Treatment of attention deficit hyperactivity disorder
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Treatment of Attention Deficit/Hyperactivity Disorder. Lyn Billington Deputy Pharmacy Manager Latrobe Regional Hospital. ADHD. Symptoms are Persistent inattention-becomes a problem at school Hyperactivity - often the most prominent feature Impulsivity

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Treatment of attention deficit hyperactivity disorder

Treatment of Attention Deficit/Hyperactivity Disorder

Lyn Billington

Deputy Pharmacy Manager

Latrobe Regional Hospital

Lyn Billington June 2006


ADHD

  • Symptoms are

  • Persistent inattention-becomes a problem at school

  • Hyperactivity - often the most prominent feature

  • Impulsivity

  • Accurate diagnosis essential before commencing treatment

Lyn Billington June 2006


Course of the condition
Course of the condition

  • In most cases - spontaneous remission

  • Late adolescence about 50% still show the full syndrome

  • This falls to about 1/3 by early 20’s

  • Late 20’s 10% still fully affected.

Lyn Billington June 2006


Complications
Complications

  • Academic failure

  • Truancy

  • Misconduct

  • In adult years - more likely to have antisocial personality disorder & substance misuse

Lyn Billington June 2006


Etiology
Etiology

  • Some studies show genetic causes

  • Most appear idiopathic

  • Small number may be related to lead encephalopathy or rare, inherited resistance to thyroid hormones

Lyn Billington June 2006


Differential diagnosis
Differential diagnosis

  • Chaotic upbringing

  • Foetal alcohol syndrome

  • Mental retardation

  • Autism

  • Children with mania

  • Children with agitated depression ( however have other symptoms not typical of ADHD)

  • Children with schizophrenia ( Have other symptoms which rules out ADHD)

  • Difficult to diagnose in adults

Lyn Billington June 2006


Treatment
Treatment

  • Medication is not the only treatment.

  • Parent education & school support are of major importance

  • Psychostimulants can reduce symptoms

Lyn Billington June 2006


Rationale for drug use
Rationale for drug use

  • Symptom relief

  • To reduce function impairment in daily life (home, school, peer)

  • Minimise long term adverse effects on academic performance

  • Minimise impact on social and emotional development

Lyn Billington June 2006


Medication used
Medication used

  • Short acting psychostimulants

    • Dexamphetamine

    • Methylphenidate

      Up to 90 % will respond ( to one or the other)

      Effect is often immediate improvement in impulsive behaviour and task completion

Lyn Billington June 2006


Mode of action and childrens doses
Mode of action and Childrens doses

  • Thought to enhance dopaminergic and noradrenergic transmission

  • Dose - dexamphetamine2.5-10mg daily increasing by 2.5-5mg/day each week to a maximum of 30mg per day

  • Dose - methylphenidate 5-10mg/day in two doses increasing by 5-10mg/day each week to a maximum of 40mg /day

Lyn Billington June 2006


Short acting stimulants
Short acting stimulants

  • Rapid absorption – peak response 1-3 hours

  • Dose titrated according to response

  • Need to be given more than once daily.

  • Should not be given after early afternoon to minimise sleep disturbance

Lyn Billington June 2006


  • Methylphenidate also available as

  • Ritalin LA ®20mg,30mg & 40mg

  • Concerta®18mg, 36mg & 54mg

  • Use conventional tables first to establish dose then swap to the long acting formulation

  • Advantage - once daily dose

Lyn Billington June 2006


Adverse effects
Adverse effects

  • Headache

  • Abdominal discomfort

  • Appetite suppression

  • Insomnia

  • Minor effect on growth – but need to monitor weight and height

Lyn Billington June 2006


Atomoxetine strattera
Atomoxetine (Strattera ®)

  • May be a useful alternative for children who do not respond to stimulants

  • Indicated for children > 6 years old

  • May be useful where diversion of medication is a problem

  • Monitor liver function

Lyn Billington June 2006


Mode of action and dose
Mode of action and dose

  • Selectively inhibits presynaptic noradrenaline reuptake in the CNS

  • Dose: < 70 kg Initially 0.5mg/kg/day for 3 days, increasing to 1.2mg/kg/day

Lyn Billington June 2006


Adverse effects1
Adverse effects

  • Nausea

  • Vomiting

  • abdominal pain

  • decreased appetite

  • irritability

  • temper tantrums

  • Rare- suicidal thoughts and behaviors - monitor

Lyn Billington June 2006


Other therapies
Other therapies

  • Tricyclic antidepressants – not approved for ADHD in Australia.

  • If used start low - go slow

  • ECG before commencement (cardiotoxicity)

  • Consider Imipramine or Nortriptylline

Lyn Billington June 2006


  • Clonidine

  • No reliable evidence of effectiveness in ADHD

  • May be useful in children with ADHD who are aggressive and where sleep disturbance is a problem

Lyn Billington June 2006


Disadvantages of clonidine
Disadvantages of clonidine

  • Several weeks for clinical effect

  • Does not seem to affect inattention symptoms

  • Risk of causing depression

  • Monitor BP and pulse during therapy

  • Avoid sudden cessation

Lyn Billington June 2006


Note

  • Pharmacological treatment for children and adolescents difficult because of the lack of clinical trials in this age group.

  • Most information extrapolated from adult trials

  • Care is needed.

Lyn Billington June 2006


References
References

  • Therapeutic Guidelines - Psychotropic 2003

  • The Maudsley 2005-2006 Prescribing Guidelines

  • Moore & Jefferson Handbook of Medical Psychiatry, 2nd ed

  • AMH 2006

  • Jacobson: Psychiatric Secrets, 2nd ed

Lyn Billington June 2006


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