Basic Principles in the Pharmacologic Management of ADHD

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Approved by: Rosa Kim, MD and Fanisha Porter, MD
Updated on: June 2017 

Overview

• Adjunctive Behavioral and Physiological interventions may be indicated in ADHD to address organizational skills deficits or oppositional behavior. Nonetheless, medication is a first-line treatment for ADHD. The treatment of choice is a stimulant. The decision regarding which medication to start and when to start will need to be made as part of an informed consent decision with the patient and the parent/guardian.
• A routine physical exam, including blood pressure, pulse, height, and weight, should be performed prior to initiating stimulants. Vital signs should be checked at each visit for potential tachycardia or hypertension. Obtaining a lead level should be considered for exposed children, but is not part of routine assessment. Baseline EKGs are not recommended unless there is a history of cardiac disease, symptoms suggestive of significant cardiac disease, or a family history of cardiac disease, including but not limited to sudden cardiac death before the age of 50 years, cardiomyopathy, arrhythmias, or tachycardia. Cardiac evaluation is recommended in the presence of excessive increase in blood pressure or pulse, exertional chest pain, or unexplained syncope.

Signs and symptoms

• Inattention
• Hyperactive
• Impulsive behavior

Causes

• Genetics
• Environment
• Development

Treatment

Methylphenidate

• “Rebound” in ADHD symptoms is common in the late-afternoon as the stimulant wears off, even with the sustained-release formulations. An immediate release dose may be given late in the afternoon to help avoid this phenomenon. Watch for sleep disturbances when the stimulants are given later in the day.
• The American Academy of Child and Adolescent Psychiatry (AACAP) identifies the following contraindications to the use of stimulants: glaucoma, symptomatic cardiovascular disease, hyperthyroidism, hypertension, active psychosis, and concomitant use of an MAO-I. If there is a history of substance use in the home, consider Vyvanse or other non-stimulant medications.
• The FDA identifies the following relative contraindications: motor tics, severe anxiety, and a family history or diagnosis of Tourette’s Disorder. In the presence of seizure disorder, it is best to initiate stimulant treatment following adequate seizure control with antiepileptic drugs.
• Vanderbilt rating scale:
  • NICHQ Vanderbilt Assessment Scales
• Common side effects of stimulants and strategies to address them:
  • decreased appetite: dose after meals, frequent snacks, drug holidays, nutritional supplement
    use medication as a last resort:
    • cyproheptadine: 4mg or 8mg
  • sleep disturbance: reduce afternoon dose, move dosing regimen to earlier time, eliminate caffeine,
    use medication as a last resort:
    • melatonin: 1-9mg
    • clonidine : < 0.2mg
    • imipramine: for insomnia, anxiety, and enuresis
    • trazodone
    • mirtazapine: for insomnia + appetite suppression; Tmax=3.5h, so give at ~6 PM
    • antihistamine: acutely
  • symptom rebound: try sustained-release stimulant, add small dose of short-acting in late-afternoon
  • irritability or tearfulness (less common): decrease dose, try another medication, consider co-morbid
    conditions
  • exacerbation of tics (rare): observe, reduce dose, try another medication
  • psychosis/mania/severe depression (rare): stop stimulant, refer to mental health specialist

When to initiate referral/ consider refer to Psychiatry Clinic:

Consider referring to a child psychiatrist if two adequate trials of stimulants or Strattera have failed.

Prior to referral consider the Child Psychiatry Consultation Program (CPCP)

What can referring provider send to Psychiatry Clinic?

1. Using Epic

• Please complete the external referral order

In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:

• Urgency of the referral
• What is the key question you would like answered?

Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

• In order to help triage our patients maximize the visit time, please fax the above information to (414) 607-5288
• It would also be helpful to include:
• Chief complaint, onset, frequency
• Recent progress notes
• Labs and imaging results
• Other Diagnoses
• Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.

Specialist's workup will likely include

After referral to Psychiatry Clinic:
Medication management, or recommendations and referral back to the referring provider to continue care