Dr Uju Ugochukwu
Consultant Adult Psychiatrist
Youth Mental Health Service/Early
Intervention in Psychosis
Great Yarmouth and Waveney
(Norfolk and Suffolk NHS Trust)
This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014.
The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.
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Pharmacological Management of ADHD by Dr Uju Ugochukw
1. Pharmacological
Management of ADHD in
Adults
Dr Uju Ugochukwu
Consultant Adult Psychiatrist
Youth Mental Health Service/Early
Intervention in Psychosis
Great Yarmouth and Waveney
Obianuju
Ugochukwu
(MRCPsych)
Digitally signed by Obianuju Ugochukwu
(MRCPsych)
DN: cn=Obianuju Ugochukwu (MRCPsych)
gn=Obianuju Ugochukwu (MRCPsych) c=United
Kingdom l=GB e=uju@doctors.org.uk
Reason: I am the author of this document
Location:
Date: 2014-03-30 15:37+01:00
2. Outline
Importance of treating ADHD in adults
How the drugs work
Case vignette and treatment
Common adverse effects and
management
Stimulant drugs and abuse potential
3. Why should we treat adults with
ADHD?
It is relatively common
Prevalence rates varies 3 - 4%
(Faraone et al 2005, Kessler et al 2006, Simon et al 2009)
4. Why should we treat adults
with ADHD?
70-80% of children
with ADHD
continue to have
symptoms as adults
(Kooij et al 2010)
4
5. High rates of comorbidity
30%
70%
No comorbidity Comorbidity
5
Average number of comorbid disorders in
referred patients with ADHD is three (kooij et al 2001, 2004,
Biederman et al 1993)
6. Why should we treat adults
with ADHD?
Criminal behaviour reduced by 32%
in men, 41% in women (Lichtenstein et al., 2012)
8. How many adults with ADHD requiring
medication are thought to receive it?
A. 50%
B. About 60%
C. Less than 10%
D. 30%
E. 20%
BAP Guidelines
9. How many adults with ADHD requiring
medication are thought to receive it?
A. 50%
B. About 60%
C. Less than 10%
D. 30%
E. 20%
BAP Guidelines
10. Prevalence of pharmacologically treated attention deficit hyperactivity disorder
(methylphenidate, dexamfetamine or atomoxetine) in patients aged 6-years and
over in UK general practice (with 95% confidence intervals) McCarthy et al. BMC Pediatrics
2012 12:78
12. NICE Guidelines
Drug treatment should always form part of a
comprehensive treatment programme that
addresses psychological, behavioural and
educational or occupational needs.
21. Theory of attention deficit
Prefrontal
cortex
Basal ganglia
VTA
Substantia
Niagra
-
DA
deficiency
Inattention
Professor David Nutt
22. Theory of AD Hyperactivity disorder
Prefrontal
cortex
Basal
ganglia
VTA
Substantia
nigra
-
Inattention
Excessive
activity
Reduced
descending
inhibition
Professor David Nutt
25. Case vignette
Joe a 38-year-old man presents in clinic with anxiety and low mood.
He is having increasing problems in dealing with work and family
issues. He works in advertising at a large company.
Inability to complete projects in a timely and error-free manner.
Has trouble concentrating at work because it is so boring; then he
gets behind because he puts off the really "mind-numbing" tasks in
projects.
His habit of misplacing items like his keys and forgetting family
activities has caused tension recently with his wife. His patience has
worn thin with his really hyper 12-year-old son.
29. Pre-treatment Assessment (UKAAN
website)
Have you been told by your doctor that you have
heart disease
Do you ever get chest pain on exertion?
Have you ever passed out or fainted whilst
exercising?
Has anyone in your family developed heart
disease before the age of 60?
Has anyone in your family died of heart disease
before the age of 60?
30. Pre-treatment Assessment
BP and pulse
Weight
ECG, ECHO if necessary
Risk of abuse or diversion of psycho-
stimulants
31. Pre-treatment Assessment
Atomoxetine
History of liver disease
Patients should be told how to recognise
symptoms (darkening of urine, jaundice,
malaise, nausea)
Routine Liver Function Test not recommended
History of suicidal behaviour
Inform patient of risk of suicidal ideation
32. Stimulants - Methylphenidate
Drug Ritalin Concerta XL Equasym XL Medikinet XL
Ratio of short
acting: long
acting
Short-acting 22:78 30:70 50:50
Duration of
action
3-4 hours Up to 12 hours 8 hours 7- 8 hours
Dosing Twice daily
or three times
daily
18mg/day
increase weekly
by 9 to 18mg
10mg/day
increase weekly
by 10mg
10mg/day
increase weekly
by 10mg
Maximum doses 100mg/day 108mg/day 100mg/day 100mg/day
Food intake Unaffected by
food intake.
Swallowed
whole
Before
breakfast
With or after
breakfast
33. Stimulants - Amphetamines
Drug Dexamphetamine Lisdexamphetamin
e
(Elvanse)
Duration of action 4 – 5 hours Up to 13 hours
Dosing Initially 5mg bd
Increased at weekly
intervals
30mg once-daily
Maximum doses 60mg daily 70mg
35. Case Vignette- Joe
Joe is happy to for a trial of
methylphenidate
Start Concerta XL 18mg
Prescribing for controlled drugs
Dose titrated over 6 weeks or more
35
36. When do we use Atomoxetine?
Often as second line when
Methylphenidate ineffective or not
tolerated
Substance misuse or risk of
diversion
Psychosis
36
37. Atomoxetine
Weight > 70kg = initially 40mg daily
Increase dose by 20mg/day ( max
100mg/daily
Weight < 70kg = 0.5mg/kg daily
Takes a longer time to work
At least 12 weeks on therapeutic dose (BAP Guidelines)
Metabolised via CYP2D6 pathway in the liver.
Poor metabolisers need slower titration
38. Monitoring and titration
Monitor response to treatment using rating
scales
Monitor BP and pulse after each dose change
then every 3 months
Monitor weight every 6 months
If no effect or patient cannot tolerate high
doses, switch to non-stimulant
39. What do the drugs do?
Greater control
Reduced impulsivity and irritability
Improved concentration
Improved tendency to organise and tidy
up
Rating scales – 30% reduction in
severity
40. What do the drugs do?
Improve self-esteem
Reduce anger outbursts
Improves mood swings
Improves social and family
functions
Kooij et al 2010 European consensus
statement
41. Adverse Effects
Decreased appetite and weight loss
Large breakfast, late supper, taking
medication either with or after food
Improves with time
Increased blood pressure
Rarely significant
Palpitations
Usually at start of treatment, cut out
caffeine
44. Third-line medications
Bupropion (licensed as anti-smoking)
Alpha 2 agonists
Clonidine
Guanfacine ( can cause weight gain)
Tricyclic antidepressants
Imipramine
Modafinil
45. Clonidine
Often used as an adjunct
Side effects
Sedation
Hypotension
Dry mouth
Rebound hypertension can be
dangerous in chaotic patients
46. How long should we treat?
For as long as it is clinically
effective
Effect of missed doses should be
evaluated
Review need for medication at
least annually
47. Combination treatment
Limited evidence of what works
Combination of methylphenidate and
Atomoxetine has been tried in poor
response cases
Combination of ER and IR formulations
to manage side-effects
Combination of methylphenidate and
amphetamine is not recommended
47
48. Pregnancy and Lactation
Limited evidence so consider risks and benefits
Illicit stimulants causes low birth weight, prematurity,
increased morbidity (Humphrey’s et al 2007)
No need to discontinue during lactation if baby was
exposed in pregnancy
Systematic review that suggests little methylphenidate
reaches the infant during breast feeding. But little
evidence about its longer term effect. (BAP)
Contact NSFT pharmacy and UK Teratology Information
Service (UKTIS) for latest information
48
49. Are these stimulant drugs
prone to abuse?
Abuse potential relates to route of
administration
Euphoric properties more likely with IV
injection or intranasal use
You can crush Ritalin IR and snort it
If worried, use long acting
methylphenidate, Atomoxetine or
Lisdexamphetamine
51. Adult ADHD Clinic
Special Interest Clinic, since 2006
Now under the Youth Service
Majority diagnosed as children but
discontinued medication
About 60 patients in current clinic
Majority on Concerta XL or Atomoxetine
Non-attendance is a big problem
52. Key messages
ADHD is common and comorbidity is high
Treatment is not more complex than other
common psychiatric conditions.
Treating patients can be very rewarding.
Inadequate dosing is a common cause of
non-response
Evidence does not support significant
abuse of prescribed stimulants