BCPS 2013: ADHD Pediatrics (Stimulants: Amphetamines)

Ironically enough I could stand to use an amphetamine this morning as I am struggling to wake up.  Caffeine will have to suffice.  Have you started studying yet?  I really think it's time if you want to make it a more enjoyable experience rather than cramming as I did last year.  It just doesn't work for an old 40 year-old brain like myself.  That's right.  I'm turning 40 today.  I cannot believe it.  Ask anyone around me though, (ok maybe this is just a hope I have) I still am youthful.  Perhaps it's the young toddler almost kindergartner and 2 1/2 year-old I have.  Perhaps it's my mindset.  Whatever it is, I hope it sticks around the next 40 years.  

Amphetamine-containing products in ADHD

1.  Adderall - mixed amphetamine salts immediate release

2.  Adderall XR - mixed amphetamine salts extended release:  indicated for the treatment of ADHD in children 6 years and older.  50/50 immediate release and extended release beads.  Duration 10-12 hours.  Once daily dosing.  Can sprinkle on applesauce.

3.  Vyvanse - Lisdexamfetamine dimesylate (say that one three times fast!):  prodrug, designed for less abuse, duration 10 hours, no clinical superiority over other amphetamine-containing meds.

Adverse Effects of Amphetamine-containing products:  appetite loss, insomnia, abdominal pain, and nervousness, hypertension worsening, tic disorder worsening.  *Recent labeling change warns of association with sudden cardiac death (potential) so IS NOT RECOMMENDED FOR PATIENTS WITH KNOWN STRUCTURAL HEART DEFECTS.  Routine eletrocardiography is not recommended unless history and physical exam suggest cardiac disease.  And, don't withhold if you can't get an electrocardiogram or assessment by a pediatric cardiologist (if otherwise healthy).

Nonstimulant medications in ADHD

1.  Strattera - Atomoxetine Potent inhibitor of NE reuptake, once or twice daily dosing, **considered first line therapy for children with an active substance abuse problem, comorbid anxiety, or tics.

Adverse Effects - dyspepsia, decreased appetite, weight loss, and fatigue, can cause liver injury but don't monitor liver enzymes, *doesn't exacerbate tics (imagine a question like this:  kid has tics what is the best choice for ADHD), and don't forget black box warning that a lot of SSRIs have for suicidal ideation in children and teens.  AND Please don't forget CYP2D6 with atomoxetine.

2.  Antidepressants - Non-FDA label approved treatment - Bupropion and Imipramine/Nortriptyline

Bupropion obviously contraindicated in seizure disorder.  Can use immediate or extended release.

Imipramine and Nortriptyline - electrocardiogram to start and after each dose increase and desipramine used with extreme caution due to reports of sudden death.

3.  Alpha-Adrenergic Receptor Agonists - Clonidine and Guanfacine

Clonidine - KAPVAY - ADHD in 6-17 year olds (clonidine extended release), use in combo with methylphenidate lessons tics

May be more effective for hyperactivity than for inattention

adverse effect:  SEDATION

Guanfacine - Intuniv - extended release for 6-17 year olds.  Shown to improve comorbid tic disorder.  Less sedating with a longer DOA than clonidine.  Can have rebound hypertension with abrupt d/c of extended release product.