Treatment of ADHD Tallinn Håkan Jarbin, MD PhD - PDF

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Treatment of ADHD Tallinn Håkan Jarbin, MD PhD The crucial question: Assessment first! Do I have the right patient for this treatment? Making the diagnosis- look at all pieces that makes it

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Treatment of ADHD Tallinn Håkan Jarbin, MD PhD The crucial question: Assessment first! Do I have the right patient for this treatment? Making the diagnosis- look at all pieces that makes it up Family history Adhd 80% Course Adhd continuous&fluctuating Symptom criteria Adhd inatt&hyperactive Response to treatment Making the diagnosis be cautious and consider Adhd is normally distributed Less extreme = + numbers - diagnostic clarity - response to medication Multiple informants give you a better indication of your position Adhd how does it affect functioning=how severe? At home At school With friends At activities Do I have the right patient for this treatment? Life circumstances? Comorbidity? IQ?? Severity? Substance (ab)use Diagnosis?. Family history of cardiac problems before age 40 If yes GO! ADHD treatment psychoeducation Adaption at school +home Medication, severe=early, mild=wait Adhd the medicines atomoxetine Stimulants Methylphenidate amphetamines Alfa-agonists Clonidine guanfacine. The Mechanisms of Action of Stimulants AMPH blocks uptake into vesicle Presynaptic Neuron Cytoplasmic DA AMPH AMPH diffuses into vesicle causing DA release into cytoplasm Storage vesicle AMPH AMPH is taken up into cell causing DA release into synapse DA Transporter Protein Synapse MPH Inhibits AMPH Inhibits Wilens TE. J Clin Psychiatry , (suppl 8) 32-37 How many patients with adhd responds to stimulants? ADHD population Methylphenidate 70% Amphetamine 70% Methylphenidate OR Amphetamine 90% Hodgkins et al. Eur Child Adolesc Psychiatry (2012) 21: Stimulants are very effective in reducing ADHD lisdexamphetamine vs placebo vs mph (concerta) Coghill et al Article in press Stimulants and side effects Loss of appetite & weight Insomnia Dysphoria & irritability Headache & abdominal pain Tics & dyskinesia Tachycardia & hypertonia Psychotic symptoms Mean Absolute Weight (kg) Stimulants and impact on Growth- Weight Baseline Month Wilens et al 2005 JAACAP Stimulants and monitoring.. Growth accept -0.5 sd in age-adjusted height Heart blood pressure = usual age adjusted limits Pulse rate; resting 90 but in office In doubt make Home assessment! Stimulants and dosing C Medikinet C Ritalin T Concerta C Equasym What is the individual need Worst in the morning? Only for school?? Afternoons? Can t eat enough?? Handle the rebound??? Tailor the dosing Dosing Preschool 0,75 mg/kg Adolescents & adults 1-1,3 mg/kg range 2 mg/kg but sometimes higher Tips: short acting before waking up for calm mornings or split doses of concerta for calm evenings without rebound Extra short acting for special occasions Lower/shorter duration during weekends Amphetamine 2nd line Sometimes better and less dysphoria Greater risk of abuse with short acting use lisdexamphetamine. Prodrug with duration 13 hrs mg Atomoxetine- 2nd line The pros 24 hrs duration Non stimulant=no abuse Can be combined with a stimulant For comorbid adhd Anxiety & sleep Disruptive The cons Somewhat lower effect Somewhat more side effects Interactions on Cyp2D6 Fluoxetine makes ++atm QTc risk if atm is added to antipsychotics Alfa-agonists 2nd line clonidine and guanfacine The pros Very good combo with stimulant Works best for hyperactivity & aggression & sleep 1st line for tics Best tolerated SE: sedation, headache, ortostatic BP The cons Somewhat less effective Clonidine very sedative Super for sleep and relax Not for school Guanfacine expensive 1. Pelham pediatr 2001, 2. Stein pediatr 2003, 3. Swanson pediatr 2004, 4. Wolraich pediatr 2001, 5. Pelham pediatr 1999,6. Biederman pediatr.2002, 7.Mc Cracken JAACAP 2003, 8.Michelson AJP 2007, 9. Spencer J ClinP 2002, 10. Michelson Pediatr 2001, 11. Kelsey Pediatr 2004, 12. Salleeet al JAACAP 2009, 13. Jain et all, 14. Connor et al CNS Drugs Fass, Swe pharmacopedia Side effects of ADHD meds Side effect MPH AMPH ATMX α-2 AGONIST Appetite decrease Abdominal pain nausea irritability + + +/- +/- Somnolens insomnia Emotional lability sadness Tics vertigo tachycardia blood pressure Combining meds? Stimulant + alfaagonist Approved combo in the US No interactions Added benefit but side effects doesn t add up Stimulant + atomoxetine Some evidence, no interactions, added benefit + side effects Atomoxetine + alfa agonist No studies, Pharmacodynamically questionnable Stimulant + neuroleptic 3-4line if adhd, works for severe aggression and tics (risp, ari) or severe sleep (que) Metabolic side effects of neuroleptic are not balanced by the stimulant-monitor!! Stimulant + melatonin 1st line and Good for sleep No interactions and few side effects Treatment refractory adhd 30% either doesn t respond to or tolerate a stimulant Try 2nd line = alfaagonists or atomoxetine Reassess!! Comorbidity? Prodromal disorder (schizophrenia, personality) Drug ab(use)
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