Making the Diagnosis
Name two of the criteria for ADHD diagnosis on the DSM5
This class of medication is first-line pharmacotherapy for adult ADHD without co-occurring conditions.
Stimulants (amphetamines and methylphenidate)
Because stimulants are controlled substances, physicians should check this state database before prescribing. What else should we do at Elk Ridge?
PMDM. CSA. UDS.
This is the non-pharmacologic therapy with the strongest evidence base for adult ADHD.
CBT
What decision making with patient goes into selecting short vs long-acting stimulant? Name 3 things that you consider in shared decision making.
Our choice of stimulant preparation is based on the patient’s preference, time to onset and length of desired effect, concern about misuse or diversion, cost, and availability of the medication
Symptoms must have been present before this age to meet criteria
What is greater than or equal to age 12.
This non-stimulant that is an SNRI is an established second-line agent and is preferred when substance use disorder is a concern.
Atomoxetine
If a patient is on Amphetamines, what monitoring are you going to do. Name 3.
•Cardiac evaluation: At baseline and if exertional chest pain, unexplained syncope, or other cardiac symptoms develop
•Blood pressure & heart rate: Baseline, after dose increases, and periodically
•Growth & appetite (children): Monitor height, weight, and appetite
•Weight (adults): Monitor periodically
•Peripheral vasculopathy: Monitor for digital/circulatory changes
•Sleep & behavior: Monitor for changes
•Tics/Tourette syndrome: Assess personal/family history before treatment; monitor for new or worsening symptoms
•Abuse/misuse: Assess risk before prescribing and monitor for misuse, abuse, or substance use disorder throughout treatment
Before escalating ADHD treatment for worsening attention, clinicians should assess this modifiable behavior because inadequate amounts can mimic or worsen inattention and executive dysfunction.
Sleep
You are going to start a patient on either amphetamine or methylphenidate. Pt has no contraindications to either. Which one put of the two is considered first line per up to date?
Among the stimulant medications, our first choice is typically an amphetamine rather than methylphenidate.
Symptoms of ADHD must have presented for how long before a diagnoses is made?
6 months
If a patient has ADHD, substance use disorder, and depression, what is first line therapy?
Wellbutrin
Name four significant side effects of methylphenidate
Cardiovascular events, growth suppression, priapism, psychiatric effects
What is best practice treatment for ADHD in patients without comorbidities?
For most adults with ADHD, we suggest a combination of stimulant medication plus cognitive behavioral therapy targeting executive dysfunction (CBT-EF) rather than either treatment alone
You have a patient with anxiety and ADHD. They are not on any medications, and they want to start medications. What is your plan for this patient?
Treat anxiety first with SSRI/SNRI, then add stimulant
What are the three types of presentations of ADHD?
Combined presentation – If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past six months.
Predominantly inattentive presentation – If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past six months.
Predominantly hyperactive/impulsive presentation – If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A 1 (inattention) is not met for the past six months.
What neurotransmitters does methylphenidate block?
Mild CNS stimulant; blocks the reuptake of norepinephrine and dopamine into presynaptic neurons
This antidepressant class must be stopped for at least 14 days before starting an amphetamine
MOAI
A 10-year-old with ADHD is struggling academically despite appropriate treatment. Name two formal school-based supports that may provide accommodations or individualized educational services.
504 Plan and an Individualized Education Program (IEP)
A patient is 2 months pregnant with well managed ADHD on Adderall. Explain your decision making with this patient regarding their Adderall now that they are pregnant.
In all pregnant individuals with ADHD, we review the risk of exposure to stimulant medication and weigh this against the risk of deterioration of functioning due to untreated symptoms. After reviewing the potential risks and benefits, all decisions are made using shared decision-making.
For adults (age 17+), this is the minimum number of inattentive OR hyperactive-impulsive symptoms required
5
What area of the brain does methylphenidate and amphetamines stimulate?
Appears to stimulate the cerebral cortex and subcortical structures
A patient is currently on IR methylphenidate and wants to switch to long acting as they feel they forget to the 2nd pill in the afternoon. Currently, they take 5 mg IR methylphenidate in the AM and they should take 5 mg IR methylphenidate afterwork. You want to switch them to Concerta. What is a safe/equivalent dose of Concerta that you can start them on?
18 mg Concerta daily in AM
The combination of CBT targeting executive dysfunction plus stimulate medication is what grade of evidence? (number and letter)
2c
What is the scale is used to monitor symptoms severity during treatment (can also be used as diagnostic tool)?
The Conners’ Adult ADHD Rating Scales for diagnosis and monitoring of symptom severity during treatment.