitors of CYP2D6 (e.g. paroxetine, fluoxetine, buproprion, quinidine) may increase atomoxetine serum concentrations Decongestants possible increase in blood pressure and heart rate Watch QT prolonging agents with Atomoxetine

14 Cardiac Risk Assessment Cardiac risk assessment before the use of stimulant medications in children and youth SA Bélanger, MD PhD, AE Warren, MD MSc, RM Hamilton, MD, C Gray, MD, RM Gow MB, BS, S Sanatani, MD, J-M Côté, MD, J Lougheed, MD J LeBlanc, MD MSc, S Martin, MD, B Miles, PhD C Psyc, C Mitchell, MD DA Gorman, MD, M Weiss, MD PhD, R Schachar, MD, Mental Health and Developmental Disabilities Committee Paediatrics & Child Health, Volume 14, Issue 9, 1 November 2009, Pages

15 What s covered by Nova Scotia Pharmacare (2018) Covered Exception Status Not covered Amphetamine XR Adderall (5-30mg) Dexedrine 5mg Dexedrine spansules (10,15mg) Methylphenidate (generic and Ritalin ) Methylphenidate SR Ritalin SR Vyvanse (10-60mg) Biphentin (10-80mg) Concerta (18-54mg) Methylphenidate ER Atomoxetine (generic or Strattera )* Guanfacine (Intuniv )

16 Case 1 - Jimmy continued Started on a long acting methylphenidate-based psychostimulant medication, followed in peds clinic and has been on a stable dose for the last 6 months with good efficacy and no significant side effects Discharged back to family physician

17 Monitoring a child on psychostimulant medication for ADHD Q4weeks after initial prescription and with every altering dose* Once stable q3-6 months Efficacy (history/checklists) Growth parameters Blood pressure and heart rate Side effects (sleep, appetite) New mood, anxiety, substance use disorder, psychotic or manic symptoms

18 Case 1 continued Jimmy is now 10 and in grade 4. His first semester report card is not as good as in the past He has trouble completing homework and it seems to take longer than it should His hockey coach has mentioned that he doesn t seem as focused during drills

19 Adjusting when low efficacy Increase dose of stimulant Add short acting stimulant later in day Switch to another stimulant with longer duration of action Add adjunct non-stimulant medication (less likely)

20 Case 1 wrap up Jimmy s dose was increased He is back to clinic in 2 months with improved symptoms and no side effects

21 Case 2 - Julie Julie is a 10 year old girl who has just been diagnosed with ADHD inattentive type. She has been started on a long acting methylphenidate-based psychostimulant and is back for her first follow up appointment The information from home and school suggests she has had some benefit but she her appetite has decreased and she has lost weight

22 Side effects general principles Waiting it out if early on Weighing risk and benefit Managing side effects Decreasing dose Switching classes different stimulant vs switch to non-stimulant

23 Appetite suppression Later supper Good breakfast Manageable lunch Bedtime snack Nutritional supplements/meal replacements Wait it out Follow more closely

24 Delayed Sleep Onset Review sleep hygiene Give meds earlier Increase activity during day Trial of melatonin Consider changing meds

25 Mood changes During medication effect vs wearing off period? Review possible contributing factors/other diagnosis Take an additional short acting dose of same stimulant just before rebound usually occurs Consider changing meds

26 Somatic effects Headaches, GI upset, dry mouth, increased heart rate, increased blood pressure Often improve or resolve over days to weeks Consider poor appetite and poor sleep as contributors Minimize caffeine and other sympathomimetic agents

27 Tics Commonly comorbid with ADHD Can worsen with stimulant medication-but not a contraindication Monitor Consider non-stimulant medication, especially selective alpha 2A adrenergic receptor agonist

28 Case 2 In Julie s case, significant weight loss and already low BMI Switched to an amphetamine-based psychostimulant 1 month later, still no weight gain and mom finds she is more emotional Switched to non-stimulant medication and this was more successful

29 What if nothing is working? Is diagnosis wrong? Is there a comorbidity? Is there a medical issue? Adherence issue? Something new/changed in environment? Watch for normal times of change e.g. holiday breaks, end of school

30 Resources position statement on Cardiac risk assessment before the use of stimulant medication in children and youth useful screening tools, resources, parent and child handouts for many mental health conditions information for parents and children or adolescents Strongest Families (parents of kids age 3-12) Referral process differs by province, in NS is through Mental Health Community Health Teams (NS)

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