Pediatrics Book

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ADHD MedicationAka: ADHD Stimulant

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  1. General
    1. Medication is not a cure, only control
    2. Medication holiday is not needed
      1. Medication should be taken on weekends and holidays
      2. Summer use of medication is optional
        1. Restart medication well before school
        2. Do not trial off medication at onset of school year
    3. Myths (Stimulant non-causes)
      1. Stimulants do not cause Sedation
      2. Stimulants do not cause growth delay
        1. Weight does however need to be watched closely
      3. Stimulants do not cause Drug addiction
  2. Medication Protocol
    1. Start with short acting first-line stimulant (below)
    2. Advance dose to desired affect and per adverse affects
    3. Advance to combine long-acting with short-acting agents
    4. Consider rapid onset long-acting agents as single med
      1. Adderall
      2. Concerta
  3. First Line Medications: Stimulants
    1. Rapid Onset agents with short duration
      1. Methylphenidate (Ritalin)
      2. Dextroamphetamine (Dexedrine)
    2. Rapid Onset agents with long duration
      1. Methylphenidate LA (Ritalin LA)
      2. Amphetamine-Dextroamphetamine (Adderall XR)
      3. Methylphenidate (Concerta)
    3. Slow Onset agents with long duration (not recommended)
      1. Methylphenidate (Ritalin-SR or Metadate ER)
      2. Dextroamphetamine (Dexedrine Spansules)
      3. Pemoline (Cylert)
        1. Not first line due to liver toxicity risks
    4. Selective Norepinephrine Reuptake Inhibitor (SNRI)
      1. Tomoxetine (Strattera) - Non-stimulant agent
    5. Equivalent dosages
      1. Methylphenidate (Ritalin) 20 mg SR
      2. Dextroamphetamine (Dexedrine) 10 mg spansules
    6. Investigational Agents (Stimulant)
      1. Modafinil (Provigil)
  4. Second Line Medications
    1. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Indications
        1. Comorbid Major Depression
        2. Hyper-focused on activity (e.g. computer games)
        3. Obsessive-Compulsive type unproductive behavior
      2. Agents
        1. Bupropion (Wellbutrin)
        2. Venlafaxine (Effexor)
    2. Tricyclic Antidepressants
      1. Indications
        1. Insomnia
        2. Poor appetite
        3. Enuresis
      2. Agents
        1. Imipramine (Preferred of tricyclics)
          1. Start 10 mg PO qhs (Up to 150 mg/day divided bid)
        2. Desipramine (Risk of sudden CV death)
          1. Start 10 mg PO qhs (Up to 150 mg/day divided bid)
  5. Adjunctive medications for modulating emotions
    1. Indications
      1. Impulsivity
      2. Hyperactivity
      3. Conduct problems
      4. Tics (Tourette's)
    2. Agents
      1. Clonidine 0.05 mg PO qhs to 0.4 mg/day divided tid
      2. Guanfacine (Tenex)
      3. Beta Blocker
      4. Carbamazepine (Tegretol)
      5. Divalproex (Depakote)
    3. Other specific agents
      1. Risperidone (Risperdal)
        1. Indicated for severe oppositional defiant disorder
      2. Wellbutrin (Bupropion)
        1. Indicated for aggression
  6. References
    1. (1996) Pediatrics 98:301
    2. Andesman (1999) Pediatr Clin North Am 46:945
    3. Bennett (1999) Pediatr Clin North Am 46:929
    4. Challman (2000) Mayo Clin Proc 75:711
    5. Silver (1999) Pediatr Clin North Am 46:965
    6. Syzmanski (2001) Am Fam Physician 64(8):1355

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