II. General

  1. Medication is not a cure, only control
  2. Medication holiday is not needed
    1. Medication may 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
      1. Drug Abuse occurs six times more commonly in Attention Deficit Disorder
      2. Stimulants do not increase that risk (and might decrease Substance Abuse risk)
      3. Drug Diversion is a higher risk

III. Contraindications

  1. See Specific medications
  2. Age under 6 years old
    1. May be used in ages 4-5 years old for severe refractory symptoms
    2. If used in ages 4-5 years old, start with short-acting low dose Methylphenidate (slower metabolism in young children)
  3. Cardiovascular risks (relative)
    1. Stimulants are low risk of increased cardiovascular events
      1. (2012) Presc Lett 19(2): 12
      2. (2014) Presc Lett 21(9): 54
    2. Monitor Blood Pressure and Heart Rate
    3. See Attention Deficit Disorder for Electrocardiogram indications
    4. Reasons to avoid stimulants
      1. Uncontrolled Hypertension
      2. Serious arrhythmias
      3. Symptomatic heart disease
      4. Recent cardiovascular event (e.g. Syncope)
      5. Congenital Heart Defect (ask related PMH, Family History and screen on ADHD exam)
        1. Consider an EKG before prescribing
        2. Vetter (2008) Circulation 117(18):2407-23. [PubMed]

IV. Adverse Effects: Stimulant Neuropsychiatric Effects (Methylphenidate and Amphetamines)

  1. Rebound ADHD behavior when medication level wanes
  2. Emotional lability, irritability or tearfulness
  3. Social withdrawal
  4. Flat affect
  5. Insomnia (30%)
    1. See Sleep Hygiene
    2. Shift medication dosing to earlier in day
    3. Consider shorter acting stimulant
    4. Consider Melatonin
  6. Anxiety or Tic Disorder
    1. Consider alternative medication (see below)
    2. Consider lower stimulant dose
  7. Headache
  8. Psychosis (at excessive doses)

V. Adverse Effects: Stimulant Gastrointestinal and Growth Effects (Methylphenidate and Amphetamines)

  1. Poor appetite (40%)
    1. Consider holding medication on weekends
    2. Consider decreased stimulant dose or shorter acting agent
    3. Consider larger breakfast (before medication onset of action)
    4. Consider high calorie supplementats (e.g. Boost or Ensure)
  2. Stomach pain
  3. Unintentional Weight Loss
  4. Reduced Growth Velocity

VI. Management: Medication Protocol

  1. Start with short acting first-line stimulant (below)
    1. See Dextroamphetamine (Dexedrine, Dextrostat, Adderall) or Lisdexamfetamine (Vyvanse)
    2. See Methylphenidate (Ritalin, Methylin, Concerta)
  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 medication
    1. Options: Concerta, Adderall XR or Vyvanse
    2. Once daily dosing in sufficient in most cases (these agents typically last 12 hours)
    3. Breakthrough symptoms at end of day
      1. Consider twice daily dosing of intermediate-acting agent (e.g. Ritalin SR)
      2. Consider using 12 hour preparation in morning, and a short-acting stimulant (e.g. Ritalin) in the afternoon
      3. (2013) Presc Lett 20(9): 50-1
  5. Converting between stimulants
    1. Methylphenidate 1 mg is roughly equivalent to 0.5 mg Amphetamine salt, Dextroamphetamine or dexmethylphenidate
    2. Concerta 18 mg/day is roughly equivalent to Methylphenidate 15 mg/day
    3. Switching from Adderall to Dextroamphetamine or Methylphenidate
      1. Start with same total daily dose and titrate up for effect
    4. Switching from Methylphenidate to Adderall
      1. Start with one half of total daily dose and adjust based on effect and adverse effects
  6. Refractory cases with inadequate Attention Deficit Control on a single agent (30% of cases)
    1. Consider confounding diagnoses (comorbidity is present in 70% of attention deficit)
      1. Major Depression
      2. Anxiety Disorder
      3. Chemical Dependency
      4. Other Learning Disorder
    2. Consider increasing dose above labeled maximums in older teens and adults
      1. Consider Consultation with local expert opinion
      2. Methylphenidate has been used up to 100 mg/day
      3. Concerta has been used up to 108 mg/day
      4. Adderall has been used up to 60 mg/day
    3. Consider adjunctive measures
      1. See ADHD Non-Pharmacologic Management
      2. Consider adding or switching to non-stimulants (e.g. Strattera) as below
      3. Consider Third-Line Medications (Antidepressants) as below
      4. Consider Adjunctive medications for modulating emotions as listed below
  7. Long-acting chewable, sprinkle or dissolving preparations for children with difficulty swallowing medication
    1. Methylphenidate preparations (long acting)
      1. Generic
        1. Ritalin LA
        2. Metadate CD Sprinkle caps
      2. Expensive
        1. Aptensio XR spinkle caps (lasts 12 hours)
        2. QuilliChew ER chewable tabs (lasts 8 hours)
    2. Amphetamine preparations (long acting)
      1. Generic
        1. Adderall XR (may be sprinkled on apple sauce)
      2. Expensive
        1. Adzenys XR ODT
        2. Dynavel XR Suspension
    3. References
      1. (2016) Presc Lett 23(3):16

VII. Management: First Line Medications (Stimulants)

  1. Rapid Onset agents with short duration (3 to 6 hours)
    1. Methylphenidate (Ritalin)
    2. Dextroamphetamine (Dexedrine)
    3. Dexmethylphenidate (Focalin)
    4. Dextroamphetamine/Amphetamine (Adderall)
  2. Rapid Onset agents with long duration
    1. Duration 8 hours
      1. Methylphenidate LA (Ritalin LA)
        1. May last up to 12 hours
      2. Amphetamine-Dextroamphetamine (Adderall XR, Focalin XR)
    2. Duration 10 hours
      1. Lisdexamfetamine (Vyvanse)
        1. Onset delayed up to 2 hours
    3. Duration 12 hours
      1. Methylphenidate (Concerta, Daytrana)
      2. Dexmethylphenidate (Focalin XR)
  3. Agents to use if Substance Abuse is a concern (see myths above)
    1. Vyvanse
    2. Bupropion
    3. Strattera
  4. Slow Onset agents with long duration (not recommended)
    1. Methylphenidate (Ritalin-SR or Metadate ER)
    2. Dextroamphetamine (Dexedrine Spansules)
  5. Equivalent dosages
    1. Methylphenidate (Ritalin) 20 mg SR
    2. Dextroamphetamine (Dexedrine) 10 mg spansules
  6. Investigational Agents (Stimulant)
    1. Modafinil (Provigil)
  7. Agents avoided due to toxicity risk
    1. Pemoline (Cylert): Liver toxicity risks

VIII. Management: Second-Line Medications

  1. Atomoxetine (Strattera) - Non-stimulant agent

IX. Management: Third Line Medications (Antidepressants)

  1. Newer Antidepressants (SNRI or Bupropion)
    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)
      3. SSRIs are unlikely to be beneficial
  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)

X. Management: Adjunctive medications for modulating emotions

  1. Indications
    1. Impulsivity
    2. Hyperactivity
    3. Conduct problems
    4. Tics (Tourette's)
  2. Cardiovascular Agents
    1. Clonidine (Catapres)
      1. Regular release
        1. Start 0.05 mg qhs for 3-7 days, then increase to 3-4 doses per day
        2. Maximum 0.2 mg/day if <41 kg, 0.3 mg/kg if <45 kg and 0.4 mg/kg if >45 kg
      2. Extended release
        1. Start 0.1 mg qhs for 7 days, then increase by 0.1 mg twice daily each week as needed to a maximum of 0.4 mg/day
    2. Guanfacine (Tenex)
      1. Regular release
        1. Start 0.5 mg qhs for 7 days, then increase by 0.5 mg twice daily every 3-7 days
        2. Maximum 2 mg/day if <40.5 kg, 3 mg/day if <45 kg, and 4 mg/day if >45 kg
      2. Extended release
        1. 1 mg daily for 7 days, then increase by 1 mg/week up to maximum of 4 mg/day
    3. Beta Blocker
  3. Antiepileptic agents used as mood stabilizers
    1. Carbamazepine (Tegretol)
    2. Divalproex (Depakote)
  4. Psychiatric agents
    1. Risperidone (Risperdal)
      1. Indicated for severe Oppositional Defiant Disorder
      2. Avoid Antipsychotic agents in most cases
    2. Wellbutrin (Bupropion)
      1. Indicated for aggression

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