Psychopharmacologic Approaches to Treatment of Psychopathology

  // Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder A Young Girl With ADHD

 

Decision Point One Begin Intuniv extended release 1 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Katie’s teacher reports no change in her classroom behaviors
• Katie's parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”

Decision Point Two

Select what the PMHNP should do next:

Increase Intuniv to 2 mg orally at BEDTIME

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• katie's parents report that Katie is even more sedate and has been refusing to get out of bed in the morning. Her teacher reports that she has gone from being a “daydreamer” in class to being on the “verge of falling asleep.”
• Katie's parents state that there were two instances where Katie fell asleep on the school bus on her way to school in the morning prompting the school nurse to call Katie’s parents

Decision Point Three

Select what the PMHNP should do next:

Maintain current dose of Intuniv

Guidance to Student

Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.

Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.

Start Over

Decrease Intuniv to 1 mg orally daily at BEDTIME

Guidance to Student

Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.

Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.

Start Over

Discontinue Intuniv and begin Strattera (atomoxetine) 10 mg orally daily

Guidance to Student

Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.

Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.

Start Over

Discontinue Intuniv and begin Dexedrine (dextroamphetamine) 5 mg orally daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are better, but that she can be a bit “hyper” at times. Katie’s parents report that Katie is sometimes too “wound up” to go to bed and bedtime has become a “difficult” time in the house
• Katie's parents are also concerned about her appetite, which has decreased since beginning the Dexedrine. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened

Decision Point Three

Select what the PMHNP should do next:

Maintain current dose of Dexedrine and reevaluate in 4 weeks

Guidance to Student

Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. The PMHNP should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily.

Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.

Start Over

Increase Dexedrine to 10 mg extended release

Guidance to Student

Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. The PMHNP should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily.

Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.

Start Over

Discontinue Dexedrine and begin Concerta (methylphenidate) 18 mg orally daily

Guidance to Student

Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. The PMHNP should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily.

Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.

Start Over

Discontinue Intuniv and begin Focalin (dexmethylphenidate) XR 10 mg orally daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better, and that her academic performance has improved considerably
• Katie’s parents are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened

Decision Point Three

Select what the PMHNP should do next:

Maintain current dose of Focalin XR and re-evaluate at next clinic visit in 4 weeks

Guidance to Student

Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.

Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).

Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.

Start Over

Increase Focalin XR to 20 mg orally daily

Guidance to Student

Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.

Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).

Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.

Start Over

Discontinue Focalin XR and begin Strattera (atomoxetine) 10 mg orally daily

Guidance to Student

Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.

Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).

Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.

Start Over