1. ADHD
Diagnosis &
Pharmacological
Management
Lori Dewey, MSN, PMHCNS-BC
September 2014

2. Objectives
 Understand the screening and diagnosis of
ADHD
 Develop knowledge of common
medications used to treat ADHD in adults
 Know the indications, dosage ranges,
mechanisms of actions, monitoring, and
contraindications of medications used to
treat ADHD

3. ADHD Defined
 ADHD is a problem with inattentiveness,
over-activity, impulsivity, or a combination
these
– http://www.ncbi.nlm.nih.gov/pubmedhealth/P
MH0002518/

4. Inattentive Symptoms
 Fails to give close attention to details or makes careless
mistakes in schoolwork
 Has difficulty keeping attention during tasks or play
 Does not seem to listen when spoken to directly
 Does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace
 Has difficulty organizing tasks and activities
 Avoids or dislikes tasks that require sustained mental
effort (such as schoolwork)
 Often loses toys, assignments, pencils, books, or tools
needed for tasks or activities
 Is easily distracted
 Is often forgetful in daily activities

5. Hyperactivity Symptoms
(More likely in children)
 Fidgets with hands or feet or squirms in seat
 Leaves seat when remaining seated is expected
 Runs about or climbs in inappropriate situations
 Has difficulty playing quietly
 Is often "on the go," acts as if "driven by a
motor," talks excessively

6. Impulsivity Symptoms
 Blurts out answers before questions have
been completed
 Has difficulty awaiting turn
 Interrupts or intrudes on others (butts
into conversations or games)
– http://www.ncbi.nlm.nih.gov/pubmedhealth/
PMH0002518/

7. Diagnosis
 Screening tool:
– Adult ADHD Self-Report Scale (ASRS-
v1.1)
http://www.help4adhd.org/documents/adulta
dhdselfreportscale-asrs-v1-1.pdf

8. DSM IV Criteria
A. Either (1) or (2)
1) Six or more of the following symptoms of inattention have persisted for at least six months to a
degree that is maladaptive and inconsistent with the developmental level:
Inattention
 often fails to give close attention to details or makes careless mistakes in schoolwork, work, or
other activities
 often has difficulty sustaining attention in tasks or play activities
 often does not seem to listen when spoken to directly
 often does not follow through on instructions and fails to finish schoolwork, chores, or duties in
the workplace (not due to oppositional behaviour or failure of comprehension)
 often has difficulty organizing tasks and activities
 often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such
as schoolwork or homework)
 often loses things necessary for tasks or activites at school or at home (e.g. toys, pencils, books,
assignments)
 is often easily distracted by extraneous stimuli
 if often forgetful in daily activities

9. DSM IV Criteria Cont.
2) Six or more of the following symptoms of hyperactivity-impulsivity have
persisted for at least 6 months to a degree that is maladaptive and
inconsistent with the developmental level:
Hyperactivity
 often fidgets with hands or feet or squirms in seat
 often leaves seat in classroom or in other situations in which remaining
seated is expected
 often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective
feelings of restlessness)
 often has difficulty playing or engaging in leisure activities quietly
 often talks excessively
 is often 'on the go' or often acts as if 'driven by a motor'
Impulsivity
 often has difficulty awaiting turn in games or group situations
 often blurts out answers to questions before they have been completed
 often interrupts or intrudes on others, e.g. butts into other children's games

10. DSM IV Criteria Cont.
 B. Some hyperactivity - impulsive or inattentive symptoms that cause impairment
were present before the age of 7 years.
 C. Some impairment from the symptoms is present in more than two or more
settings (e.g. at school or work or at home).
 D. There must be clear evidence of clinically significant impairment in social,
academic, or occupational functioning.
 E. The symptoms do not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder, and are not
better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety
Disorder, Dissociative Disorder, or a Personality Disorder).
Based on these criteria, three types of ADHD are identified:
 ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
 ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not
met for the past six months
 ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but
Criterion 1A is not met for the past six months.

11. Treatment
 Behavioral and cognitive therapies
– Focused on reducing impulsivity and
reinforcing positive long-term habits
 Pharmacological management
– Stimulants
– Non-stimulants

12. Treatment
 Stimulants:
– Adderall and Adderall XR
– Vyvanse
– Ritalin and Ritalin LA
– Daytrana
– Concerta
– Focalin and Focalin XR
 Non-stimulants:
– Strattera
– Wellbutrin
– Tenex
– Intuniv – no adult dosing available
– Clonidine
– Kapvay – no adult dosing available

13. Stimulants
 Monitor mood symptoms:
– Depression
– Anxiety
– Agitation
– Psychosis
– Emotional lability
– Exacerbation of bipolar sx

14. Stimulants
 Monitor LFTs
 Short acting stimulants have a higher potential for abuse
and more street value than longer acting stimulants
 All stimulants carry a black box warning of potential drug
dependence and abuse
 Collaborate care with other providers/specialists for pt
with CV diseases/disorders, HTN, seizure disorders, liver
impairment, etc
 Caution with drugs that inhibit metabolism of stimulants
– Especially Prozac

15. Stimulants
 Adderall XR, Ritalin LA, Focalin, and
Vivanse may be opened up and sprinkled
on food
 Vyvanse capsule may be dissolved in
water

16. Adderall
 Adderall
(dextroamphetamine/amphatimine)
– Dosage forms: 5, 7.5, 10, 12.5, 15, 20, 30mg
– 5-40 mg/day PO divided qd-tid
– Start 5 mg po qam or bid
– Increase 5 mg/day qwk
– Dose 4-6 hours apart
– Doses >40 mg rarely more effective

17. Adderall
 BLACK BOX WARNING: HIGH ABUSE
POTENTIAL, DEPENDENCY
– SERIOUS CARDIOVASCULAR ADVERSE
EVENTS & SUDDEN DEATH REPORTED WITH
MISUSE

18. Adderall
 ^^ dopamine & norepinephrine in the
presynaptic neuron
– More robust in it’s action
– ^^ incidence of side effects
– Highly abused
– Works well at low doses
– Good for someone with no hx of mood
disorders or substance abuse

19. Adderall
 Caution with: cardiovascluar disease, HTN,
arrhythmias, drug abuse hx, psychosis, bipolar,
depression, Tourettes/tics, seizures
 May cause dysthymia
 Side effects are dose dependent
 ^^ GI effects if taken on an empty stomach
 Avoid abrupt withdrawal

20. Adderall
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate

21. Adderall XR
 Adderall XR
(dextroamphetamine/amphatimine)
– Dosage forms: 5, 10, 15, 20, 25, 30mg ER
– Start 20 mg i po qam
– Increase 10 mg/day q week
– Maximum dose: 60 mg/day
– 6-10 hour duration
– May augment with IR

22. Adderall XR
 BLACK BOX WARNING: HIGH ABUSE
POTENTIAL, DEPENDENCY
– SERIOUS CARDIOVASCULAR ADVERSE
EVENTS & SUDDEN DEATH REPORTED WITH
MISUSE

23. Adderall XR
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures
 Avoid abrupt withdrawal

24. Adderall XR
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate

25. Vyvanse
 Vyvanse (lisdexamfetamine)
– Dosage forms: 20, 30, 40, 50, 60, 70 mg
– 30 mg po qam
– Increase 10-20 mg/day q week
– Maximum dose: 70 mg/qd
– Use lowest effective dose
– Molecules dissolve in the stomach. Less street
value
– Difficult to get insurance to cover

26. Vyvanse
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures

27. Vyvanse
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate
– Hyperhydrosis

28. Ritalin
 Ritalin (methylphenidate)
– Dosage forms: 5, 10, 20 mg
– Start 5-10 mg po bid
– Increase 10 mg/day q week
– May be dosed bid-qid
– Duration: 3-5 hours
– Give 30-45 min before meals
– Last dose before 6 pm

29. Ritalin
 BLACK BOX WARNING: DRUG
DEPENDENCE

30. Ritalin
 Avoid use within 14 days of MAOI
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures

31. Ritalin
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate

32. Ritalin LA
 Ritalin LA (methylphenidate)
– Dosage forms: 10, 20, 30, 40 mg ER
– Start 20mg po qam
– Increase 10 mg/day q week
– Maximum dose: 60 mg/qd
– Duration: 8-20 hours
– Do not crush or chew

33. Ritalin LA
 BLACK BOX WARNING: DRUG
DEPENDENCE

34. Ritalin LA
 Avoid use within 14 days of MAOI
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures

35. Ritalin LA
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate

36. Daytrana
 Daytrana (methylphenidate transdermal)
– Dosage forms: 10, 15, 20, 30/9 h patch
– Apply 1 patch qd x 9h. Off 15h
– Start 10mg/9h patch qd x 9h off x 15 h
– Increase next size patch q week
– Maximum dose: 30 mg/9 h patch qd
– Apply 2 h before desired effect
– Drug effects may persist 5 hours after removal
– Use same titration when converting from po
– Do not alter/cut patch

37. Daytrana
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures

38. Daytrana
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate
– ALT/AST elevation

39. Concerta
 Concerta (methylphenidate) – long acting ritalin
– Dosage forms: 18, 27, 36, 54 ER
– Dose: 18-72 mg po qam
– Start 18-36 mg po qd
– Increase by 18 mg/day q wk
– Maximum dose: 72 mg/day. May be dosed bid in some cases
– Duration: 8-12 hours
– Do not cut, crush or chew
– Dissolves in stomach in layers
– Less potent effect. Only effects dopamine. More tolerable in pt
with emotional problems

40. Concerta
 BLACK BOX WARNING: DRUG
DEPENDENCE
– CHRONIC ABUSE MAY LEAD TO MARKED
TOLERANCE AND PSYCHOLOGICAL
DEPENDENCE

41. Concerta
 Avoid use within 14 days of MAOI
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures

42. Concerta
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate

43. Focalin
 Focalin (dexmethylphenidate)
– Pure molecule of ritalin
– Dosage forms: 2.5, 5, 10 mg
– Start 2.5 mg po bid
– Increase 5-10 mg/day q week
– Maximum dose: 20 mg/day
– Difficult to get insurance to cover
– To convert from methylphenidate:
 Start at 50% of current methylphenidate daily
dose

44. Focalin
 BLACK BOX WARNING: DRUG
DEPENDENCE

45. Focalin
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures

46. Focalin
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate

47. Focalin XR
 Focalin XR (dexmethylphenidate)
– Dosage forms: 5, 10, 15, 20, 25, 30, 35, 40
mg ER
– Start 10 mg po q am
– Increase 10mg/day q week
– Maximum dose: 40 mg/day
– To convert from IR form use same same daily
dose. To convert from methylphenidate start
at 50% of current methylphenidate daily dose
– Do not crush/cut/chew

48. Focalin XR
 BLACK BOX WARNING: DRUG
DEPENDENCE

49. Focalin XR
 Caution with:
 cardiovascluar disease/arrhythmias
 HTN
 drug abuse hx
 psychosis
 bipolar
 Tourettes/tics
 seizures

50. Focalin XR
 Common side effects:
– Loss of appetite/weight loss
– Dry mouth
– Difficulty sleeping
– Headaches
– Abdominal pain, nausea, vomiting
– Temporary increases in blood pressure
– Emotional changes
– Increased heart rate

51. Strattera
 Strattera (atomoxetine)
– NON STIMULANT
– May take up to 4-6 weeks to see results
– Dosage forms: 10, 18, 25, 40, 60, 80, 100 mg
– Start 40 mg po qam x 3 days
– Increase to 80 mg/day
– May increase to 100 mg/day after 2 weeks if needed
– Maximum dose: 100 mg/qd
– Requires slower titration if pt is poor CYP2D6 metabolizer or on
strong CYP2D6 inhibitor
– Norepinephrine reuptake inhibitor
– Doses >40 mg/day may be divided bid
– Dosing accd to weight= 0.5-1.4 mg/kg/day

52. Strattera
 Avoid use within 14 days of MAOI
 cardiovascluar disease/arrhythmias
 HTN/hypotension
 tachycardia
 hepatic impairment
 depression
 bipolar

53. Strattera
 Common side effects:
– Headache
– Dizziness
– Loss of appetite/weight loss/dry mouth
– Difficulty sleeping/somulance/fatigue
– Abdominal pain, nausea, vomiting/constipation
– Erectile dysfxn/decreased libido/ejaculatory dysfxn
– Urinary hesitancy/retention
– Dysmenorrhea
– Diaphoresis
– Emotional changes
– Increased heart rate/BP

54. Wellbutrin
 Wellbutrin (buproprion)
– NON STIMULANT
– ADHD: 100 mg po tid
– Dosage forms: 75, 100 mg
– Start 100 mg po bid
– Increase after 3 days
– Maximum dose: 150 mg/dose up to 450
mg/day
– ADHD responds to high doses

55. Wellbutrin
 Avoid use within 14 days of MAOI
– Seizure Disorder/decreased seizure threshold
– Appetite disturbance
– Head injury
– HTN
– Bipolar
– Hepatic/renal impairment
– Bulemia – may cause e-lyte imbalance

56. Wellbutrin
 Common side effects:
– Agitation/anxiety
– Headache/dizziness
– Nausea/constipation/appetite decrease/weight loss/abd.
pain/diarrhea
– Tremor
– Diaphoresis
– Abnormal dreams/insomnia
– Tinnitus
– Palpatations

57. Wellbutrin SR
 Wellbutrin SR (bupropion)
– NON STIMULANT
– Dosage forms:100, 150, 200 mg ER
– Start 100 mg po qam
– Increase 100 mg/day q week
– Divide dose bid
– Maximum dose: 400 mg/day
– Do not cut, crush or chew

58. Wellbutrin SR
 Avoid use within 14 days of MAOI
– Seizure Disorder/decreased seizure threshold
– Appetite disturbance
– Head injury
– HTN
– Bipolar
– Hepatic/renal impairment

59. Wellbutrin SR
 Common side effects:
– Agitation/anxiety
– Headache/dizziness
– Nausea/constipation/appetite decrease/weight loss/abd.
pain/diarrhea
– Tremor
– Diaphoresis
– Abnormal dreams/insomnia
– Tinnitus
– Palpatations

60. Wellbutrin XL
 Wellbutrin XL (bupropion)
– NON STIMULANT
– Dosage forms: 150, 300 mg ER
– Start 150 mg po qam
– Increase after 7 days to 300 mg
– Maximum dose: 450 mg/day
– Do not cut, crush or chew

61. Wellbutrin XL
 Avoid use within 14 days of MAOI
– Seizure Disorder/decreased seizure threshold
– Appetite disturbance
– Head injury
– HTN
– Bipolar
– Hepatic/renal impairment

62. Wellbutrin XL
 Common side effects:
– Agitation/anxiety
– Headache/dizziness
– Nausea/constipation/appetite decrease/weight loss/abd.
pain/diarrhea
– Tremor
– Diaphoresis
– Abnormal dreams/insomnia
– Tinnitus
– Palpatations

63. Tenex
 Tenex (guanfacine)
– NON STIMULANT – OFF LABEL
– Dosage forms: 1, 2 mg
– Start: 0.5 mg po q evening
– Increase 0.5 mg/day q week
– Given bid-qid
– Maximum dose: 4 mg/day

64. Tenex
 Caution with:
– Elderly
– Hepatic impairment
– Renal impairment
– Cardiovascular disease
– Hypotension
– Avoid abrupt withdrawal – may cause
withdrawal sx & rebound HTN

65. Tenex
 Common side effects:
– Somnolence
– Hypotension
– Dizziness
– Constipation
– Fatigue
– Headache
– Impotence

66. Intuniv
 Intuniv (guanfacine) – long acting tenex
– 24 hr release
– Dosage forms: 1, 2, 3, 4 mg ER
– Weight dose – 0.05-0.12 mg/kg/day
– Start 1 mg po qd x 1 week then 2 mg po qd
– Hypotension & ^^ HR common
– NO DOSAGE RANGE FOR USE IN ADULTS

67. Clonidine
 Clonidine
– NON STIMULANT – OFF LABEL
– Dosage forms: 0.1, 0.2, 0.3 mg
– Start: .025-.05 mg po q evening
– Increase 0.025-.05 mg/day q week
– Given bid-qid
– Maximum dose: 0.3 mg/day

68. Clonidine
 Caution with:
– Elderly
– Hepatic impairment
– Renal impairment
– Cardiovascular disease
– Hypotension
– Avoid abrupt withdrawal – may cause
withdrawal sx & rebound HTN

69. Clonidine
 Common side effects:
– Somnolence
– Hypotension
– Dizziness
– Constipation
– Fatigue
– Headache
– Sexual dysfxn

70. Kapvay
 Kapvay (clonidine)
– NON STIMULANT – OFF LABEL
– Dosage forms: 0.1, 0.2, mg ER
– Start: 0.1 mg po q evening
– Increase 0.1mg/day q week
– Given qd-bid
– Maximum dose: 0.4mg/day
– Must taper dose when discontinuing
– NO DOSAGE RANGE FOR USE IN ADULTS