Transcript After beginning dose and increases

Pharmacological Treatment of
Child & Adolescent
ADHD
Baseline Measurement
CBC
Ht
Wt
BP
Pulse
SNAP-IV
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W
F
I C
R F
S A
\
P
History
KSES-A
 Complete blood count (CBC)
 Height; Weight; Blood Pressure; Pulse Rate
 SNAP-IV 18 Items Rating Scale
 WFIRS-P (Weiss Functional Impairment Rating Scale- Parent Report)
 CFA (Child Functional Assessment)
 KSES-A (Kutcher Side Effects Scale for ADHD Meds)
 Family history of heart disease
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Facts About Stimulants
 Do not cause addiction in ADHD treatment
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


› Tolerance develops occasionally
Decreases rates of future substance abuse
Improves outcomes in functioning
“Drug holidays” are not needed
Long acting, once per day dose easiest
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Stimulants & Non-Stimulants
Stimulants
Highly effective
Available for decades
Well studied
Safe prescribed to healthy
patients under medical
supervision
Available in two different forms
Short-Intermediate
Release Preparations
Repeated doses/day
More adverse effects
Stigma associated with
taking at school.
Methylphenidate’s
Ritalin®
Ritalin® SR
PMS or Ratio Methylphenidate
Dextroamphetamine Sulphate’s
Dexedrine
Non-Stimulants
For youth…
1. Not responding well to
stimulant medications
2. At risk for substance
abuse
3. With other conditions
with ADHD
Extended Release Preparations
Preferred over short-acting
medications, Better compliance; less
diversion.
More expensive, not all Canadian
medication insurance plans cover.
Mixed Salts Amphetamine
*Adderall XR
Methylphenidate
*Biphentin
*Concerta
*Novo-Methylphenidate ER-C
Lisdexamfetamine Dimesylate
*Vyvanse
Atomoxetine
*Strattera
Is the only non-stimulant
medication that is
approved to treat children /
adolescents with ADHD.
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Additional ADHD Medications
 Tricyclic antidepressants (not recommended)
› Imipramine or Desipramine
 Bupropion
› Wellbutrin
 Clonidine
Reserve these medications for specialty mental health services
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“N of 1” Model
 Evaluating response to Methylphenidate
› 3-day baseline assessment
 SNAP-IV 18
 Alternate every 3 days for 12 days:
› Dose of methylphenidate (standard release)
 5 mg/BID or 10 mg/BID depending on weight
› Dose of placebo
 Daily measurement
› Symptoms (SNAP-IV 18)
› Side Effects (KSES-A)
Day
1
Day
2
No Medication
Day
3
Day
4
Day
5
Day
6
510mg
/bid
510mg
/bid
510mg
/bid
Day
7
Day
8
Day
9
Day
10
Day
11
Day
12
Placebo Medication
510mg
/bid
510mg
/bid
510mg
/bid 6
Stimulants Misuse
 Concerning with alcohol/drug
abuse
> Careful evaluation and monitoring
> Avoiding drug diversion
> Sustained-release preparations
> Non-stimulants
> Consider using Atomoxetine
> Studying for exams
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Collaborative Prescribing Agreement for ADHD
Medications
http://www.health.gov.bc.ca/ph
armacare/sa/criteria/restricted/
methylphenidate.html
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CADDRA Medication Tables
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Methylphenidate Treatment
START LOW & GO SLOW
Begin: 2.5mg – 5mg; morning and noon; 30 – 45 minutes before meals.
Maintain for 1 wk.
If insufficient effect, tolerable and no significant side effects increase to 5mg - 10mg in morning and 2.5mg 5mg at noon and maintain for a week
If needed, increase: to 5 mg – 10mg in the morning and 5mg – 10mg at noon. Maintain for 1 wk.
If insufficient effect, tolerable and no significant side effects increase: to 5 mg – 10mg in the morning, 5mg –
10 mg at noon and 2.5 – 5mg at 4pm. Maintain for 1 wk.
Continue stepped titration by 2.5mg - 5mg weekly to a maximum total daily dose of 2mg/kg/d not to exceed
60 mg, measuring outcomes every week following the step increase.
After beginning dose and increases:
Measure outcomes using SNAP-IV 18 items
(aiming for a score of less than or equal to 18) and the KSES-A
If Side Effects…
…become a problem, while no substantial improvement, increase time between increases from 1 wk to 2 wks;
continue steps.
…limit dose increases to optimize symptom control, refer to specialty services or change to
Dextroamphetamine .
Discontinuation: Taper gradually over several months at low stress times
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Dextroamphetamine Treatment
START LOW & GO SLOW
Begin: 2.5 mg – 5mg in the morning and 2.5mg – 5mg at noon; 30 – 45 minutes before meals.
Maintain for 1 wk.
If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and
2.5mg - 5mg at noon and maintain for a week
If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and
5mg - 10mg at noon and maintain for a week
If insufficient effect, tolerable and no significant side effects increase: to 5mg - 10mg in the morning
and 5mg – 10mg at noon and 2.5mg – 5mg at 4pm. Maintain for 1 wk.
Continue stepped titration by 2.5mg – 5mg weekly to a maximum total daily dose of 20 mg, - 40mg
measuring outcomes every week following the step increase.
After beginning dose and increases:
Measure outcomes using SNAP-IV 18 items
(aiming for a score of less than or equal to 18) and the KSES-A
If Side Effects…
…become a problem, while no substantial improvement, increase time between increases from 1 wk
to 2 wks; continue steps.
…limit dose increases to optimize symptom control, refer to specialty services or change to
Methylphenidate if not tried yet or consider Atomoxetine .
Discontinuation: Taper gradually over several months at low stress times
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Non-Stimulant Atomoxetine Treatment
START LOW & GO SLOW
Begin: 0.5 mg/kg/d in the morning for 2 wks
Increase: to 0.8 mg/kg/d in the morning for 2 wks
Increase: to 1.0 mg/kg/d in the morning for 2 wks
After beginning dose and increases:
Measure outcomes using SNAP-IV 18 items
(aiming for a score of less than or equal to 18) and the KSES-A
If Side Effects…
…become a problem, while no substantial improvement, increase time between increases
to 4 wks
…limit dose increases to optimize symptom control, refer to specialty services.
…and symptoms are not under optimal control, increase to 1.2mg/kg/d in the morning;
maintain for a period of 2 wks.
NOTE:
If symptoms
are not under
optimal
control with
1.2mg after
maintaining it
for at least 6
weeks refer
to speciality
service.
Measure outcomes using SNAP-IV 18 items and the KSES-A.
Discontinuation: Taper gradually over several months at low stress times
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Switching to Long Acting Forms …
 When total daily dose is determined…
› Switch to long acting form
 Biphentin
 Concerta
 Nova-Methylphenidate ER-C
› Single daily morning dose
 Equivalent of initial Ritalin dose
 Long acting Methylphenidate
› Start at lowest dose; increase weekly
› Essential to evaluate twice/wk
 SNAP-IV
 Side Effects Scale
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Switching to Atomoxetine
 If switching for reasons other than side effects
› Add Atomexetine until ADHD symptoms improve
› Then stop Methylphenidate
Use PST Based Supportive Rapport
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Subjective Side Effects
Never
Somewhat
Constant
Anorexia
0
1
2
3
4
Weight Loss
0
1
2
3
4
Abdominal Pain
0
1
2
3
4
Dry Mouth
0
1
2
3
4
Nausea
0
1
2
3
4
Vomiting
0
1
2
3
4
Fearful
0
1
2
3
4
Emotional Lability
0
1
2
3
4
Irritable
0
1
2
3
4
Sadness
0
1
2
3
4
Restlessness
0
1
2
3
4
Headaches
0
1
2
3
4
Trouble Sleeping
0
1
2
3
4
Drowsiness
0
1
2
3
4
Dry Eyes
0
1
2
3
4
Suicidal Ideation
0
1
2
3
4
Rash
0
1
2
3
4
Acne
0
1
2
3
4
Dyskinesia
0
1
2
3
4
Tics
0
1
2
3
4
Other Movements
0
1
2
3
4
Sexual Effects
0
1
2
3
4
Kutcher
Side
Effects
Scale
for ADHD
Meds
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Monitoring Treatment of Attention Deficit HyperActivity Disorder
Bas
eline
Day
1*
Day
3*
Wk
1
Wk
2
SNAP-IV
18
x
x
x
x
x
x
x
x
CFA/TeF
A
WFIRS
x
x
x
x
x
KSES-A
x
x
x
x
x
Tool
x
* For Stimulants Only
x
x
Wk
3
Wk
4
Wk
5
Wk
6
Wk
7
Wk
8
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Duration of Treatment
Maintain treatment for defined length of time to:
 Allow for further improvements in symptoms
 Allow for additional therapeutic interventions to occur (e.g. CBT
or parent training)
 Decrease risk of relapse
 Decrease risk of a co-morbid mental disorder
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Medication Adherence
Checking Adherence to Treatment
 Predict non-compliance
› Openly recognize probability
 Missing one or more doses of medication
› No need to feel guilty
 Occasional misses…
…a little change in fluoxetine
(long half-life)
…a difference in missing
sertraline (shorter half life)
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Assessing Treatment Adherence
3 Methods
1. Enquire about medication use from child
2. Enquire about medication use from parent
3. Pill counts are sometimes useful
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If Relapse Occurs…
 …evaluate the following





Compliance with treatment
Medical illness
Onset of stressors that challenge patient
Onset of substance abuse
Alternative diagnostic possibility
 Depression, anxiety disorder, bipolar disorder
 Refer to mental health specialist if relapse occurs despite
adequate ongoing treatment
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