Attention Deficit Disorder

Treatment Goals for ADHD

• Primary goal: Reduce symptoms to enable functioning in all environments.
• ADHD is not curable; management focuses on symptom improvement rather than elimination.

First-Line Therapies

• Stimulants are the first-line therapy for treating ADHD.
• Atomoxetine is a second-line option if stimulants fail.

ADHD Diagnosis Types

• ADHD combined is characterized by inattention, hyperactivity, and impulsivity.
• ADHD predominantly inattentive subtype shows difficulty focusing without hyperactivity.

Symptoms Across Ages

• In adults, inattention is the most common symptom of ADHD.
• Hyperactivity tends to dominate in children, while inattention is more prevalent in adults.

Nonpharmacologic Treatments

• EndeavorRx, a game-based device, is an approved nonpharmacologic treatment for children with ADHD.
• Cognitive Behavioral Therapy (CBT) is effective for adults with ADHD, though less effective than stimulants.

Treatment Age Guidelines

• Children aged 4-5 years should start ADHD treatment with behavioral therapy instead of medication.
• Stimulant medications are recommended for children aged 6-18 years as the first-line treatment.

Stimulant Therapy Considerations

• Monoamine oxidase inhibitors (MAOIs) should not be used with stimulants due to the risk of hypertensive crisis.
• Combining methylphenidate with clonidine can lead to increased cardiovascular effects.

Atomoxetine Overview

• Atomoxetine (Strattera) works by inhibiting norepinephrine reuptake.
• Potential adverse effect includes hepatotoxicity.
• Full efficacy of atomoxetine is reached in approximately 4 weeks.

Clonidine and Guanfacine (Alpha-2 Agonists)

• Clonidine and guanfacine act primarily by stimulating alpha-2 adrenergic receptors, which helps in treating ADHD.
• A common side effect of clonidine includes hypotension, affecting blood pressure regulation.
• Guanfacine is noted for being less sedating compared to clonidine, making it preferable in certain cases.

Alpha-2 Agonists: Side Effects and Use

• Drowsiness is a frequently observed adverse effect when using alpha-2 agonists for ADHD treatment.
• Abrupt cessation of clonidine can lead to a hypertensive crisis, necessitating careful management of dosage.
• Clonidine is FDA-approved for treating both ADHD and hypertension, showcasing its versatility.

Non-Stimulant Medications

• Atomoxetine is recognized as the FDA-approved non-stimulant medication specifically for ADHD.
• A significant advantage of atomoxetine is its lower risk of abuse compared to stimulant medications, an important consideration in ADHD treatment.
• The therapeutic effects of atomoxetine typically manifest within 4 to 6 weeks, indicating a longer initiation period compared to stimulant medications.

Atomoxetine Adverse Effects

• Hepatotoxicity is a serious potential side effect of atomoxetine that requires close monitoring of liver function.
• Gastrointestinal upset is a more common adverse effect noted in children on atomoxetine, which may affect adherence to treatment.
• Regular monitoring of liver function tests is essential for patients receiving atomoxetine to prevent serious complications.

Combination Therapy

• Combination therapy for ADHD is utilized when a single drug does not sufficiently control symptoms, aiming for enhanced treatment efficacy.
• Commonly combined classes in ADHD treatment include stimulants and alpha-2 agonists, leveraging their complementary effects.
• The primary goal of combination therapy is to enhance efficacy while managing side effects, providing a more tailored approach to treatment.

Non-Stimulants (Atomoxetine)

• Atomoxetine is the only non-stimulant medication approved specifically for ADHD treatment.
• A common adverse effect of atomoxetine is hepatotoxicity, posing a risk for liver damage.
• Therapeutic effects of atomoxetine typically manifest after 4-6 weeks of treatment.

Non-Stimulant Therapy

• Atomoxetine acts as a norepinephrine reuptake inhibitor in ADHD management.
• Preference for atomoxetine over stimulant medications arises due to its lower risk of abuse and dependence.
• Monitoring of liver function is recommended while using atomoxetine to prevent potential liver complications.

Alpha-2 Agonists

• Clonidine and guanfacine are alpha-2 agonists used to treat hyperactivity and impulsivity symptoms in ADHD.
• Common side effects of these agonists include sedation, affecting daily functioning.
• When used in combination with stimulants, alpha-2 agonists help reduce hyperactivity symptoms and offer sedative benefits.

Bupropion

• Bupropion, utilized off-label for ADHD, primarily influences dopamine and norepinephrine neurotransmitter systems.
• A significant contraindication for bupropion use includes the presence of seizure disorders, increasing the risk of seizures.
• Insomnia is a common side effect associated with bupropion in ADHD treatment.

Viloxazine (Qelbree)

• Viloxazine operates through norepinephrine reuptake inhibition as its mechanism of action.
• This medication is approved for treating ADHD in patients aged 6 years and older, expanding treatment options for children.
• A potential adverse effect of viloxazine includes increased blood pressure and heart rate, requiring monitoring during treatment.

Stimulants: Abuse and Dependence

• Common adverse effect of stimulant abuse includes tremors and cardiac arrhythmias.
• Signs of stimulant withdrawal feature mental depression and lethargy.
• Stimulant drugs like amphetamines primarily affect dopamine and norepinephrine neurotransmitters.

Stimulants: Treatment of Overdose

• Recommended treatment for stimulant overdose involves supportive care and seizure control.
• Hypertensive crisis is the most common cardiovascular complication linked to stimulant overdose.
• Bradycardia is NOT a typical symptom of stimulant overdose; common symptoms include hyperreflexia, hyperthermia, and seizures.

Cocaine Abuse and Effects

• Cocaine acts by inhibiting dopamine reuptake, significantly affecting mood and behavior.
• Chronic cocaine abuse may lead to complications such as cerebral hemorrhage.
• A notable feature of cocaine withdrawal is severe mood depression.

Amphetamines: Abuse and Overdose

• Hallucinations and paranoia are common psychiatric symptoms of chronic amphetamine abuse.
• Characteristic signs of amphetamine overdose include hypertension, tachycardia, and seizures.
• Treatment for severe amphetamine toxicity requires supportive care and managing hyperthermia and seizures.

Withdrawal Symptoms from Stimulants

• During stimulant withdrawal, symptoms such as excessive sleep and mental depression are prevalent.
• Management of stimulant withdrawal typically includes psychosocial support and symptomatic treatment.
• Stimulant tolerance is marked by the necessity for progressively higher doses to achieve the same effects.

Amphetamines

• Common overdose symptoms include tachycardia (rapid heartbeat) and hyperthermia (elevated body temperature).
• Primary neurotransmitter affected by amphetamines is dopamine, influencing mood and energy levels.
• Chronic use leads to withdrawal symptoms such as sleepiness and mental depression.

Cocaine

• Cocaine inhibits the reuptake of serotonin, norepinephrine, and dopamine, enhancing their effects in the brain.
• Fatalities in cocaine overdose are often caused by respiratory depression and arrhythmias (irregular heartbeats).
• Withdrawal from cocaine can result in severe mood depression, impacting emotional stability.

Nicotine and Caffeine

• Nicotine acts primarily by stimulating the release of dopamine and norepinephrine, affecting pleasure and alertness.
• Caffeine withdrawal symptoms typically include fatigue and headache, indicating a reliance on its stimulating effects.
• Nicotine toxicity can lead to respiratory paralysis, a serious condition affecting breathing.

Test your knowledge on the primary goals and therapy options for Attention Deficit Hyperactivity Disorder (ADHD). This quiz covers foundational concepts in ADHD treatment and first-line medications used for management. Understand the strategies to reduce symptoms and improve patient functionality.