1. No category

ADHD is Color Blind – Understanding and Eliminating Treatment
Disparities in Minorities
Event Type
Live Online
ACPE Expiration Date
12/18/2016
Credits
1.25 Contact Hours
Target Audience
Nurses, Pharmacists, Pharmacy Technicians
Program Overview
ADHD, like most other medical conditions is color blind. ADHD doesn't discriminate between
white, black, male, female, etc. But we as health care professionals, including pharmacists, can
be barriers to improving the diagnosis and treatment of our patients. By better understanding
cultural differences and biases, then developing culturally relevant management strategies;
pharmacists can help minimize treatment gaps and ensure that treatment of ADHD is color
blind. This activity will satisfy the education need by creating a program for pharmacists that
will enhance their understanding of ADHD, identify the cultural differences that may limit
diagnosis, pharmacotherapy, counseling points, and information needed to work with all the
patients to manage ADHD and improve quality of life.
Nurse Educational Objectives
 Describe the cultural differences that may limit diagnosis and barriers to care facing
minorities with ADHD
 Review the pharmacological approaches to the management of ADHD (pharmacologic
profiles, efficacy, side effects, & adverse events)
 Outline the effective guideline based, culturally relevant counseling techniques that nurses
can use with patients and caregivers in daily practice to eliminate disparities in treatment and
maximize quality of life for all patients
Pharmacist Educational Objectives
 Describe the cultural differences that may limit diagnosis and barriers to care facing
minorities with ADHD
 Review the pharmacological approaches to the management of ADHD (pharmacologic
profiles, efficacy, side effects, & adverse events)
 Outline the effective guideline based, culturally relevant counseling techniques that
pharmacists can use with patients and caregivers in daily practice to eliminate disparities in
treatment and maximize quality of life for all patients
Pharmacy Technician Educational Objectives
 List signs and symptoms of ADHD
 Recognize that cultural differences in patients and when to refer a patient to a pharmacist
Activity Type
Knowledge
Accreditation
Nurse
Pharmacist
Pharmacy Technician
N-864
0798-0000-13-258-L01-P
0798-0000-13-258-L01-T
PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a
provider of continuing pharmacy education.
PharmCon, Inc. has been approved as a provider of continuing education for nurses by the
Maryland Nurses Association which is accredited as an approver of continuing education in
nursing by the American Nurses Credentialing Center’s Commission on Accreditation.
Faculty
Julie Dopheide, PharmD, BCPP
Associate Professor of Clinical Pharmacy, Psychiatry and the Behavioral
Sciences, USC School of Pharmacy
Financial Support Received From
Shire Pharmaceuticals
Disclaimer
PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the
value of the material is decreased. The content of the activity was planned to be balanced and
objective. Occasionally, authors may express opinions that represent their own viewpoint.
Participants have an implied responsibility to use the newly acquired information to enhance
patient outcomes and their own professional development. The information presented in this
activity is not meant to serve as a guideline for patient or pharmacy management. Conclusions
drawn by participants should be derived from objective analysis of scientific data presented
from this activity and other unrelated sources.
Page 1
ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
ADHD is Color Blind – Understanding and
Eliminating Treatment Disparities in Minorities
Accreditation
Faculty
Pharmacists: 0798-0000-13-258-L01-P
Pharmacy Technicians: 0798-0000-13-258-L01-T
Nurses: N-864
Julie Dopheide
PharmD, BCPP
Associate Professor of Clinical Pharmacy,
Psychiatry and the Behavioral Sciences
USC School of Pharmacy
CE Credit(s)
Faculty Disclosure
1.25 contact hour(s)
Dr. Dopheide has no actual or potential conflicts of interest
in relation to this program.
Learning Objectives
•
•
•
Describe the cultural differences that may limit diagnosis and barriers to care facing minorities with ADHD
Review the pharmacological approaches to the management of ADHD (pharmacologic profiles, efficacy, side effects,
& adverse events)
Outline the effective guideline based, culturally relevant counseling techniques that pharmacists can use with patients
and caregivers in daily practice to eliminate disparities in treatment and maximize quality of life for all patients
Legal Disclaimer
Julie Dopheide, PharmD, BCPP
Learning Objectives
• Describe the cultural differences that may limit
diagnosis and barriers to care facing minorities with
ADHD.
• Review the pharmacological approaches to the
management of ADHD (pharmacologic profiles,
efficacy, side effects, & adverse events).
• Outline effective guideline based, culturally relevant
counseling techniques that a pharmacist can use with
patients and caregivers in daily practice to eliminate
disparities in treatment and maximize quality of life.
The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that
support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed.
Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.
Symptoms of ADHD Typically First
Noticed in the Classroom
• Undiagnosed
and untreated
ADHD can:
• Impair learning
• Impair social
development
• Lead to low self
esteem
• Contribute to
family discord
Am Academy of Pediatrics Clinical Practice Guideline for ADHD Pediatrics 2011.
American Psychiatric Association’s DSM-5, copyright 2013.
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Diagnostic Criteria for ADHD
• Signs and Symptoms:
• Duration:
• Comorbid Conditions:
U.S. African American and Hispanic Children
Lower Diagnosis and Treatment Rates
• N = 17,100 Kindergarten students 1998-1999
• Nationally representative sample from Early Childhood
Longitudinal study
• Data collected on diagnosis and treatment from children,
parents, teachers in 1st, 3rd, 5th and 8th grade
• Diagnosis for non-white youth
• 69% lower - African American
• 50% lower - Hispanic
• 46% lower - Other ethnicities (Asian, Native Am, Pacific Islander)
• Ethnic minorities less likely to be taking ADHD medication
compared to Caucasian youth
Am Academy of Pediatrics Clinical Practice Guideline for ADHD Pediatrics 2011.
American Psychiatric Association’s DSM-5, copyright 2013.
Plot of the Hazard Function of ADHD Diagnosis by Race/Ethnicity.
Morgan P L et al. Pediatrics 2013;132:85-93
©2013 by American Academy of Pediatrics
Morgan P L et al. Pediatrics 2013;132:85-93
Plot of the Survival Function of ADHD Diagnosis by Race/Ethnicity.
Morgan P L et al. Pediatrics 2013;132:85-93
©2013 by American Academy of Pediatrics
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Worldwide Rates of ADHD Similar when
Standardized Criteria Used
Cultural and Societal Barriers to
Diagnosis and Treatment
Analysis of 102 studies representing 171,756 youth from seven regions: North
America, Europe, Latin America, Asia, Oceania, Africa, and the Middle East.
• “Hyperactivity and impulsivity are part of being a boy”
• “A firm hand, or discipline is all the child needs”
• “I don’t want my child to be labeled “
• “I don’t want my child to become a drug addict”
• Lack of health insurance
• Distrust of psychiatry or psychology
• Language and communication barriers with health care
providers and families
Polancyk G et al. Am J Psychiatry 2007; 164:942–948.
Region
Prevalence of
ADHD
Number of studies
South America
11.5%
9
Africa
9.0%
4
North America
5.8%
32
Europe
4.9%
32
Oceania
4.8%
6
Asia
4.6%
15
Middle East
3.0%
4
Study methodology accounts for the difference in prevalence rates
When standardized criteria used, worldwide pooled prevalence rates similar:
DSM-5 American Psychiatric Association 2013
Polancyk G et al. Am J Psychiatry 2007; 164:942–948)
ADHD Across Life Cycle
ADHD Symptoms Decrease in Number Over
Time but Severity can Persist
Onset of symptoms before age 12: present in 2 or more settings
Childhood
•
Children
with ADHD
75%
persists
into
adolescence
Adolescents
with ADHD
Prevalence in juvenile population
5%
Diagnostic and Statistical Manual of Mental Disorders –DSM-5 2013
50%
persists
into
adulthood
Adults with
ADHD
Prevalence in
adult population
2.5%
•
•
•
•
•
•
•
Adolescence
Highest number of
symptoms
Unable to focus on task
or assignments
Unable to complete
assignments
Poor listener
Hyperactive
Can’t wait turn
Talks excessively
Intrudes on others
•
•
•
•
•
•
•
•
Symptoms ↓ in
number over time
Less hyperactive
Disorganization
Difficulty prioritizing
Unable to balance
school schedule
Late for appts.
Speeding, accidents
Over-reacting to
frustration
Adults
•
•
•
•
Fewer symptoms but
still impairing
Pattern of unstable
interpersonal and
occupational
relationships
Inflexible, controlling,
flaky
Compelled to talk on
cell phone during
meetings
Am Academy of Pediatrics Clinical Practice Guideline for ADHD Pediatrics. 2011.
Table Adapted from the American Psychiatric Association’s DSM-5, copyright 2013.
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
ADHD – Cigarettes, Alcohol & MJ Use and Abuse
• Compared to youth
without ADHD, higher
rates of:
• Cigarette smoking
• Alcohol use and abuse
• Marijuana use
SAMSHA Illicit Drug & Alcohol
Use and Health Survey Results 2002 to 2011
• Marijuana most abused substance with 14.5 million
users in 2007 and 18.1 million users in 2011
• Alcohol use steady in all age groups
Youth Ages 12 – 17 years
2002
2011
• Conduct and Mood
disorders increased the
risk of etoh use and abuse
Overall Substance Dependence
8.9%
6.9%
Cigarette Smoking Male/Female 12.3/13.6%
8.2/7.3%
• ADHD 2nd most common
diagnosis in youth who
abuse MJ
Binge Drinking Rate (12-20yr)
19.3%
15.8%
Marijuana Use Increasing
2008 – 6.7%
2011-7.9%
Brooke SG, et al. Alcoholism: Clinical and
Experimental Research 2007
Past Month Use of Selected Illicit Drugs among
Youths Aged 12 to 17: 2002-2011
http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011
Goals of Diagnosis and Treatment
(include in patient and family counseling)
• Improve Quality of Life
• Promote educational achievement
• Develop healthy social relationships
• Achieve sustained employment
• Decrease Adverse Life Outcomes
Substance Abuse and Mental Health Services Administration, Results from the 2011
National Survey on Drug Use and Health: Summary of National Findings,
HHS Publication No. (SMA) 12-4713. Rockville, MD: SAMSHA, 2012.
•
•
•
•
Incarceration
Substance abuse
Unemployment
Disability
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Effective Treatment can Improve
Academic Achievement
• n= 594 medicated vs. 594 non-medicated ADHD
• 5 standardized tests kindergarten to 5th grade
• NIMH funded 1998-1999 to 2003-2004
Pharmacologic Treatment of ADHD
Improves Quality of Life
Combined MPH /Clonidine improved Impact on Family scale by a
mean of 0.45 (22.3%) compared to the placebo group, which was
slightly worse by a mean of 0.03 (-1.4%)
• Results – 90% taking a stimulant:
• Medicated children math score 2.9 pts higher
• Medicated children reading score 5.4 pts higher
• Gains insufficient to eliminate test score gap between
ADHD and Non-ADHD youth
• Academic Achievement improved for effectively treated
adolescents and young adults as well.
N=122
7-16 yrs
4 groups:
MPH
MPH/Clonidine
Clonidine
Plbo
Scheffler. Positive Association with ADHD Med Use and Academic Achievement in Elementary School. Pediatrics
2009;123:1273. Pliszka SR. Psychostimulants, in Pharmacotherapy of Child and Adolesc Psychiatric Disorders. WileyBlackwell, 2012, pp 65-104.
Cannon M. J Child & Adolescent Psychopharmacology 2009;19(5):511.
MTA – 3yrs Follow-up
Delinquency/Substance Abuse
Multimodal Treatment Study (MTA)
Methylphenidate vs Behavioral Interventions
•
•
•
•
579 children age 7-10 yrs, 6 sites across U.S.
DSM-IV ADHD combined type
Multisource assessment at baseline, 3, 9 & 14 mo
3 active treatments vs. community care
Delinquency
NIMH MTA Group Archives Gen Psychiatry 1999;56(12):1088-1096.
Abikoff H. NIMH MTA x 2 yrs JAACAP 2004;43(7): 802.
Local Normal
Controls
27.1%
7.4%
17.4%
7.8%
Stealing, violence
• Medication management
• Behavioral therapy, parent training
• Combination
• Medication superior to behavioral interventions
Results maintained at 24 months
MTA – all groups
Substance Abuse
Cigarettes, MJ, etoh
•
•
Intensive behavioral therapy, ↓ sub abuse and delinquency at 2
years vs. other MTA children who did not receive such intensive
behavioral therapy.
No significant difference at 3 years and beyond
Jensen et al. 3yr Follow-up of NIMH MTA JAACAP 2007;46(8):989-1002
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
MTA – 8 year Follow Up
• Children with the best response to any treatment will
have the best long-term prognosis
• Rates of ADHD diagnosis were constant at 3 years but
decreased into adolescence
• Adolescents fewer symptoms than in childhood but
functioning was worse than normal controls on 91%
of variables tested (aggression, depression, anxiety)
• Twice as likely to have police contact or be arrested
• 10% psychiatric hospitalization vs. 1% controls
• Inattention most persistent symptom at 6, 8 yrs
Practice Parameter for Psychotropic
Meds in Youth
1.
2.
3.
4.
5.
6.
7.
8.
Thorough Psychiatric Evaluation
Medical History and Medical Evaluation
Collateral Information/Coordinate Care
Evidence Based Treatment
Plan for Short and Longterm monitoring
Counseling / Feedback / Consent & Assent
Documentation of Drug Therapy Decisions
Specific plan: Titration, Monitoring, Withdrawal
Molina B et al. The MTA at 8 yrs.
Walkup J et al. J Am Academy of Child Adolescent Psychiatry
Practice Parameter for Use of Psychotropic Meds in Youth 2009
J Am Acad Child Adol Psych 2009;48(5):484.
Rating Scales for Assessment of ADHD
Stimulants are 1st Line for ADHD but How
do They Compare?
• Broad-band scales
• Comparable in efficacy
• Evaluate symptoms associated with ADHD plus comorbid
conditions
• Example: Child Behavior Checklist (Achenbach)
• Narrow band scales - preferred
•
•
•
•
•
Focus on ADHD symptoms based on DSM criteria
Use of at least one is considered standard of care
Examples: Conner’s scales, ACTeRS, SNAP-IV,
Vanderbilt assessment can detect comorbid conditions
Can also be used to monitor treatment outcomes
Dopheide JA, Pliszka SR. ADHD: An Update. Pharmacotherapy 2009;6:656-679
• 85% response rates when both stimulants tried
• NNT 2.6 for methylphenidate, 2.0 amphetamine
• Methylphenidate/dexmethylphenidate
• Most well-studied, less likely to exacerbate tics
• Ritalin LA, Metadate CD, Concerta, Focalin XR
• Dextroamphetamine, mixed amphetamine salts
• More potent, slightly longer duration of action
• Dexedrine, Adderall, Adderall XR, Vyvanse
• 2010 Meta-analysis shows moderately > efficacy
Pliszka SR. Psychostimulants, in Pharmacotherapy of Child and Adolesc Psychiatric Disorders. Eds. Rosenberg &
Gershon Wiley-Blackwell, 2012, pp 65-104.
American Academy of Pediatrics ADHD Treatment recommendation;s Pediatrics 2011.
Faraone & Buitelaar Eur Child Adolesc Psych 2010;19:353
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Comparing Once Daily Dosing Options
in > 6 yrs old
– 3 pulse drug delivery 20/40/40 may appear in
stool, cannot crush/snort, less abuse risk; dosing: 18 to
54mg/d; adolescent/adult up to 72mg
– 30/70: start 10mg; max: 60mg/day
– 50/50- ↑ [drug] early compared to Concerta; start
10mg; max: 60mg/day
– 50/50 – dexmethylphenidate; max: 30mg in child;
40mg in adult
– 50/50 – for longer duration, start 10mg/day
child max: 30mg; 40mg in adult
– Lisdexamfetamine – converted in gut to
dextroamphetamine, slower onset: 20 – 70mg/day
Transdermal Methylphenidate - Daytrana
• 10, 15, 20, 30 mg patches available
• Apply to clean, dry area on hip, rotate site
• Onset within 2 hrs after applying patch
• Peak drug blood level – 8 hrs
• Avoids 1st pass effect (enterohepatic)
• 20mg patch ~ 20mg tid methylphenidate po
• 9 hours of wear time recommended
• Absorption continues 3 hrs after patch removal
Anderson & Scott, Methylphenidate Transdermal System. Drugs 2006.
Lisdexamfetamine – Vyvanse (LDX)
• Dextroamphetamine covalently linked to l-lysine (MAS=
mixed amphetamine salts)
• 20 - 30mg, ↑ weekly to response, max: 70mg/d;
• 10mg MAS XR ~ 30mg LDX
• 20mg MAS XR ~ 50mg LDX
• 30mg MAS XR ~ 70mg LDX
• Less abuse potential due to longer onset vs. IR
• Approved in children, adolescents and adults
• Longterm studies show effective x 1 year at same dose
Biederman J. et al. Clin Therapeutics 2007. Weisler et al. CNS Spectrums 2009.
Methylphenidate Powder
Long-acting Suspension: Quillavant XR
• 20 % Immediate release / 80% extended release
• Starting dose 20mg in the morning, increase weekly to
maximum recommended dose of 60mg/day
• Must be reconstituted by pharmacist 25mg/5ml
•
•
•
•
300 mg / 60 mL
600 mg / 120 mL
750 mg /150 ml
900 mg / 180 ml
• Stable for 4 months after reconstituted
• Onset 30 to 60 minutes
• 8 to 12 hour duration
Medical Letter on Drugs and Therapeutics Quillavant XR 2013
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Stimulant Side Effects and Management
(counseling points)
• Upset Stomach - give on a full stomach, lower dose,
titrate slowly
• Insomnia - dose earlier in the day, melatonin,
cyproheptadine or alpha2-adrenergic agonist
• Headache – tolerance over time, acetaminophen
• Tics - lower dose, change drugs
• Dysphoria, irritability - reassess diagnosis,  dose,
change drugs
• Hallucinations - d/c drug
• Over-focused, zombie-like, lower dose
Dopheide JA, Pliszka SR. ADHD: An Update.
Pharmacotherapy 2009;6:656-679
Minimize Risk of Growth Deficit
• Lowest effective dose of stimulant, Combine
behavioral therapy consistently
• Give favorite foods when stimulant effects low
• Drug holiday during school breaks
• Atomoxetine effects on growth considered
“minimal” (0.44 cm over 2 yrs)
• Alternative treatments: bupropion, guanfacine XR,
clonidine XR
Stimulants and Growth - Counseling needed
(34 studies reviewed, including MTA)
•
•
•
•
•
•
Height deficit: ~ 1 cm/yr over 1-3 yrs continuous tx
Weight deficit 1st year: ↓ 3 kg in weight
Weight deficit 2nd year: ↓ 1.2 kg in weight
MTA: inconsistent use less ↓ grow vs. continuous
Growth effects lessen over time
Amphetamines = methylphenidate
• LDX study over 15 months showed > growth effects in taller, heavier
kids and those never treated with stimulants
• Possible alterations in growth hormone or growth factor
secretion, appetite loss → to ↓ calorie intake
Poulton Growth on stimulant medication. Arch Dis Child. 2005;90:801-806
Swanson Effects of stimulants on growth x 3 yrs. JAACAP 2007;46(8):1015.
Faraone Effects of Lisdexamfetamine for ADHD on growth. JAACAP 2010;49.
Non-stimulant Treatment Options
• Atomoxetine – selective NE reuptake inhibitor
• FDA approved all ages; less effective than stimulants
• Longer onset of effect than stimulants
• Less insomnia, less growth effects, ↑ pulse, hepatic risk
• Bupropion – DA and NE reuptake inhibition
• Not FDA approved for ADHD, depression; smoking
• Seizure risk, insomnia
• Clonidine & Guanfacine extended release- ↑ blood flow in
prefrontal cortex in attempt to improve
attention/behavior
• FDA approved as monotherapy and adjunct to stimulant
• Not as effective in older adolescents and heavier children
Poulton 2005, Pelham 2005, Spencer 2005, Faraone 2010
Dopheide JA & Pliszka SR. ADHD: An Update. Pharmacotherapy 2009
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
3.1 per 100,000 person-yrs
No ECG required prior to
stimulant use
Screen for family history of
structural cardiac
abnormalities
Counsel to report symptoms
Adjusted Rate per 100,000 Person-Yr
Serious CV Events in Those Taking ADHD
Medications No Greater than Nonusers
One-year prevalence in
patients with ADHD
Oppositional defiant disorder
or Conduct Disorder
30-50%
4
Anxiety
30-50%
3
Depression
20-40%
2
Substance abuse
20-30%
1
Epilepsy
10-20%
0
Autism Spectrum disorder
10-20%
7
6
5
Nonuser
Former User
Current User
Tourette’s
Figure 1. Adjusted Rates of Serious Cardiovascular
Events, According to the Use of ADHD Drugs.
Cooper WO et al. N Engl J Med 2011;365:1896-904.
Co-occurring Conditions Guide Treatment
• Chadd.org
• Consumer publication
ADHD - Comorbidity
Neuropsychiatric Disorder
Co-occurring with ADHD
Bipolar disorder
5-10%
unknown
Dopheide & Pliszka Pharmacotherapy 2009; McPheeters Pediatrics 2011
Kaplan & Newcorn Ped Clin NA 2011; DSM-5 2013.
High Comorbidity in Adolescent/Adult ADHD
• Depression/ADHD treat
predominant disorder 1st may
use antidepressant
• Anxiety/ADHD, stimulant may
worsen anxiety symptoms
• Tourette’s/ADHD stimulants
may/may not worsen tics
• Bipolar disorder: stabilize
mood and reassess ADHD
symptoms
• Stimulants can worsen ASD
in some children
Dopheide & Pliszka Pharmacotherapy 2009;
McPheeters Pediatrics 2011
Wilens Expert Review in Neurotherapeutics 2011
Kaplan & Newcorn Ped Clin North America 2011
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
SSRIs - Most Evidence for Depression
and Anxiety Disorders in Youth
Antidepressant
Indication (Peds)
Dosing/day
Considerations
Fluoxetine
MDD > 8 yrs old
OCD > 7 yrs old
Initial 5-10mg
20 - 80mg
↑ levels of
amphetamine &
atomoxetine
Sertraline
OCD, > 6 yrs old
Initial 12.5-25mg; Less drug intx vs.
50-200
fluoxetine
Escitalopram
MDD > 12 yrs old
Initial 5-10mg
10-20mg
Low drug
interactions
Citalopram
none
10 – 40mg
Adolescents
Fluvoxamine
OCD > 8 yrs old
Initial 25mg
50-200mg
↑ olanzapine
level, caffeine
Emslie G. J Child Adolescent Psychopharmacology 2012;22(1):2-4.
Wells KB et al. J Child Adolescent Psychopharmacology 2012;22(1):80-90.
ADHD - Substance Abuse Risk
• ADHD confers 2 to 7 x ↑ risk of substance abuse
• Cannabis Youth Treatment study found ADHD 2nd
most frequent comorbidity. ADHD present in 38%
(both sexes) of those with MJ abuse disorders.
• Alcohol abuse significantly greater if ADHD
• Treatment can facilitate substance abuse recovery
• Atomoxetine is a good option for those with active
substance abuse dx
• Bupropion also an option if substance abuse
although risk of seizures
Schubiner CNS Drugs 2005, Szobot &Bukstein, Child Adoles Clin NA 2008
Upadhyaya HP, J Child Adolesc Psychopharm 2005;15:799-809.
Wilens TE, American J of Addictions 2007;16:14-23
Antipsychotics not for Core ADHD
Symptoms but for Associated Aggression
SGA
Bipolar Disorder
Mixed or Manic
episodes
Schizophrenia
Aggression &
Irritability from
Autism or PDD
Aripiprazole
(Abilify)
> 10 years old
> 13 years old
> 6-17 years old
Olanzapine
(Zyprexa)
> 13 years old after > 13 years old after
failing other
failing other
antipsychotic
antipsychotic
Quetiapine
(Seroquel)
> 10 years old
> 13 years old
Risperidone
(Risperdal)
> 10 years old
> 13 years old
Paliperidone
(Invega)
> 5-16 years old
>12 years old
AHRQ Pub. No. 11(12)-EHC077-3 August 2012; Seida J et al. Pediatrics 2012;
Townsend L & Findling R. Expert Opin Pharmacother 2010
www.t-may.org.
Atomoxetine (Strattera®)
• Selective NE reuptake inhibitor
• FDA approved for ADHD in children > 6 years,
adolescents and adults
• Advantages: no abuse potential, less insomnia, less
growth effects, effective if Tourette’s disorder or anxiety
• Disadvantages: longer onset of therapeutic benefit (2-4
weeks) vs. stimulants, less effective
• Adverse effects similar to stimulants, urinary
hesitation/retention, more sedation, slightly more ↑
heart rate compared to stimulants, rare hepatoxicity
and rare treatment emergent suicidality
Dopheide JA, Pliszka SR. ADHD: An Update
Pharmacotherapy 2009;6:656-679
Page 11
ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
© 2013 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Bupropion - for ADHD
(FDA approved for adult depression)
• Less effective than TCAs but safer
• Dosing 3-6mg/kg/day or 50 -75mg am or 50mg bid ,
100mg qam of SR, titrate to response; range 100450mg/d (generic, SR, XL formula.)
• Less effective for distractibility compared to
stimulants, may be effective for depression
• For adolescents and adults, not pre-pubertal
• Nausea, tics, rash, insomnia, seizures possible
Dopheide JA, Pliszka SR. ADHD: An Update.
Pharmacotherapy 2009;6:656-679
Stimulant and Guanfacine XR
N= 75 (6-17yrs) - residual ADHD symptoms after 1 month stimulant
Guanfacine XR added and titrated to 4mg/day; significant improvement in
symptoms measured on the ADHD RS-IV. Less clinically significant appetite
suppression and less insomnia
Spencer T. J Child Adolesc Psychopharmacology 2009;19(5):501
)
FIG. 1.
ADHD-RS-IV mean scores at baseline
Guanfacine XR – (Intuniv)
• Intuniv FDA approved in 2009
• More selective for alpha-2a receptor vs. clonidine, less
sedation and dizziness
• 0.1mg of clonidine = 1mg of guanfacine
• Clonidine 2 to 4 x/day, guanfacine once daily
• 1 to 4 mg given in AM more effective vs. placebo in ages 6
to 17 years; more effective in < 12 yrs old
• Onset at week 2, may take 1-3 months until therapeutic
• Dizziness, sleepiness, constipation possible
• Rebound hypertension possible if abruptly discontinued
Biederman J. Guanfacine XR in Children & Adolesc. with ADHD. Pediatrics 2008
Cinnamon L. Alpha-2 agonists in ADHD. Curr Psych Reports 2010.
Clonidine Extended- Release
• Kapvay® – released in September of 2010
• 0.1 and 0.2mg extended release tabs
• Dosing once or twice daily starting at bedtime
• Approved for ADHD as monotherapy or adjunct
to stimulant medication in 6 – 17 year olds
• Non-selective vs. guanfacine alpha-2a selective
• More sedating than guanfacine
• Approved for hypertension in adults - Jenloga®
• Child ADRS: somnolence, fatigue, bradycardia,
upper abdominal pain, less common: nightmares
• Not for use if underlying CV abnormality
Cinnamon L. Alpha-2 agonists in ADHD. Curr Psych Reports 2010;12:366
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ADHD is Color Blind – Understanding and Eliminating Treatment Disparities in Minorities
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ADHD Medication Counseling
• Stimulants most effective, improve symptoms within 1
to 2 hours of an effective dose; other treatments take 2
to 4 weeks for therapeutic trial
• Once daily stimulants preferred to improve adherence,
persistence and decrease diversion
• Never abruptly stop treatment, particularly with alpha2adrenergic agonists due to rebound effects and relapse
• Adverse effects can be managed
• Attention to drug interactions
• Vigilance for drug and alcohol use
Notes
Summary on Ethnic Disparities in ADHD
• Children of all ethnicities
struggling academically or
behaviorally can benefit from
assessment for ADHD
• Thorough evaluation by
experienced clinician best
• Bio-psychosocial treatment
• Evidence-based
Pharmacotherapy
• Monitoring and counseling on
ADRs and management
Notes