Psychopharmacologic Approaches to Treatment of Psychopathology

  // Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder A Young Girl With ADHD

 

Decision Point One Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

RESULTS OF DECISION POINT ONE

• 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 in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
• Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute

Decision Point Two

Select what the PMHNP should do next:

Continue same dose of Ritalin and re-evaluate in 4 weeks

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Katie’s academic performance is still improved, but her attention continues to worsen throughout the school day
• Katie is still reporting that her heart feels “funny.” Today’s pulse rate is 122 beats per minute, regular rhythm

Decision Point Three

Select what the PMHNP should do next:

Change to Ritalin LA 20 mg orally daily in the morning

Guidance to Student

Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.

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Obtain a STAT EKG

Guidance to Student

Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.

Start Over

Discontinue Ritalin and begin Adderall (amphetamine d, l) 10 mg orally daily

Guidance to Student

Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.

Start Over

Change to Ritalin LA 20 mg orally daily in the MORNING

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Katie’s academic performance is still improved, and the switch to the LA preparation is lasting Katie throughout the school day
• Katie’s reports of her heart feeling “funny” have gone away. Pulse was 92 during today’s office visit

Decision Point Three

Select what the PMHNP should do next:

Maintain current dose of Ritalin LA and reevaluate in 4 weeks

Guidance to Student

At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.

Start Over

Increase Ritalin LA to 30 mg orally daily

Guidance to Student

At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.

Start Over

Obtain EKG based on current heart rate

Guidance to Student

At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.

Start Over

Discontinue Ritalin and begin Adderall XR 15 mg orally daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Katie’s academic performance is still improved, and the XR preparation has helped sustain her attention throughout the school day, however, you also learn that Katie is having tachycardia with this medication, too

Decision Point Three

Select what the PMHNP should do next:

Maintain current dose of medication and re-evaluate in 4 weeks

Guidance to Student

Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.

Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.

There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.

Start Over

Decrease to Adderall XR 10 mg orally daily

Guidance to Student

Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.

Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.

There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.

Start Over

Discontinue Adderall XR and begin Strattera 10 mg orally daily

Guidance to Student

Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.

Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.

There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.

Start Over