Presentation about ADHD

1. (ADHD)
PH: Haider R Fadhil
Clinical Pharmacy Section
Al-kadhumya pediatric HospitalHaider R Fadhil

2. Haider R Fadhil

3. Definition of ADHD
• Attention-deficit/hyperactivity disorder
describes children who display persistent age-
inappropriate symptoms of inattention,
hyperactivity, and impulsivity that are
sufficient to cause impairment in major life
activities. (American Psychiatric Association
[APA], 2000)
Haider R Fadhil

4. Common signs of ADHD
• Inattention
- Often does not give close attention to details or
makes careless mistakes in schoolwork, work, or other
activities.
• hyperactivity
- Often runs about or climbs when and where it is not
appropriate.
• Impulsivity
- Often blurts out answers before
questions have been finished.
Haider R Fadhil

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6. Causes of ADHD
• ADHD is a medical disorder despite many myths
• early theories thought minor head injuries or brain damage were
the cause
• the exact cause is currently unknown, but it is now thought to be
caused by biological factors that influence neurological activity
• genetic influence
• toxins in the environment
• the use of drugs/alcohol during pregnancy
• environmental/family influence
Haider R Fadhil

7. Continue..
Haider R Fadhil

8. The Pathophysiology of ADHD Involves
DA and NE Neurotransmission
• ADHD is associated with abnormal DA and NE
neurotransmission in frontal/striatal areas1,2
• Corticostriatal circuits play an important role in
ADHD1,3,4
• Efficacy of ADHD medications with
pharmacologic activity affecting DA and NE
lends support to the theory of monoamine
dysfunction in ADHD3
• 1. Mercugliano M. Ment Retard Dev Disabil Res Rev. 1995;1:220-226; 2. Krause K-H
et al. Neurosci Let. 2000;285:107-110; 3. Markowitz JS et al. Pharmacotherapy.
2003;23:1281-1299; 4. Zametkin AJ et al. J Clin Psychiatry. 1998;59(suppl 7):17-23.
Haider R Fadhil

9. Low self-
esteem
Smoking and
substance abuse
Injuries Motor vehicle
accidents
Legal
problems
Occupational/
vocational
difficulties
Childhood Adolescence Adulthood
American Academy of Pediatrics. Pediatrics. 2000;105:1158-1170; Kelly PC et al. Pediatrics. 1989;83:211-217; Murphy K
et al. Compr Psychiatry. 1996;37:393-401; Biederman J. J Clin Psychiatry. 2004;65(suppl 3):3-7; Barkley RA et al.
Pediatrics. 1996;98:1089-1095; Swensen A et al. J Adolesc Health. 2004;35:346.e1-9.
Impaired family and
peer relationships
Academic
limitations
Potential Impact of Untreated ADHD Across the Lifespan
Haider R Fadhil

10. Diagnosis
• ADHD is diagnosed by an assessment of a person's
childhood behavioral and mental development,
including ruling out the effects of drugs, psychiatric
problems as explanations for the symptoms.
• It often takes into account feedback from parents and
teachers.
• In North America, DSM-5 criteria are used for
diagnosis, while European countries usually use the
ICD-10. With the DSM-IV criteria a diagnosis of ADHD
is 3–4 times more likely than with the ICD-10 criteria.
Haider R Fadhil

11. Theraputic optins
psychotherapy
interventions
Medications
Management
Haider R Fadhil

12. Medication options
2 main Classes of Medication
Stimulents
Methylphenidate Amphetamine
Non-stimulents
Atomoxetine
(strattera)
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13. Medications Used to Treat ADHD
Stimulant Drugs
• Central nervous system (CNS) stimulants are
agents that increase physical activity, mental
alertness and attention span
• Stimulant drugs are often beneficial in curbing
hyperactivity and impulsivity, and helping the
individual to focus, work, and learn.
• Sometimes the drugs will also help with
coordination problems which may hinder sports
and handwriting.
Haider R Fadhil

14. • Stimulant medications commonly prescribed for
attention deficit disorder include
methylphenidate (Ritalin, Concerta, Metadate,
Methylin) and certain amphetamines (Dexedrine,
Dextrostat, Adderall).
• Methylphenidate is a short acting drug, and in
older forms, had to be taken multiple times a day
• Under medical supervision, these stimulant drugs
are quite safe and do not make the child feel
“high”, although they may feel slightly different
Haider R Fadhil

15. • To date, there is not convincing evidence that
children risk becoming addicted to these
drugs, when used for ADHD
• Many of the stimulant drugs come in short-
term and long-term forms
• some are made as “sustained-release” — they
are taken in the morning before school and
are effective all day
Haider R Fadhil

16. Lisdexamphetamine
• a central nervous system stimulant.
• It is a prodrug of dextroamphetamine
• FDA-approved drugs used to treat attention deficit
hyperactivity disorder (ADHD).
• help increase attention and decrease impulsiveness
and hyperactivity in patients with ADHD.
• doesn’t become active until it’s in your digestive
system, its potential for misuse may be less than the
risk of other stimulants that act as soon as they’re in
your body.
• Vyvanse is a brand name for the drug lisdexamfetamine
dimesylate
Haider R Fadhil

17. Mechanisms of Action
• alters brain chemicals It is a central nervous
stimulant drug that works by restoring the
balance of chemical substances in the brain.
• However, it targets dopamine as well as
norepinephrine
• It’s thought that this drug helps keep more
dopamine in the brain and helps stimulate the
release of norepinephrine.
• As a result, more of these chemicals are available
to stimulate the brain. This helps increase
attention and focus
Haider R Fadhil

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19. Dose by oral
• Children 6–12 years of age: Initially, 30 mg once daily
(as initial treatment for ADHD or in patients being
switched to lisdexamfetamine from other drugs);
dosage may be adjusted in 10- or 20-mg increments at
weekly intervals; maximum 70 mg daily.
• If the initial 30-mg daily dosage is not tolerated, dosage
may be decreased to 20 mg daily.
• Vyvanse is a long-acting drug. It enters your body in an
inactive form. As you digest the drug, your body slowly
converts it into its active form. Then it starts working.
You take Vyvanse once per day. Taking it in the morning
gives the most benefits during waking hours.
Haider R Fadhil

20. General Instructions for Use
Take Vyvanse by mouth in the morning with or without food
avoid afternoon doses because of the potential for insomnia
Dosage form
- capsule:
Swallow Vyvanse capsules whole or Open capsules,
empty and mix the entire contents with yogurt, water, or orange
juice.
- chewable tablets
Haider R Fadhil

21. Pharmackokinetic
Bioavailability
• Lisdexamfetamine (a prodrug of dextroamphetamine) is
rapidly absorbed from the GI tract. Peak plasma
concentrations of lisdexamfetamine occur in approximately
1 hour; concentrations are low and transient;
nonquantifiable by 8 hours after administration.1 Peak
plasma concentrations of dextroamphetamine occur in
approximately 3.5–3.7 hours.
Onset
• Occurs within 2 hours after oral administration.
Duration
• Approximately 10–12 hours.
Haider R Fadhil

22. price
• Quantity Per unit Price
100 $9.50 $949.80
strength
• 10 mg , 20 mg ,30 mg, 40 mg, 50 mg, 60 mg, 70 mg
Haider R Fadhil

23. Contraindications
• Known hypersensitivity to amphetamine
products
• ​Patients taking monoamine oxidase inhibitors
(MAOIs), or within 14 days of stopping MAOIs
(including MAOIs such as linezolid or
intravenous methylene blue), because of an
increased risk of hypertensive crisis
Haider R Fadhil

24. Atomoxetine
FDA-approved drugs used to treat attention deficit hyperactivity disorder (ADHD)
Classified as a norepinephrine reuptake inhibitor (NRI)
Atomoxetine is an immediate-release drug.
It begins to work quickly after you take it.
You can take it once or twice per day, depending on your prescribed dosage
Haider R Fadhil

25. Mechanism of action
• It works by changing the way your brain absorbs
the chemical norepinephrine as well as how that
chemical acts in your body.
• Norepinephrine affects your overall mood. By
changing how it works in your body,
• may be able to:
- decrease hyperactivity
- improve attention span
- reduce impulsive behaviors
Haider R Fadhil

26. Dosage Forms and Strengths
• Each capsule contains atomoxetine HCl equivalent
to 10 mg ,18 mg , 25 mg , 40 mg 60 mg, 80 mg or
100 mg
• Quantity Perunit Price
30 $6.92 – $14.03 $207.63 – $420.80
Haider R Fadhil

27. Clinical trial of atomoxetine
• an 8-week randomized, double-blind, placebo-controlled,
dose-response, acute treatment study of children and
adolescents aged 8 to 18 (N=297), patients received either
a fixed dose of Strattera (0.5, 1.2, or 1.8 mg/kg/day) or
placebo. Strattera was administered as a divided dose in
the early morning and late afternoon/early evening. At the
2 higher doses, improvements in ADHD symptoms were
statistically significantly superior in Strattera-treated
patients compared with placebo-treated patients as
measured on the ADHDRS scale. The 1.8 mg/kg/day
Strattera dose did not provide any additional benefit over
that observed with the 1.2 mg/kg/day dose. The 0.5
mg/kg/day Strattera dose was not superior to placebo.
Haider R Fadhil

28. Pharmacokinetic
Bioavailability
63 to 94%
Protein
binding 98%
Biological
half-life 5.2 h
Haider R Fadhil

29. Contraindication
• Hypersensitivity to atomoxetine or any of the
excipients in the product
• Symptomatic cardiovascular disease
• Concomitant treatment with monoamine oxidase
inhibitors
• Should at least 14 day stoped MAOIs to take
atomoxetine.
• WARNING: SUICIDAL IDEATION IN CHILDREN AND
ADOLESCENTS
- atomoxetin increased the risk of suicidal
ideation in short-term studies in children or
adolescents with Attention-Deficit/Hyperactivity
Disorder (ADHD)
Haider R Fadhil

30. Both Strattera and Vyvanse can cause side effects. The
side effects that both drugs can cause are:
abdominal pain aggressive behavior
agitation anxiety
constipationdecreased appetite
decreased sex drivedepression
diarrhea
Haider R Fadhil

31. Haider R Fadhil

32. Essential Fatty Acids
• Omega 3 , omega 6 , omega 9
• Essential fatty acids are polyunsaturated fatty acids
• They are essential in the human diet because there is
no synthetic mechanism for them.
• Nutritionally important n−3 fatty acids include -
eicosapentaenoic acid (EPA),
docosahexaenoic acid (DHA)
• DHA – important for brain/eye development
NAS, 2002
Haider R Fadhil

33. Omega-3 FAs
• EPA – eicosapentaenoic acid – C20:5 n-3
• DHA – docosahexaenoic acid – C22:6 n-3
Haider R Fadhil

34. ADHD
• "Omega-3 fatty acids in ADHD and related
neurodevelopmental disorders".
• a b c Richardson, Alexandra J. (2006). "Omega-3 fatty acids in ADHD and related
neurodevelopmental disorders". Int Rev Psychiatry 18 (2): 155–
172.doi:10.1080/09540260600583031. PMID 16777670.
Haider R Fadhil

35. Clinical Report
• Omega-3 fatty acids are dietary essentials, and
are critical to brain development and function.
• Increasing evidence suggests that a relative lack
of omega-3 may contribute to many psychiatric
and neurodevelopmental disorders.
• Theory and experimental evidence support a role
for omega-3 in ADHD
• Dietary supplementation with fish oils (providing
EPA and DHA) appears to alleviate ADHD-related
symptoms in at least some children
• Given their relative safety and general health
benefits, omega-3 fatty acids offer a promising
complementary approach to standard
treatments. Haider R Fadhil

36. • "Omega-3/Omega-6 Fatty Acids for Attention
Deficit Hyperactivity Disorder: A Randomized
Placebo-Controlled Trial in Children and
Adolescents.".
• Johnson M, Ostlund S, Fransson G, Kadesjö B, Gillberg C. (2008 Apr 30). "Omega-
3/Omega-6 Fatty Acids for Attention Deficit Hyperactivity Disorder: A Randomized
Placebo-Controlled Trial in Children and Adolescents.". J Atten Disord 12 (5): 394–
401. doi:10.1177/1087054708316261. PMID 18448859.Haider R Fadhil

37. Clinical Report
• Objective: The aim of the study was to assess
omega 3/6 fatty acids in attention deficit
hyperactivity disorder (ADHD).
• Results: 25% reduction of ADHD symptoms and a
drop of CGI scores to the near-normal range.
• After 6 months, 47% of all showed such
improvement.
• Responders tended to have ADHD inattentive
subtype and comorbid neurodevelopmental
disorders. Haider R Fadhil

38. Clinical report
• Conclusion: Children and adolescents with
ADHD, characterized by inattention and
associated neurodevelopmental disorders,
treated with omega 3/6 fatty acids for 6
months responded with meaningful reduction
of ADHD symptoms.
(J. of Att. Dis. 2009; 12(5) 394-401
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