Newer Treatments and Medications for Depression and Substance Use Disorders, Exams of Pharmacology

Download Newer Treatments and Medications for Depression and Substance Use Disorders and more Exams Pharmacology in PDF only on Docsity! NR546 EXAM / NR 546 FINAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS AGRADE Pharmacologic Treatment of Bipolar Disorder - ANSWER>>Lithium Anticonvulsants Second generation antipsychotics Unipolar depression - ANSWER>>major depressive disorder (MDD) one of the most common mental disorders -Approximately 7.1% of adults in the U.S. had episode in last year, prevalence highest (13.1%) among individuals aged 18-25 S/S -depressed mood -loss of interest or pleasure in daily activities -irritability -withdrawal -problems with sleep, eating, energy, concentration, or self-worth -severe depression: may experience thoughts of suicide or psychotic symptoms. Bipolar disorder (BD) - ANSWER>>Chronic condition characterized by extreme fluctuations in mood, energy, and ability to function -Moods may be manic, hypomanic, or depressed and may include mixed mood or psychotic features -many have only experienced only one manic episode in their lifetime -Mood fluctuations may be separated by periods of high stability or may cycle rapidly -diagnosed when a client has one or more episodes of mania or hypomania with a history of one or more major depressive episodes -high risk for suicide mania - ANSWER>>characterized by a persistently elevated, expansive, or irritable mood. Related symptoms may include inflated self-esteem, increased goal-directed activity or energy, including grandiosity, decreased need for sleep, excessive talkativeness, racing thoughts, flight of ideas (FOI), distractibility, psychomotor agitation, and a propensity to be involved in high-risk activities. Mania leads to significant functional impairment and may include psychotic features or necessitate hospitalization Bipolar Type I: - ANSWER>>requires at least one episode of mania for at least one week (or any duration if hospitalization due to symptoms is required) Bipolar Type II: - ANSWER>>diagnosis requires a current or past hypomanic episode and a current or past major depressive episode. Symptoms last for at least 4 days but fewer than seven. -Hypomanic symptoms are not of sufficient duration or severity to cause significant functional impairment, psychosis, or hospitalization. -Anger and irritability are common. -Clients often enjoy the elevation of mood and are reluctant to report these symptoms, making bipolar more difficult to diagnose if the client presents in the depression phase. Cyclothymia: - ANSWER>>involves the chronic presentation of hypomanic and depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode. • inhibit 5-HT reuptake • inhibit NE reuptake (increase energy, focus) • increase DA in prefrontal cortex (increase cognition) Adverse effects -elevated blood pressure -anxiety -insomnia -constipation NDRI's - ANSWER>>Mechanism of action • inhibit DA reuptake (increase alertness, motivation) • inhibit NE reuptake (increase energy) Adverse effects -agitation -headache -dry mouth -constipation -weight loss SSRI Prescribing Pearls: med with mild antihistamine effects - ANSWER>>citalopram (Celexa) SSRI Prescribing Pearls: med with no known drug interactions - ANSWER>>escitalopram (Lexapro) SSRI Prescribing Pearls: med with longest half-life - ANSWER>>fluoxetine (Prozac) SSRI Prescribing Pearls: med that also treats social anxiety and insomnia - ANSWER>>paroxetine (Paxil) SSRI Prescribing Pearls: med that treats anxious depression; smokers require an increased dose - ANSWER>>fluvoxamine (Luvox) SSRI Prescribing Pearls: med that also treats social anxiety and hypersomnolence - ANSWER>>sertraline (Zoloft) venlafaxine (Effexor) - ANSWER>>INDICATION -Depression -GAD -Social anxiety disorder -Panic disorder Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine. TESTS -Check bp before initiating tx & regularly during tx Starting Dose -Initial 37.5 mg daily (extended-release) or 25-50 mg divided into 2-3 doses (immediate- release) Adverse Effects -H/A, nervousness, insomnia, sedation, nausea, diarrhea, decreased appetite, sexual dysfunction, asthenia, sweating, SIADH, hyponatremia, increase BP PEARLS -treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication -preferred treatments for treatment-resistant depression desvenlafaxine (Pristiq) - ANSWER>>INDICATION -MDD Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine TESTS -Monitor BP before and during treatment. client education for specific medication classes: SNRI's - ANSWER>>- Medications should not be abruptly stopped to avoid discontinuation symptoms. -NE effects of the medication may increase anxiety in some clients. Report worsening anxiety to the provider. client education for specific medication classes: NDRI's - ANSWER>>-Take medication in the morning. -Stop taking medication if seizures occur. -Stop taking medication if anxiety is noted. Other tx options: SARI's - ANSWER>>Serotonin Antagonist and Reuptake Inhibitors -potently block 5-HT2A and 5HT 2C receptors, allow more 5-HT to interact at postsynaptic 5-HT1A sites -Trazodone most common -adverse effects: • sedation • drowsiness • blurred vision • constipation • dry mouth • severe: priapism (Medical emergency) Patient education: side effects, take at HS due to sedation Off-label uses: insomnia, anxiety Mirtazapine (Remeron) - ANSWER>>INDICATION -MDD Mechanism of Action -Serotonin norepinephrine receptor agonist, alpha2 receptor agonist. Boosts neurotransmitters serotonin and norepinephrine/noradrenaline. TESTS -Monitor weight and BMI during tx Starting Dose -15 mg/day in the evening Adverse Effects -Sedation, weight gain, dry mouth, constipation, abnormal dreams, confusion, hypotension, Changes in urinary function. Flu-like symptoms may indicate low white blood cell or granulocyte count. PEARLS -sedation/drowsiness, useful for clients with insomnia. -increased appetite/weight gain, useful for clients with depression-related weight loss -Precautions: May cause photosensitivity, avoid alcohol (increase sedation) Vilazodone (Viibryd) - ANSWER>>INDICATION -MDD Mechanism of Action -Dual-acting serotonin reuptake inhibitor plus 5HT1A partial agonist. Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose -10 mg/day Adverse Effects -Nausea, diarrhea, vomiting, insomnia, dizziness, bruising, sexual dysfunction, SIADH. -Rare: Bleeding, hyponatremia. PEARLS -Appropriate for depression/comorbid anxiety, action similar to combination of SSRI and buspirone. -not used first-line because of the high incidence of adverse effects and the risk of potential overdose and death • amitriptyline (Elavil) • desipramine (Norpramin) • doxepin (Sinequan) • imipramine (Tofranil) • nortriptyline (Pamelor) Alpha-1 adrenergic effects - ANSWER>>Orthostatic hypotension Anticholinergic effects - ANSWER>>Dry mouth Blurred vision Urinary retention Constipation Histamine effects - ANSWER>>Weight gain Sedation MAOIs - ANSWER>>first developed, LAST CHOICE medication class for depression due to the many potential, serious side effects -specific dietary restrictions, Foods that contain tyramine should be avoided (Red wine, Sauerkraut, Cheese, Soy, Smoked meats) -block enzymes responsible for the breakdown of 5-HT, NE, and DA • two primary forms of the MAO enzyme: MAO-A and MAO-B • both located in the brain, MAO-A also in gut Drugs: -phenelzine (Nardil) - duration 14 days -selegiline (Emsam) - MAOI-B - duration 14 days -tranylcypromine (Parnate) -duration 14-30 days -isocarboxazid (Marplan) - duration 14 days Side effects: -Confusion -Dizziness -Insomnia -Sedation -Vivid dreams Pearls: -high risk for hypertensive crisis if tyramine is ingested -Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation due to an increased risk of serotonin syndrome -Wait at least 5 half-lives after discontinuing a serotonergic medication before initiating an MAIO MAO-A - ANSWER>>breaks down 5-HT, DA, NE, and tyramine -used to treat depression and anxiety "A" is for antidepressant or anxiolytic MAO-B - ANSWER>>responsible for the breakdown of dopamine, phenylethylamine, and tyramine -used to treat Parkinson's disease; however, high-dose selegiline (Emsam) may be used to treat anxiety or depression Foods to avoid when taking MAOIs - ANSWER>>Tyramine is present in many aged or preserved foods including aged cheeses, tap and nonpasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products, and tofu. Adjunct treatment for depression - ANSWER>>Antipsychotic medications are sometimes prescribed at low doses as adjunctive medications for severe depression Newer tx for resistant depression: esketamine (Spravato) - ANSWER>>nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal ideation or behavior -reaches peak onset in the body in between 20-40 minutes -risk of adverse outcomes due to sedation and dissociation *must be administered in a supervised healthcare setting Newer tx for resistant depression: Ketamine clinics - ANSWER>>Ketamine is an N- methyl-D-aspartate (NMDA) receptor inhibitor, results in the downstream release of glutamate -high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid effect on depression -Ketamine clinics have provided intravenous ketamine for treatment- resistant unipolar and bipolar depression *required frequent dosing, inconvenient, expensive -autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia) -neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination) -seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea) If such symptoms occur, clients should discontinue serotonergic agents and initiate treatment of symptoms. Clients should be educated about the signs and symptoms of serotonin syndrome and monitored -particularly during treatment initiation and dose increases. match the specific complaint to the best antidepressant medication: Eric, 49, is concerned about sexual side effects of antidepressant medications - ANSWER>>Bupropion -has fewer sexual side effects than other first-line treatments. Bupropion can also be prescribed as an adjunct to a SSRI. match the specific complaint to the best antidepressant medication: Terry, 76, has lost several pounds in the past few months. She has little appetite. - ANSWER>>Mirtazapine -may be used to increase appetite/weight gain in older clients. match the specific complaint to the best antidepressant medication: Karl, 35, complains of "brain fog" as a part of his depression symptoms. - ANSWER>>Vortioxetine -can improve the speed of processing and cognitive function due to its unique mechanism of action. Role of L-Methylfolate in depression tx - ANSWER>>Suboptimal folate levels in depressed patients (adjunct to antidepressant) • L-Methylfolate is a bioavailable form of folate • L-methylfolate, or 6-(S)-5-methyl-tetrahydrofolate, is derived from folate and is the form that enters the brain and works directly as a methyl donor and monoamine synthesis modulator Why is L-Methylfolate recommended as an adjunct in depression? - ANSWER>>Treatment with l-methylfolate seems to be safe, has few if any side effects, and is generally less expensive than augmenting with a second branded antidepressant or atypical antipsychotic match the specific complaint to the best antidepressant medication: Lauren, 19, reports she sometimes forgets to take her pills on time. - ANSWER>>Fluoxetine -has a 2-3 days half-life, an excellent option for forgetful people. Not approved for depression in US, only OCD - ANSWER>>Fluvoxamine Only SSRI approve for eating disorders - ANSWER>>Fluoxetine -5HT2C antagonism may contribute to its efficacy in this disorder match the specific complaint to the best antidepressant medication: Edna, 62, has difficulty falling asleep most nights. - ANSWER>>Trazodone -The sedative effects of trazodone can assist with sleep disturbances when given at bedtime. This medication is most appropriate for sleep concerns. Trazadone is not first line for depression due to the significant sedation side effect. Antidepressants Lifespan Considerations: Pregnancy - ANSWER>>Paroxetine is contraindicated in pregnancy due to the risk of congenital defects, including atrial septal defects. Antidepressants Lifespan Considerations: Breastfeeding - ANSWER>>Infant irritability should be monitored when SNRIs are prescribed. Antidepressants Lifespan Considerations: Older Adult - ANSWER>>-Older adults may not respond to antidepressants as robustly as younger people if the first episode of depression occurs after age 65. -Citalopram and escitalopram should be dosed at 1/2 dose due to the risk of QTc prolongation. -2019 American Geriatric Society (AGS) Beers Criteria include the following recommendations: • Avoid paroxetine in clients with a history of falls/fractures. • Avoid tricyclic antidepressants prescribed with other central nervous system (CNS) depressants. Antidepressants Lifespan Considerations: Children - ANSWER>>Antidepressants increase the risk of death by suicide in children and adults younger than 25. Christina is a 34-year-old who presents to the office with complaints of loss of energy, anxiety, and excessive sleeping. She has no past medical history. She is diagnosed with depression. She is concerned about starting on antidepressants because she has heard they cause weight gain, and she isn't great at remembering to take pills "unless I can take them in the morning." Using the prescription pad below, write a prescription for Christina to treat her depression. What medication? - ANSWER>>Escitalopram best-tolerated SSRI -300 mg 2-3 times per day. ADVERSE EFFECTS -Ataxia, dysarthria, delirium, tremor, memory problems, polyuria, polydipsia, diarrhea, nausea, weight gain, sedation, goiter possibly with increased TSH & reduced thyroxine levels, acne, rash, alopecia, leukocytosis. PEARLS: -Monitor plasma levels (1.0 and 1.5 mEq/L for acute treatment, 0.6 and 1.2 mEq/L for chronic treatment) -Reduce dose in clients with renal failure. -Use caution with concurrent diuretics. -Use to protect against suicide -Prevents suicide in pt. with mood disorder -Precautions: Toxic levels are near therapeutic levels; signs of toxicity include tremor, ataxia, diarrhea, vomiting, sedation lamotrigine (Lamictal) - ANSWER>>For BP INDICATION -maintenance tx of BP I -Seizures (ages 2+) ACTION -affects sodium channel ion transport and enhances the activity GABA STARTING DOSE: -25 mg/day ADVERSE EFFECTS -Benign rash, blurred or double vision, dizziness, ataxia, sedation, headache, tremor, insomnia, poor coordination, fatigue, nausea, vomiting, dyspepsia, rhinitis PEARLS: -Educate clients and assess for rash at each visit. Ten percent of rashes are benign. -There is a risk for rare Stevens-Johnson Syndrome rash and multi-organ failure. -Take at bedtime due to sedation side effect. -First-line treatment option that may be best for patients with bipolar depression. -Drug interactions: Valproate increases plasma concentrations and half-life of lamotrigine, requiring lower doses, use together may increase risk of rash. -photosensitivity -does bind to melanin-containing tissues so opthalmological checks may be considered. valproic acid (Depakene) - ANSWER>>For BP INDICATION -GI effects PEARLS: -Indications vary with each medication. Check for monotherapy vs. adjunct indication. -Monitor for extrapyramidal effects. -XR form may improve adherence. -Monthly injection may improve adherence. -Select SGAs first to decrease risk of side effects and long-term adverse effects. carbemazepine (Tegretol) - ANSWER>>INDICATION -Seizures -Pain associated with true tigeminal neuralgia -Acute mania/mixed mania ACTION -glutamate voltage gated sodium and calcium channel blocker (Glu-CB) STARTING DOSE -200 mg BID (tablet), or 100mg QID (suspension) ADVERSE EFFECTS -GI effects -sedation -hyponatremia -neutopenia -rash (Stevens-Johnson Syndrome) TESTS -Before starting get blood count, liver, kidney, and thyroid function tests. -During treatment get blood count every 2-4 weeks for 2 months, then every 3-6 months. And liver, kidney, and tyroid function tests every 6-12 months PEARLS: -Monitor plasma levels. -Consider genotyping clients with Asian ancestry; the HLA-B 1502 allele increases risk of Steven-Johnson Syndrome. -Drug interactions: CYP450 3A4 inhibitors, such as nefazodone, fluvoxamine, and fluoxetine, can increase plasma levels of carbamazepine. Citalopram (Celexa) - ANSWER>>INDICATION -Depression Mechanism of Action -SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose -20mg/day Adverse Effects -Diarrhea, constipation, nausea, sexual dysfuction, activation, insomnia, agitation, tremors, headache, dizziness, sweating, bruising, SIADH. Rare: bleeding, hyponatremia. PEARLS -mild antihistamine properties that may contribute to sedation and fatigue Escitalopram (Lexapro) - ANSWER>>INDICATION -MDD (ages 12+) -GAD Mechanism of Action -SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin. Fluvoxamine (Luvox) - ANSWER>>INDICATION -OCD -Social anxiety disorder Mechanism of Action -SSRI (selective serotonin reuptake inhibitor); Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose -: IR initial 50 mg/day, controlled-release initial 100 mg/day Adverse Effects -Sexual dysfunction, nausea, diarrhea, constipation, insomnia, sedation, agitation, tremors, headache, dizziness, sweating, bruising. Rare: bleeding, hyponatremia PEARLS -May cause photosensitivity -treats anxious depression -smokers require an increased dose Paroxetine (Paxil) - ANSWER>>INDICATION -MDD -OCD -Panic disorder -Social anxiety disorder -PTSD -GAD -Premenstual dysphoric disorder -Vasomotor symptoms Mechanism of Action -SSRI (selective serotonin reuptake inhibitor);Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose -20 mg/day Adverse Effects -Sexual dysfunction, decreased appetite, neausea, diarrhea, insomnia, agitation, tremors, headache, dizziness, weight gain, sweating, Constipation, dry mouth, sedation, bruising, SIADH. Rare: Bleeding. CONTRAINDICATED -Pregnancy -Avoid in clients with a history of falls/fractures (elderly) Sertraline (Zoloft) - ANSWER>>INDICATION -MDD -Premenstrual dysphoric disorder -Panic disorder -PTSD -Social anxiety disorder -OCD Mechanism of Action -SSRI (selective serotonin reuptake inhibitor);Boosts neurotransmitter serotonin. Lithium levels can be increased by and and decreased Demographics -male -younger -lower education level -single Other -poor insight -negative attitude -low self-esteem Lurasidone (Latuda) should be taken with: - ANSWER>>food, at least 350 calories, for maximum absorption Lithium carbonate (Lithobid) starting dose is reduced by at least 50% in clients with - ANSWER>>renal impairment and . - ANSWER>>NSAIDs, ACE inhibitors, caffeine, mania lab tests required for: Lithium - ANSWER>>serum lithium level renal function thyroid function Rationale: Lithium has a narrow therapeutic index and should be monitored carefully. Serum levels should be evaluated 5 days after any dosage change and regularly at 6- month intervals. Lithium can cause renal and thyroid toxicity. Renal and thyroid function should be evaluated every 6 months. lab tests required for: Valproic acid (Depakote) - ANSWER>>serum valproate level liver function CBC Rationale: Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and liver function tests (LFTs) every 3 months for 1 year and then annually. lab tests required for: Carbamazepine - ANSWER>>serum carbamazepine level renal function liver function CBC Rationale: Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Order a CBC, LFT, and renal function every 3 months for 1 year and then annually. lab tests required for: Atypical antipsychotic medications - ANSWER>>CBC HbA1C Rationale: Atypical antipsychotics can cause increased blood glucose and an increased risk of developing diabetes mellitus (DM) II. Measure HbA1C every 3 months for 1 year and then annually. Certain medications, such as Clozapine, may cause blood dyscrasias and CBC should be monitored closely. Medications for Bipolar Disorder Lifespan Considerations: Pregnancy - ANSWER>>- Lithium, valproic acid, and carbamazepine are teratogenic and are contraindicated during pregnancy. -Lurasidone has been used in pregnancy without teratogenic effects. Medications for Bipolar Disorder Lifespan Considerations: Breast Feeding - ANSWER>>Avoid breastfeeding for clients prescribed carbamazepine, lithium, and lamotrigine. Medications for Bipolar Disorder Lifespan Considerations: Older Adult - ANSWER>>Use caution. Reduced renal and hepatic function may impact metabolism and elimination. Reduce dose as necessary. 2019 American Geriatric Society (AGS) Beers Criteria include the following recommendations: -Avoid carbamazepine (may cause syndrome of inappropriate antidiuretic hormone secretion [SIADH]). -Use caution with antipsychotic medications (may increase the risk of falls). -Antipsychotic medications may increase the risk of stroke, cognitive decline, and death in dementia clients. -Avoid lithium in clients taking ACE inhibitors or loop diuretics. Medications for Bipolar Disorder Lifespan Considerations: Children - ANSWER>>Medications approved for children are limited. Kristin is a 56-year-old client of Asian descent recently diagnosed with bipolar disorder. Which medication would require genetic testing to ensure safe administration? - ANSWER>>Carbemazepine Rationale: Carbemazepine may cause Stevens-Johnson Syndrome in people of Asian descent who have a higher risk of HLA-B 1502. Genetic testing would need to be performed prior to prescribing this medication. Acute agitation in mania may be treated with: - ANSWER>>rapid-acting oral, inhaled, or IM antimanic agents Match diagnostic symptom to Malfunctioning Brain Circuit: Prefrontal Cortex (PFC) - ANSWER>>Manic Episode -Racing thoughts -Grandiosity -Distractibility -Talkative/pressured speech Major Depressive Episode -Concentration -Interest/pleasure -psychomotor -fatigue (mental) Match diagnostic symptom to Malfunctioning Brain Circuit: Basal Forebrain (BF) - ANSWER>>Manic Episode -Decreased sleep/arousal Match diagnostic symptom to Malfunctioning Brain Circuit: Striatum (S) - ANSWER>>Major Depressive Episode -Psychomotor -Fatigue (physical) Match diagnostic symptom to Malfunctioning Brain Circuit: Nucleus Accumbens (NA) - ANSWER>>Manic Episode -Racing thoughts -Goal-directed -Grandiosity Major Depressive Episode -Pleasure -Interests -Fatigue/energy Match diagnostic symptom to Malfunctioning Brain Circuit: Thalamus (T) - ANSWER>>Manic Episode -Decreased sleep/arousal Match diagnostic symptom to Malfunctioning Brain Circuit: Hypothalamus (Hy) - ANSWER>>Manic Episode -Decreased sleep/arousal Major Depressive Episode -Sleep -Appetite Match diagnostic symptom to Malfunctioning Brain Circuit: Amygdala (A) - ANSWER>>Manic Episode -Mood Major Depressive Episode -Guilt -Suicidality -Worthlessness -Mood Match diagnostic symptom to Malfunctioning Brain Circuit: Spinal Cord (SC) - ANSWER>>Major Depressive Episode -Fatigue (physical) Match diagnostic symptom to Malfunctioning Brain Circuit: Cerebellum (C) - ANSWER>>Major Depressive Episode -Psychomotor adverse effects associated with the acute use of opioids: - ANSWER>>-Itching -pregnant, a risk benefit ratio is necessary as fetal outcomes are improved as compared to illicit drug use, however can have decreased birth weight, length, head circumference and fetal growth Opioid medication: Ketamine - ANSWER>>-Medication useful in general anesthesia and procedural sedation -off label usage as infusions for acute pain, as both a stand-alone treatment, as an adjunctive option with opioids, as well as an intranasal formulation. Opioid medication: Tramadol - ANSWER>>-Opioid agonist, with similar indications and side effect profile as other opioids, but that also blocks reuptake of serotonin and norepinephrine. -Indicated for acute pain management, with added benefit for patients with neuropathic pain and nociceptive pain. -Has a lower risk of constipation and dependence than other opioids, but does have risk of serotonin syndrome. Opioid medication: Naloxone - ANSWER>>-pure antagonist, with clinical indication for treatment of acute opioid overdose. -IV naloxone can dramatically reverse opioids, even in comatose states -recent widespread community availability of intramuscular and intranasal administration options available given the prescription and recreational opiate crisis, and related deaths. -Given the short duration of action, patients can relapse into coma or previous overdose state, and may need continued monitoring and potentially further doses or constant infusion. Opioid medication: Clonidine - ANSWER>>-antihypertensive agent, and Alpha2- Adrenergic Agonist -off-label adjunctive treatment for medically supervised opioid withdrawal. -Initial treatment is 0.1mg-0.2mg, with ability to repeat up to 4 doses until symptoms resolve, while assuring stability of blood pressure and heart rate. -Maintenance would be determined by severity of symptoms, with treatment every 6-8 hours. -Thought to produce analgesia at presynaptic and post junction alpha-2 adrenoceptors in the spinal cord, with pain transmission to the brain prevented. Substance use disorder occurs when: - ANSWER>>The recurrent use of a substance, such as alcohol or drugs, causes clinically significant impairment, including health problems, disability, or failure to meet responsibilities at home, work, or school. Dual Diagnosis and Substance Use Disorders - ANSWER>>Dual diagnoses are common in addiction medicine -up to 60% of adolescents in community-based substance use disorder treatment programs may meet the diagnostic criteria for another mental health condition -Clients may self-medicate to treat distressing symptoms of other conditions -Common comorbidities include: • anxiety disorders • depression • bipolar disorder • psychotic illness • borderline personality disorder • antisocial personality disorder neurobiological factors that contribute to substance use disorders: Genetics - ANSWER>>-between 40-60% of a client's vulnerability to substance use disorders may be attributed to genetic factors -Vulnerability involves complex interactions between multiple genes, and between genes and the environment -Example: specific genetic factors predispose an individual to alcohol dependence and tobacco use -Genetic involvement may impact an individual's experience of a drug as pleasurable or not or how long a drug remains in the body. -Epigenetic factors influence whether genes associated with substance use disorder are activated neurobiological factors that contribute to substance use disorders: Neuroanatomy - ANSWER>>-Brain circuits that mediate reward, impulse control, decision-making, learning, and emotions play a role in substance use disorder -mesolimbic dopamine pathway has been identified as the key pathway that mediates reward -mesolimbic pathway connects the ventral tegmental area of the midbrain to the ventral striatum of the basal ganglia • begins in the ventral tegmental area (VTA) and connects to the ventral striatum/nucleus accumbens, amygdala, hippocampus, and prefrontal cortex (PFC) • VTA is one of the major dopamine-producing areas of the brain • nucleus accumbens is an area found within the ventral striatum and has a strong association with motivation and reward Addiction - ANSWER>>A change in behavior caused by biochemical changes in the brain after continued substance use characterized by preoccupation with and repeated use of a substance despite negative outcomes. Withdrawal - ANSWER>>Physiological and psychological reactions that occur when the use of a substance is stopped abruptly. Intoxication - ANSWER>>Condition following the ingestion of a substance resulting in changes in level of consciousness, cognition, perception, judgment, and behavior. MAT - ANSWER>>medication-assisted therapy (MAT) -clients use prescription medications as part of a treatment plan for substance use disorders -substitutes the drug of abuse for a prescribed medication that targets the same receptor as the preferred substance. • can reduce cravings, improve relapse rates, reduce mortality from overdoses, and increase the likelihood of abstinence either alone or in combination with psychosocial interventions -most prescribed for opioid use disorder, may be used for alcohol or tobacco Goals of MAT to include: -improved survival -improved treatment retention -decreased illegal activity -increased quality of life -improved birth outcomes in people who use substances while pregnant -reduced human immunodeficiency virus (HIV) and Hepatitis B & C infections why avoid bupropion in individuals with anorexia nervosa and bulimia nervosa - ANSWER>>bupropion lowers the seizure threshold in these individuals putting them at significantly increased risk for new-onset seizures Opioid use disorder - ANSWER>>the "chronic use of opioids that causes clinically significant distress or impairment" -Drugs of abuse: illicit drugs, such as heroin, or prescription medications, including morphine, fentanyl, and oxycodone -experience overwhelming cravings to use the drugs, dependence, increased tolerance, and withdrawal symptoms when the drug is ceased abruptly -MAT is first-line therapy, essential part of tx match the appropriate MAT to the client: Bernita is a 64-year-old who has been using heroin for 6 years. She is currently unemployed and lives with her daughter in the city center. She does not have health insurance. - ANSWER>>Methadone a full μ-receptor agonist with a long half-life, which can prevent withdrawal symptoms for 24 hours and provide steady control of cravings throughout the day. Only administered in methadone federally regulated opioid treatment programs (OTP). Methadone clinics incorporate psychosocial interventions and require daily attendance for the first several months, so this is a good option for a client that has the flexibility to attend daily meetings. The use of methadone in MAT for opioid use disorder helps extend client survival. When clients stop methadone, they have a high likelihood of relapsing, even 10 years after starting treatment. match the appropriate MAT to the client: Antoine is a 34-year-old who has been abusing prescription oxycodone. He is employed but is on probation at work for increased absenteeism. He desires MAT but is concerned about his roommates stealing his medication to get high. - ANSWER>>Buprenorphine plus naloxone (Suboxone) In combination with naloxone (Suboxone): naloxone is a mu-opioid receptor antagonist and can therefore block the effects of buprenorphine; however, because naloxone has poor sublingual bioavailability, it does not interfere with buprenorphine's effects when used properly. Naloxone does have good parenteral bioavailability; thus, if one tries to administer the buprenorphine/naloxone formulation intravenously, naloxone will prevent any rewarding effects from buprenorphine, making this drug a less desirable street drug. Suboxone is a good option for a client who may not be able to leave work for medication dosing, as it does not need to be taken under direct observation. match the appropriate MAT to the client: Lisa is a 29-year-old who admits to using "pills, heroin, and booze" regularly. She lives in a rural area and is employed part-time. She has a history of poor compliance with past treatments. - ANSWER>>Naltrexone blocks mu-opioid receptors, preventing exogenous opioids from binding there and thus preventing the pleasurable effects of opioid consumption. This medication also reduces alcohol consumption through the modulation of opioid systems, thereby reducing the reinforcing effects of alcohol. For those clients with alcohol use disorder, who have poor adherence to a regimen, and are unable to maintain abstinence, a long-acting injection of naltrexone (Vivitrol) administered monthly can be efficacious. match the appropriate MAT to the client: Miranda is a 20-year-old who is 18 weeks pregnant and uses heroin. She wants to get clean "for her baby." - ANSWER>>Buprenorphine a partial opioid agonist which binds with a strong affinity to the mu-opioid receptor, preventing exogenous opioids from binding at the receptor site, and preventing the pleasurable effects of opioid consumption. While either methadone or buprenorphine may be prescribed in pregnancy, buprenorphine does not require daily visits to an opioid treatment program and requires less need for dosage adjustments during pregnancy. Opioid Overdose - ANSWER>>significant risk with opioid abuse • is an increased risk of a neonatal withdrawal syndrome in newborns. -Suboxone (buprenorphine/naloxone) cannot be used in pregnancy. -Naloxone increases risk of neonatal abstinence syndrome • Pregnant clients must be switched to buprenorphine (Subutex) monotherapy. -Methadone is approved in pregnancy for heroin-addicted women. • Dosing requires adjustment. -Short-term newborn withdrawal effects may be seen and may require neonatal intensive care unit (NICU) admission for treatment. Special considerations when prescribing MAT for opioid use disorder: Breast Feeding - ANSWER>>-Naltrexone and buprenorphine are not recommended for breastfeeding mothers. -Methadone can be prescribed with special consideration given to feeding intervals • breastfeed prior to or 2-6 hours after dose Special considerations when prescribing MAT for opioid use disorder: Older adult - ANSWER>>-Buprenorphine use in the elderly may lead to confusion and drowsiness. -Methadone has a high potential for drug interactions, associated with QT prolongation. -It is difficult to titrate in the elderly and has a risk for accumulation due to the long half- life. Alcohol Use Disorder - ANSWER>>-may affect cardiovascular health and is associated with an increased risk of several types of cancer (especially, liver and pancreatic) -Other system morbidities: diabetes, gout, renal dysfunction, hematological complications, osteoporosis, and dementia -frequently associated with trauma and accidents MAT for Chronic Alcohol Use Disorder - ANSWER>>Medication selections based on clinical presentation, history of alcohol use/abuse with comorbid liver disease or renal impairment, concurrent opioid use disorder, and other unique client characteristics. Meds: -naltrexone (Revia, Vivitrol) -acamprosate (Campral) -disulfiram (Antabuse) -topiramate (Topamax) -chlorpromazine (Librium) MAT for Chronic Alcohol Use Disorder: naltrexone (Revia, Vivitrol) - ANSWER>>INDICATION -Alcohol dependence -Blockade of effects of exogenously administered opioids (Revia) -Prevention of relapse to opioid dependence (injection) Initial treatment for alcohol use disorder -Started while still drinking -Can treat concurrent opioid use disorder -Contraindicated in liver disease -May be given in monthly long-acting injections (Vivitrol) -Insomnia -Tremors -Nausea/vomiting Moderate -Increased blood pressure (BP) -Increased heart rate (HR) -Confusion -Mild hyperthermia -Rapid breathing Severe -Hallucinations -Seizures -Disorientation -Impaired attention -Delirium tremens -Death symptom-triggered regimen - ANSWER>>Administer CIWA-Ar • every 4-8 hours until score is lower than 8-10 for 24 hours Symptom-Triggered Regimen • Administer benzodiazepine when CIWA-Ar score is 8 or above. • PO lorazepam (Ativan), diazepam (Valium), or chlordiazepoxide (Librium) for symptom-triggered therapy • Reassess CIWA-Ar every hour. A 40-year-old male presents to your emergency department (ED) with severe anxiety, generalized tremors, complaints of dizziness, diaphoresis, and agitation. He was incarcerated 2 days ago and is brought to the ED today by the police due to the development of acute symptoms. His social history is significant for heavy alcohol use. A Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA) score is 39. The client tells you he has had withdrawal seizures in the past when he stops drinking. Which medication should you order? - ANSWER>>lorazepam (Ativan) Rationale: Benzodiazepines are the first-line treatment for clients having psychomotor agitation associated with alcohol withdrawal. This client has an increased risk of an alcohol-related withdrawal seizure, especially since he had one in the past. carbamazepine, levetiracetam, and phenytoin are not routinely used for alcohol withdrawal due to the lack of evidence demonstrating increased efficacy. Additionally, these drugs may potentially mask hemodynamic signs of withdrawal. You are discharging this client from the hospital following admission for alcohol withdrawal syndrome. He has no further withdrawal symptoms and he would like to abstain from alcohol use. He informs you that has abused opioids in the past, but he has not used them in the last several months. He is concerned that he is at risk of abusing opioids again. Which of the following is the best pharmaceutical option for this client? - ANSWER>>naltrexone (ReVia) Contraindicated: -Immediately after a myocardial infarction -Immediately after a stroke appropriate medication to each client: John is a 56-year-old with a history of seizure disorder who has smoked 1 pack-per-day (PPD) for 30 years. He has tried to quit using nicotine gum without success. He is committed to quitting smoking but feels he would benefit from medication to help - ANSWER>>varenicline Varenicline is an appropriate medication option for clients who want to quit using tobacco products. Bupropion is contraindicated in clients with seizure disorder. Ellen is a 35-year-old who has a history of drinking 4-5 alcoholic beverages per day. She was admitted to the hospital for a respiratory infection and was treated with benzodiazepines using the CIWA-Ar scale. She has abstained from alcohol for 8 days and is committed to maintaining abstinence but would like to take a medication to help her stay away from alcohol. - ANSWER>>disulfiram Disulfiram creates unpleasant physical symptoms when taken with alcohol. This mild negative stimulus can help reinforce the client's abstinence from drinking alcohol. Nori is a 24-year-old who has a history of abusing opioid medications and binge drinking. She is not committed to abstain from using at this time. - ANSWER>>naloxone Since Nori is not committed to abstaining at this time, it is important to provide naloxone along with education to help her remain safe from overdose. Juan is a 19-year-old who has a history of using oxycodone that he has taken from his grandfather and drinking occasional alcohol. He wants to stop using both substances. - ANSWER>>naltrexone Naltrexone is a good option for clients who use opioids and alcohol and are committed to abstinence. Impulsivity and compulsivity are thought to be mediated by neuroanatomically and neurochemically distinct, but in many ways parallel, components of - ANSWER>>cortico-subcortical circuitry -too much "bottom-up" limbic emotional drive or too little "top-down" cortical inhibition of these drives Impulsive-compulsive disorder construct - ANSWER>>-Impulsivity can be thought of as the inability to stop the initiation of actions and involves a brain circuit centered on the ventral striatum and linked to the thalamus, to the ventromedial prefrontal cortex (VMPFC), and to the anterior cingulate cortex (ACC). -Compulsivity can be thought of as the inability to terminate ongoing actions and hypothetically involves a brain circuit centered on the dorsal striatum and linked to the thalamus and orbitofrontal cortex (OFC). Impulsive acts such as drug use, gambling, and over-eating can eventually become compulsive due to neuroplastic changes that engage the dorsal habit system and theoretically cause impulses in the ventral loop to migrate to the dorsal loop. natural ways to trigger mesolimbic dopamine neurons to release dopamine (natural high) - ANSWER>>brains own: morphine/heroin (endorphins) marijuana (anandamide) nicotine (acetylcholine) cocaine & amphetamine (dopamine itself) Dopamine theory of addiction - ANSWER>>all drugs of abuse have a final common pathway of causing pleasure by provoking dopamine release in the mesolimbic pathway EDUCATION -patient should not take until at least 12 hours after drinking classic drug for treating alcoholism -irreversible inhibitor of the liver enzyme aldehyde dehydrogenase that normally metabolizes alcohol -alcohol ingested with disulfiram, alcohol's metabolism is inhibited, build-up of toxic levels of acetaldehyde, creates an aversive experience with flushing, nausea, vomiting, and hypotension. -compliance is a problem Buprenorphine (Subutex) - ANSWER>>INDICATION -Maintenance tx of opioid dependence -Opioid use disorder PRIOR TESTS -Liver function tests at baseline and during treatment EDUCATION -must be in a mild withdrawal state prior to starting -Allow sublingual form to dissolve under tongue completely Side effects -respiratory depression -hepatotoxicity -hypotension -implant: insertion site pain, pruritis, erythema PEARLS -Metabolized by CYP450 3A4 -Buprenorphine alone is often used to initiate treatment Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) - ANSWER>>INDICATION -Maintenance tx of opioid dependence -Opioid use disorder PRIOR TESTS -Liver function tests at baseline and during treatment CONTRAINDICATION -severe hepatic impairment PEARLS -buprenorphine/ naloxone is preferred for stabilization and maintenance treatment -Buprenorphine can be prescribed in combination with naloxone (Suboxone) to decrease the potential for abuse or diversion Sedative Hypnotics - ANSWER>>barbiturates and related agents such as ethchlorvynol and ethinamate, chloral hydrate and derivatives, and piperidinedione derivatives such as glutethimide and methyprylon. -Experts often include alcohol, benzodiazepines, and Z-drug hypnotics Gamma-Hydroxybutyrate (GHB) - ANSWER>>treatment for narcolepsy/cataplexy -sometimes also abused by individuals wanting to get high or by predators to intoxicate their dates -"date rape" drugs -agonist at its own GHB receptors and at GABA B receptors the US consumes % of the world's legal and illegal supply of opioids. - ANSWER>>85% opioid withdrawal syndrome is characterized by: - ANSWER>>the patient feeling dysphoria, craving another dose of opioid, being irritable, Pilo-erection ("goose-bumps"), and having signs of autonomic hyperactivity such as tachycardia, tremor, and sweating Hallucinogens - ANSWER>>three classes of agents that act, at least in part, as agonists at 5HT2A receptors: • tryptamines (such as psilocybin) • ergolines (such as lysergic acid diethylamide [LSD]) • phenethylamines (such as mescaline) • not waiting one's turn • interrupting -Hyperactivity • fidgeting • leaving one's seat • running, climbing • trouble playing quietly *Symptoms related to attention usually develop 2-4 years after the emergence of hyperactive symptoms in childhood ADHD lifespan considerations - ANSWER>>-Symptoms change with age. -Not only a childhood diagnosis -Hyperactivity decreases markedly with age -Primary Symptoms: inattention, restlessness, cognitive & emotional impulsivity, executive functioning deficits, and self-regulation -Adults struggling with executive functioning difficulties and disorganization may experience occupational stress or anxiety. neurobiological factors that contribute to ADHD: Genetics - ANSWER>>Important role in development of ADHD. -heritability of up to 88% Other risk factors for ADHD include -premature birth -low birth weight -maternal stress during pregnancy -prenatal substance exposure, including tobacco -adverse childhood environmental -psychosocial stress -inconsistent parenting practices neurobiological factors that contribute to ADHD: Neuroanatomy - ANSWER>>Specific ADHD symptoms may arise from abnormalities within circuits in the prefrontal cortex (PFC) -affect executive function neurobiological factors that contribute to ADHD: Neural Networks - ANSWER>>- symptoms often become noticeable at about 6-7 years of age, possibly due to abnormalities in the prefrontal cortex circuits or errors in the synaptic pruning process. -Both selective and sustained attention are modulated by the corticostriatal- thalamocortical (CSTC) loop • same loop that is associated with anxiety. • ADHD is an alternative diagnosis to consider when clients present with anxiety symptoms. neurobiological factors that contribute to ADHD: Neural Signaling - ANSWER>>Norepinephrine (NE) and dopamine (DA) are associated with inefficient information processing in the prefrontal circuits. -Rather than a deficiency, NE and DA are "out of tune." • Agents that can increase the firing of both DA and NE may help increase prefrontal activity. • ADHD medications commonly target both dopamine and norepinephrine. • Stimulants, including stimulant medications, caffeine, and nicotine enhance DA release and arousal. The PMHNP is considering treatment options for an 18-year-old man with ADHD who has a history of alcohol and marijuana abuse. Which of the following accurately explains the effects of different stimulant formulations on neuronal firing? - ANSWER>>Pulsatile stimulation amplifies undesirable phasic DA and NE firing, which can lead to euphoria and abuse. Rationale: Phasic firing is hypothetically associated with reward, feelings of euphoria, and abuse potential. Immediate-release stimulants rapidly increase DA and NE, especially increasing phasic firing, not tonic firing. Therefore, immediate-release stimulants have a higher risk of abuse. Extended-release formulations of stimulants lead to a gradual and sustained increase in NE and DA, enhancing tonic firing, which is hypothetically linked to the therapeutic effects of stimulants. They are amplifying tonic NE and DA signals, which are thought to be low in ADHD. The extended-release formulations occupy the NE transporter in the prefrontal cortex with slow enough onset and for long enough to enhance tonic NE and DA signaling; however, they do not block DA transporters fast or long enough in the nucleus accumbens to increase phasic signaling, thus reducing abuse potential. -stimulate the release of NE and DA or boost the firing of associated neurons • may help improve information processing -effective for 70-80% of clients with ADHD -first choice of medications for children -schedule II controlled substances -no refills permitted non-stimulant medications -selective inhibition of presynaptic norepinephrine reuptake in the prefrontal cortex and enhancement of norepinephrine neurotransmission -can help lower distractibility and improve attention, working memory, and impulsivity -commonly used in cases in which a client does not respond to stimulant medications or where stimulants are contraindicated -low risk of abuse or diversion -often prescribed for adults with ADHD combination of stimulant and non-stimulant medications is sometimes used when ADHD includes argumentative or oppositional symptoms Stimulant Medications - ANSWER>>Methylphenidate dexmethylphenidate (Focalin) amphetamine (Adzenys) dextroamphetamine (Adderall) lisdexamfetamine (Vyvanse) Methylphenidate (D/L) - ANSWER>>INDICATION: -ADHD (children & adult) -Narcolepsy (Ritalin) Mechanism of Action: -Increases norepinephrine and especially dopamine actions by blocking their reuptake Low risk of adverse effects (same as Focalin effects) Available formulations: -Ritalin • initial 5 mg in morning, 5 mg at lunch (2-4 hour duration) • available in immediate-release (IR) and extended-release (XR) • available in beads that may be sprinkled on food for children who cannot swallow pills -Concerta • initial 18 mg/day in morning (12 hours duration of action) • biphasic - combined immediate and delayed release in one medication -Daytrana Patch • Initial 10 mg/9 hours, applied in AM -Jornay PM • methylphenidate ER • initial 20 mg in evening at 8 pm • can be taken with or without food, but should be consistent; • capsule can be opened and the contents sprinkled onto applesauce dexmethylphenidate (Focalin) (D) - ANSWER>>INDICATION -ADHD (ages 6-17 Focalin) (ages 6-adults Focalin XR) Mechanism of Action -Increases norepinephrine and especially dopamine actions by blocking their reuptake Usual Dosage Range - 2.5-10 mg BID Side Effects -ADHD (ages 6+) -Binge eating disorder Mechanism of Action -increases norepinephrine and especially dopamine actions by blocking their reuptake and facilitating their release Starting Dose -Initial 30mg/day in AM PEARLS -Biologically inactive until metabolized by the body (Prodrug) -Less abuse and diversion potential than other stimulants -Higher-cost medication -Capsules can either be taken whole or they can be opened and the contents dissolved in water ADHD Prescribing Pearls - ANSWER>>-Before initiation of any stimulant, obtain thorough health history. -Assess for a personal or family history of cardiac disease • EKG is required if cardiac history is present in a first-degree relative -BP, height, & weight should be monitored regularly during tx -CNS stimulants may cause psychotic or manic symptoms in clients with no prior hx or may exacerbate behavior disturbance symptoms and thought disorders in clients with pre-existing psychosis -Assess all clients for bipolar disorder before tx -CNS stimulants may exacerbate comorbid anxiety & substance use disorders. -Tx efficacy will be noted within the first week of tx -Increased irritability and insomnia can be treated with a low dose of non- stimulant medication which will allow the client to fall asleep. -Abrupt withdrawal after prolonged use can result in irritability and rebound symptoms -Stimulants can cause or worsen tics; stimulants may unmask the presence of tics -When switching stimulants, D/C the current med & start the new med at a starting dose the next day -Stimulant meds available to treat ADHD are available as immediate- release or sustained-release formulations -Short-acting medications are at higher risk for diversion. Careful monitoring is required. Occasional urine drug screens should be obtained to verify the presence of amphetamines and the absence of other substances of abuse. ADHD Patient Education - ANSWER>>-Common side effects include restlessness, irritability, anxiety, insomnia, stomachache, headaches, tics, and worsening of aggression symptoms. -Clients may note a worsening of symptoms, or "crash" when the medication wears off, especially with immediate-release (IR) medications. -Medications may cause appetite changes and subsequent weight loss. • Take medication with breakfast to decrease anorexia. Non-Stimulant Medications - ANSWER>>noradrenergic (NRI) -atomoxetine (Strattera) α 2 agonists -clonidine -guanfacine Norepinephrine Dopamine Reuptake Inhibitor -bupropion (Wellbutrin) noradrenergic (NRI) - ANSWER>>atomoxetine (Strattera) -drug of choice for adults with ADHD -no abuse potential -tolerated well when prescribed in twice daily dosing-appropriate choice for comorbid substance abuse -may augment the effects of antidepressants and antianxiety medications -can be dosed at bedtime if fatigue is noted -unlikely to worsen tics Atomoxetine - ANSWER>>INDICATION -ADHD (ages 6+) -appropriate for clients with concurrent depression or tobacco abuse Mechanism of action -NDRI (norepinephrine and dopamine reuptake inhibitor); Boosts neurotransmitters norepinephrine/ noradrenaline and dopamine Side effects -dry mouth, nausea, weight loss, myalgia, insomnia, h/a, anxiety, tinnitus, sweating, rash, hypertension, seizures (rare), stevens-johnson syndrom, hypomania PEARLS -Inhibits CYP450 2D6 -Use cautiously with other drugs that increase seizure risk (TCAs, lithium, phenothiazines, thioxanthenes, some antipsychotics) -Dont use if patient is anorexic or bulimic -NDRI may improve energy, alertness, and motivation; -not first-line treatment for anxiety; -contraindicated in clients with a history of seizures Non-Stimulant Medication patient education - ANSWER>>-Common side effects include nausea, vomiting, diarrhea, fatigue, mood swings, dizziness, worsening of symptoms, changes in heart rate (HR) and blood pressure (BP), sedation, and dry mouth. -Most subside with continued use over several weeks. -Insomnia may develop over time and can be significant. ADHD and Comorbidities tx order: - ANSWER>>1. alcohol/stimulant/substance abuse 2.mood disorders 3. anxiety disorders 4. ADHD Children and adolescents 1. Nicotine dependence 2. ADHD ADHD Lifespan Considerations: Pregnancy - ANSWER>>Stimulants may cause fetal harm including increases in low birth weight and pregnancy. ADHD Lifespan Considerations: Breastfeeding - ANSWER>>Stimulants are not recommended while breastfeeding. ADHD Lifespan Considerations: Children - ANSWER>>-ADHD medications are not approved for children under 6. -Consider short-acting medications for children who have significant appetite loss or are underweight; this may improve appetite for lunch and dinner. Cora is an 11-year-old who presents to the clinic with her mom. Cora's teachers report that she has difficulty staying on task and is disruptive in class. She is argumentative and oppositional at times, will not stay in her seat, and is often impulsive. Her mom started noticing hyperactivity symptoms two years prior. The PMHNP decides to start her on 5mg methylphenidate IR in the morning. Within a few days, there is an improvement in Cora's symptoms; however, the medication seems to wear off within a few hours. Which of the following changes would you make to Cora's initial prescription? - ANSWER>>increase dose to 5 mg methylphenidate IR twice daily Rationale: Methylphenidate's immediate release has a duration of action of 3-4 hours. Increasing the dose to twice daily is an appropriate first step. Consider a second dose after lunch if appetite is affected. A non-stimulant drug is not appropriate for this client. Cora's mom reports that the new dose of medications seems to alleviate symptoms of ADHD, but Cora experiences irritability close to the time when her next dose is due. Cora's mom asks if there is something that can be done to help reduce the irritability. Which change would you make to Cora's prescription? - ANSWER>>change dose to methylphenidate 10 mg ER once daily Rationale: Cora's irritability may be due to the immediate release of methylphenidate wearing off prior to her next dose. Changing to a long- acting form may decrease irritability. Increasing the dose of methylphenidate IR, switching to a different stimulant medication, or adding guanfacine 1mg daily will not help decrease Cora's irritability. After 3 months, Cora's mom reports that her irritability has decreased somewhat with the implementation of the extended-release methylphenidate, but her teacher notes that she remains argumentative and oppositional at times. Her appetite remains good, but she is having difficulty sleeping. Which of the following medication changes might you consider at this time for Cora? - ANSWER>>add guanfacine 1mg daily Rationale: While methylphenidate is somewhat effective for Cora, her irritability and ADHD may be better controlled by adding a non-stimulant medication, such as guanfacine, to her daily medication regimen.