Microsoft powerpoint - rwu

Roger Wu, M.D.
Staff Psychiatrist, CCDCAssistant Clinical Professor, UCSF ‹First noted to reduce disruptive behavior in 1937‹Short-term use to treat ADHD symptoms is the single largest body of literature on any childhood psychiatric syndrome‹Of the 161 RCT’s, 65-75% of all patients ‹Steady increase in diagnosis and stimulant (methylphenidate, dextroamphetamine) last 3-5 hours after oral dose‹Long-duration or long-term release formulations (pemoline, Concerta, Metadate, ‹Off-task behaviors (increase on-task behaviors) ‹Increased attention in sports activities ‹Decrease response variability and impulsive responding ‹Increase accuracy, short-term memory, reaction time, math computation, problem solving in games and sustained attention ‹Most recently, the NIMH Collaborative Multisite Multimodal Treatment Study of Children with ADHD (MTA Study) ‹12-24 month follow-up showed stable improvements as long as drug is taken ‹Collateral information from parents and school ‹Apathy due to a General Medical Condition ‹No empirically proven threshold of ADHD symptoms that can be used to predict response ‹Only patients with moderate to severe impairment in two or more areas ‹Child should be living with responsible adult(s) who can administer the medication ‹If short-duration medications are used, then school personnel should be available to monitor dosing ‹Other effective modalities (parent training, psychoeducation et al.) should be considered ‹Intermittent excessive sleepiness with recurrent sleep attacks and cataplexy ‹Effective treatment (alongside of modafinil) ‹Apathy due to a General Medical Condition ‹Individuals who have suffered brain injury may exhibit apathy and symptoms similar to ADHD ‹Doses are typically lower than those used in ADHD patients ‹Toxic effects of medications (cancer drugs) ‹History of being used alongside of tricyclicantidepressants with good effect ‹Doses are typically lower than those used to treat ADHD symptomatic cardiovascular disease, hyper-hypothyroidism ‹ Substance abuse: use of illicit stimulants ‹ Family history or diagnosis of Tourette’s ‹ PEM, DEX & AMP (mixed salts) down to ‹ Name of medication, dosage, duration of trial, response and side effects, and estimation of compliance ‹ Previous school placements, behavioral medications, parent training, daily report card ‹ Selecting the Order of Stimulants to Try ‹ Most clinicians will try to minimize side- ‹ PEM should go last, because of the low ‹ Using the Recommended Starting Dose of ‹ DEX/AMP: 2.5 mg equivalent, given after ‹ Deciding on Both a Minimum and Maximum ‹ Children <25 kgs (55 lbs, 5.5--8 years old) should not receive single doses > 15 mg MPH or 10 mg DEX/AMP ‹ Larger children can receive up to 25 mg starting doses, doses should be increased ‹ Deciding on a Method of Assessing Drug ‹ This may include the use of clinical rating ‹ In adolescents and adults, self-ratings ‹ Managing Treatment-Related Side Effects ‹ Insomnia, anorexia, headaches, social ‹ Weighing the patient at each visit gives ‹ Side effect sheets (before, after and ‹ Providing a Schedule for Initial Titration and sufficient for following titration results with reliable parents ‹ Providing a Schedule for Monitoring the ‹ Factors in Scheduling Follow up Frequency ‹ Robustness of drug response (Severity significant impairment from comorbidity, problems with adherence ‹ Collection of teacher reports prior to or at ‹ Most are short-lived, rare and response to ‹ Serious side effects are short lived/rare if the medication is decreased in dose or discontinued ‹ Among severe side effects are: movement disorder, obsessive compulsive ruminations, psychotic symptoms, hepatic failure (Pemoline only) ‹ Only seven side effects routinely occur more ‹ Lowering dose or changing its timing may ‹ When insomnia or appetite loss occurs but stimulant is otherwise highly effective, then adjunctive treatment may be helpful ‹ Staring, daydreaming, irritability, anxiety, and nail-biting typically decrease with dose, representing preexisting symptoms rather than side effects (Benadryl 25-100 mg qhs) or Cyproheptadine (Periactin 2-8 mg qhs) ‹ Sometimes, adding Trazodone (Desyrel 50- ‹ Evening rebound: switch to a longer acting stimulant, give a small “booster” dose late in the day, add Clonidine or Guanfacine ‹ Headache: decrease the dose of stimulant, switch stimulants or try a non-stimulant medication ‹ “Jitters”: eliminate soda (caffeine) or may add a beta ‹ Irritability: determine if it is the underlying disorder or the medication. If it is the medication, decrease dose, change medication, change to non-stimulant ‹ Increased blood pressure/Pulse: monitor and ‹ Tics: currently, low dose stimulants are NOT thought ‹ Summary of the Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents and Adults, J. Am Acad Child AdolscPsychiatry, 40:11, November 2001 ‹ AACAP (in press), Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults J. Am Acad Child AdolescPsychiatry ‹ AACAP (1997) Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. J. Am Acad Child Adolesc Psychiatry 36(suppl):85S-121S ‹ Parallels with adult work; epidemiology, ‹ Present in treatment with a different focus ‹ Interventions are often community-based ‹ Strongly stigmatize any association to ‹ Emphasizing school “lag” as a way ‹ Finally, tolerating parents moving in (teachers and social workers) who can outreach to patient ‹ Compendium of Asian Patent
Medicines: California Department of Health
Services, Food and Drug Branch, Drug &
Cosmetic Team, 601 North 7th Street, MS-357,
P.O. Box 942732, Sacramento, CA 94234-7320
(916)-445-2263
Medication Side Effects-Stimulants (translation by Dr. Clyde Wu, 2003)

Source: http://www.fcmsdocs.org/HealthResources/FCMSConferences/2004/Document/RWu.pdf