Introduction to Stimulants

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1. Stimulants. Use throughout the day

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Introduction to Stimulants

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1. Introduction to Stimulants Cesar A. Soutullo, M.D. UC-3 Psychopharm Lectures

2. 1. Stimulants Use throughout the day & on wk-ends Not only during school Improve social interact, leisure particip. Improve oppositional, aggressive behaviors Methylphenidate short acting Dextroamphetamine long acting Ritalin-SR, Dex-Spans longer

3. 1. Stimulants Use throughout the day & on wk-ends Not only during school Improve social interact, leisure particip. Improve oppositional, aggressive behaviors Methylphenidate short acting Dextroamphetamine long acting Ritalin-SR, Dex-Spans longer

4. Stimulants: Pharmacokinetics Ritalin: Liver met, kidney excret Peak Serum Level 1.9 hr [0.3 - 4.4 hr] SR: 4.7 hr [1.3-8.2 range] Half-life: 2-2.5 hrs. Dexedrine: Liver met, kidney excret Peak: 2 hrs (Spansule 8-10 hr) Half-life: 6-8 hr kids / 10-12 adults

5. Stimulants: Side Effects Appetite suppression: HS snack Effect on height rarely clinically signif Sleep difficulty: dose before 4 pm ? Systolic BP (mild) Exacerbate Tics & Tourette’s Psychosis: discontinue Rebound effects: excitability, irritability 4-5 hrs after dose give pm dose or use spansules

6. 1.a. Methylphenidate [Ritalin] Peak 1-2 hrs, half-life 2.5 Total daily dose 1 mg/kg/day (0.6-2) In >6 y.o. start 5 mg qd or bid (AM & 12) raise 5-10 mg/wk, (can add 4 pm dose) Tablets: 5, 10, 20 mg SR 20 mg Max> dose: 60 mg/day

7. 1.b. Dextroamphetamine [Dexedrine] Half-life 6-8 hrs Optimal dose 0.3-1.5 mg/kg/day age 3-5 2.5 mg/d, ? 2.5 once-twice wk > 6 yo 5 mg/d, ? 5 mg once-twice wk Tablets: 5 mg, scored Spansules: 5, 10, 15 mg Max dose 40 mg/day Better for pt. with Seizures

8. 1.c. Adderall [dextr saccharate, sulph & amphet sulph, aspart] Half-life 7-8 hrs Dose like Dexedrine Tablets 5, 10, 20, 30 mg

9. 1.d Mg Pemoline [Cylert] Least abuse potential Rx once a day 37.5 mg/d Max dose 112.5 mg/day Reduced use, Side effects: choreoathetoid movements insomnia chronic hepatitis fulminant liver failure (rare)

10. 2. Antidepressants in ADHD TCAs: Helpful but caution IMI. Cardiac SE, ? hyperactivity 1 mg/kg/day & over PR , 210 msec, QT < 450 msec HR<130 bpm Desipramine: sudden death reports? Bupropion: Sz SSRI: Not helpful Venlafaxine: Improves behavioral Sx?

11. 2.b. Bupropion [Wellbutrin] ? Hyperactivity-Impulsivity Improve cognitive performance? Effects: DA reuptake block Start 37.5 to 50 mg bid, gradual increase Seizure risk Do not use > 150 mg/dose or 450 mg/day Separate doses > 4 hours

12. 3.a. Clonidine [Catapress] Presinaptic Alpha-agonist, ?NE release ? frustration tolerance, ? hyperarousal ? hyperactivity Clonidine+Ritalin: 3 cases sudden death EKG, Hx of Syncope, FHx sudden death Helpful in ADHD + Tics Start Dose 0.05 mg hs (tablets 0.1 mg) slow up to 0.15-0.3 mg/day Slow D/C, rebound hyypertension Skin patch: toxic if eaten or damaged

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