February 1, 2023

Alright attention disorders whether you’re called a td or adhd i think adhd is the correct terms basically from what i understand they’re just called attention disorders now oh sorry yes pretty much yep you don’t have to know any of the labs or anything just know that it requires extra monitoring that’s happens for treatment-resistant yep okay so anyway this

Disease was thought to be more commonly pediatric for a while however there’s actually a decent percentage of adults that have been found to suffer from it to the symptom presentation is quite different adults might present more depressed or more anxious or in different ways than a child might possess as hyperactive or doing poorly in school or something like that

More common in males and females but actually fairly decent rates in between the two slightly more common in males and drugs are pretty straightforward there’s really just like three drugs we use but there’s a whole bunch of different stimulants out there so we’ll talk about why you might choose one or the other but the idea here is that you have some kind of a

Catecholamine imbalance in the cerebral cortex miscommunication between your dopamine and norepinephrine systems so your body’s either your brains either clearing dopamine transported or increase in dopamine transporter density so you clear dopamine too quickly from the synapse you’re using more than your body can produce and serotonin has some role but no one quite

Understands exactly what it does clinical manifestations probably self-explanatory but poor concentration tractability and motor activity impulsive impulsivity distant envisioned future disrupt at least two domains in daily life to qualify for a diagnosis of school work family and peer relationships other things poor self-regulation hyperactive component again

That is a burden adults more commonly kids disorganization and learning disabilities are also ceated with attention deficit disorders alright pharmacotherapy is first-line psychotherapy may be helpful for addressing and restoring problematic behaviors but it might not get at the root cause per se norepinephrine pathway so using something that manipulates the way

Your synapses are using norepinephrine seems to be the best at treating adhd stimulants are the mainstay of therapy and our goal is just restore your functions of daily living so that you don’t interview with schoolwork peer relationships alright so stimulant what they do they release catecholamines from cns storage sites so they increased synapse norepinephrine

And dopamine they increase norepinephrine and dopamine the brain stem midbrain and frontal cortex kind of all over the brain there are actually really safe drugs at low dose i think stimulants get kind of a stigma behind them because people abused the heck out of them right i mean these are probably the most highly abused drugs in the country next to opioids so

They’re there they get that bad rep but if you actually take them at a normal dose it’s not like taking a hit of methamphetamine right yeah that’s that’s going like way way way beyond the spectrum and potency in dose so you’re doing like an oral stimulant really really safe there’s not a lot of side effects believe it or not i’m cochran and former current substance

Abusers for obvious reasons you have an addiction history and probably not the best choice more effective in children than adults showing to be shown to improve daily living skills there’s no real difference in efficacy between the different stimulants on the market just really a preference of your release mechanism that’s the difference that i’ll talk about here

In a second good short-term benefits a questionable long-term so the short-term benefits are pretty well proven clinically the long-term benefits we don’t really know on the studies that do show i don’t really show a huge benefit in taking stimulants long-term for life improvement quality of life is group interesting ly enough a couple different chemicals out there

Methylphenidate is a ka ritalin so there’s short-acting intermediate and long acting this is really gonna break down what comes into play i’m not gonna test you on all these different things what i’d like to even know is a couple items so i want you to know a few different products so just so you don’t have to memorize these whole list cuz i don’t think it’s worth

It and i can’t even keep them all straight alright so short-acting ritalin comes as a generic you need it release product it lasts a few hours and that was one of the first drugs available that was a stimulant proof for this condition obviously a few hours isn’t great so if we can extend that so it lasts entire day that’s good but we don’t want it to go into the

Evening where it’s keeping you up all night either so obviously stimulants or the opposite of sedating right so even if you’re taking the right dose you’re probably still going to be more alert and awake than you would if you if you weren’t taking it at all so making sure that drug tapers off towards the evening hours so you can get some sleep is important so most

Of these tried in some way to accomplish that and you’ll see lots of different creative ways to do it so for example one way i see a lot is people might take like a long-acting drug in the morning and then they might take a short-acting drug in the afternoon early wise and then that kind of bridges them into the evening hours or they might say you know when i get

Home i don’t really need that okay i just need to concentrate more at work or my my attention deficit kicks in more while i’m working or at school so that’s where i need the drug when i get home i don’t really need a tip as much but some people might want it throughout that entire basically waking hours so it depends on the person depends on what they’re using it

For some people may take it as needed and that’s a little bit controversial so but the point is there’s lots of different products available i think the one i recommend knowing is concerta concerned is a really popular choice it actually comes as a generic copper the generic product it’s technically not an exact equivalent conservatives got this really interesting

Release mechanism so it has these shelves you can see it broken up here what happens is the shell is automatic so it allows water to pass through its membrane sort but it’s kind of like a hard plastic i think it kind of like an eggshell a little bit for us so anyway water can go through and then as water gets in it pushes the drug out slowly and then or quickly at

First and then more slowly so the density of the drug depends on how fast it’s going to release from that shell it’s kind of a unique delivery mechanism again it’s really popular choice because of that release mechanism gives you sort of a fast onset with them a nice delayed release effect throughout the rest of your day so conservative has been widely used very

Popular choice that reason some other interesting stuff that i won’t talk about i won’t test you on and talk about very much but des trauma is a patch so i’ve been a kid especially i don’t think of adults is using these but you have a kid who would not take their medication or you want something that’s they don’t have to remember use patches might be better there’s

Also a suspension for people that want to take pills that’s extended-release little like granules lots of different options out there just in case you’re curious to look at like the duration of actions if you look at they don’t actually have just a regular dose of here but if you look at like ritalin sr which is the exo as you kind of get at peak around 4 to 6

Hours and it’s pretty much out of your system by 10 hours or so not that good but it’s got this big curve on it so can you want that a little bit conspirator concerta here you get this immediate effect and sort of a slow release and i’m sort of a hurst and then a tapering off you get a little bit more area under the curve later throughout the day with this drug

So again this is all the same drug it’s all effectives depends on how your patient wants to take it which one’s going to work best lots of these formulations could mix the match lots of them be used like once really that better much better than the other but there’s some creative pharmacology are mokou kinetics at work here other stimulants dex methylphenidate

Is focalin or focal and x-two ours comes as immediate release extended release dextroamphetamine dexedrine dex is strat dentist at excuse-me dexedrine spaniels long-acting adderall or adderall is actually amphetamine mix salt so it’s a combination of dextroamphetamine and some different amphetamine salts mixed together at different doses a little confusing but it

Comes as a immediate release generic adderall and then adderall xr both products are collegiate america most of these products are actually all generic the only exception here is vyvanse is brand name only it’s a really popular long-acting one why i met entirely sure why it’s people liked it better than other ones but it seems to be relatively popular choice for

Long-acting stimulants all right side effects cardiovascular more concerning in adults and children basically increased blood pressure and heart rates so if your patient has underlying hypertension other cardiovascular issue is probably not the best choice for them neurologic psychiatric sleep disturbance obviously if you get that too close to bedtime that’s where

You gonna see it adhd also make us sleep disturbances so actually counter-intuitively if you treat this by i always tell people people are like i think it’s the whole idea of adhd is a little counterintuitive right you take a stimulant to calm down or focus more i think the way i think about it is that if your brain is really over producing a certain hormone or it’s

Over utilizing a certain hormone these drugs help kind of like funnel it or channel it more so so it’s i think about like if you open a hopf can and v out right away versus if you like opened it really slowly so it kind of regulates the way your body can process and release the neurotransmitters versus your body releasing them overly aggressively so that’s how i

Look at it whereas somebody who doesn’t have adhd they took the medication yeah they’re probably going to get a kick of those hormones so it’s gonna affect them differently than somebody with the disease but will they be able to focus yeah they’re gonna be probably kind of wired right like if they drink a bunch of caffeine but a little bit differently okay anyway

Sleep disturbances on appetite suppression tic development abuse potential have a whole lot of things going on here most of this is pretty good the one thing i will say appetite suppression for kids can be problematic and that’s thought to be associated with growth stunting as well with these so some kids or it’s recommended in some cases to have drug holidays so

Kids will take these during the school year and then they’ll stop them for the summer and thence that actually studies have shown that kids who get growth during stimulant use will catch on later in life so it all kind of averages out at some point so it’s not like it’s a permanent thing they’re gonna be really short because they took stimulants priapism so males

Of all ages it’s kind of a rare effect i think of any time you manipulate norepinephrine and serotonin there’s always some risks you could get an unwanted erection that does not go away and of course that can be medical emergency in some cases so just something to be aware of sense to me more tabbing and stimulants than other medications out there some other

Pearls i talk about drunk holidays prn again a little bit controversial so if you need it prn like why do you really need it at all shouldn’t this be like a daily thing if this is truly a disorder you have like prn kind of border lines on a view this personally but it depends on the person some people may have like a really low grade adhd and maybe they just

Need it a couple times a week in the evening or something like that to help them focus on getting housework done doesn’t really affect their work affects their home life more so so you can see some may be situations where it’s appropriate but i think it’s also a little bit questionable if you’re taking as you told me a lot of people will have like a long-acting

On board day liam they might have an extra dose they can use that’s needed i think that’s much more common to see growth retardation and talked about that withdrawal if people stop these suddenly it’s usually pretty mild but temp ends on the formulation dose and how long they’ve been on higher doses longer time more extended release gonna quicker release is going

To cause more withdrawal usually provisions and probably gonna exacerbate and cause some rebound effects of the underlying disease right all right that’s stimulants talking about a couple other drugs quick adam oxy tea mr. terris or tara’s and norepinephrine reuptake inhibitor so think about our snris or ssris this one’s just a pierre nri it’s not addictive it’s

Not controlled it’s non-stimulant it is effective but not quite as good as stimulants and clinical trials it’s brand only actually think it would generic recently so ignore that adverse effects fatigue insomnia dry mouth headache weight loss gi issues some erectile dysfunction potentially also causes priaprism rarely rare but severe hepatic toxicity and can cause

Some see the effects like our other stimulants do so maybe not the best choice for a cd patients but this is a good alternative for somebody who doesn’t want to take a stimulant or isn’t getting good effects out of stimulants or finds that stimulants keep them awake too long or listen cuz insomnia – but i think it’s less than the average stimulant so certainly

A good alternative option but generally thought of the second line – stimulant therapy if you had somebody with abuse though this would be a first-line option how does it cause erectile dysfunction i get dosing yeah maybe i think the prices it was just a a rare reaction that can happen with some medication so erectile dysfunction probably more of a common thing

Seen with it and you know really reporting that as a higher incidence than the average man yeah kind of bizarre all right antidepressants can be used a lot of times again adults present with some depressive like symptoms too and there’s some studies that show that combining therapy can be helpful in those patients so an antidepressant and stimulant however if

You didn’t want to use the stimulant tricyclic antidepressants actually have some decent response rates by themselves for adhd we talked about tricyclics is not being ideal there anticholinergic they’re sedating but it could be an option to try and save a potentially the appropriate has more stimulant that should say stimulant properties than tcas not sedating two

Weeks to response so i’m shown to become somewhat effective for attention disorders mao is don’t worry about them you wouldn’t use them in this case i don’t think there’d ever be a situation where you use them for adhd but it could be wrong you really ought esse ssris and snris really not going to be used as mono therapy gonna be used as an adjunct option to treat

The depressive symptoms after whatever you prescribed for the adhd isn’t quite working kind of in their own tier alpha-2 agonist guanfacine is 10x their intuitive and intuitive to the extended-release product 10x is the immediate release i think 10x is brandon and i believe in starting 10x is generic so immediate release is generic intuniv is still brand product

A little bit expensive children adolescence is gonna be the most common use for this for adults it’s it just doesn’t have a lot of evidence behind it it might work and might be worth a shot but who knows we just don’t have a good body of evidence to base that decision on but if children have aggressive behavior or significant hyperactivity and stimulants seem to

Enhance that which can happen in some cases this is a great option for those kids because it’s gonna work on a different mechanism so the alpha-2 agonist thought remember clonidine our drug for hypertension guanfacine is actually kind of similar at how it works so it works on the alpha 2 receptors in the central nervous system and because it’s kind of a psychomotor

Downstream effect where you get some delayed or not delayed but some inhibitory responses so clonidine it decreases blood pressure and actually guanfacine would probably do that too you just don’t really notice it quite as much in kids but it has some effects and just how their brain processes the information it’s kind of a unique mechanism of action you can combine

Blancas scene with a stimulant too if you wanted to so if you both work for that patient could be an option i think of clonidine it’s like the male or female adult patient with hypertension and you don’t have a good option you don’t wanna get them a stimulant probably don’t want to give them a damn oxy teen clonidine might actually work well for their blood pressure

And i’ve actually might help with their attention deficit as well so that’s my recommendation for somebody with those cardiac comorbidities stimulant abuse i mentioned this already stimulants are all scheduled to there’s prescription limitations with those usually you can only prescribe a month with a schedule 2 i think there’s some states i think minnesota is

One of them that allow you to do 90 days in some cases depending if you can prove the patient’s been on it for a while college and high school student abuse is rampant as probably everyone knows i don’t need to tell you this thought it was a study drug whatever i had this roommate in college at bethel who would like you’d go in and try and get like the weirdest

Drugs one time he got prescribed side prex because he was trying to get adderall from a psychiatrist they kept giving him slip rexha i don’t know why i think they thought he was bipolar and i’m not sure if he’s faking the symptoms or what it was just it was bizarre who knows what happened i didn’t know enough about drugs at the time but i think that gum and i’m

Like how is that even possible like you prescribed somebody zyprexa they never follow up with them it’s really bad so anyway he took psych practice it for like a week and he was just a total zombie but it’s so any like you would have like a pharmacy in his basement i said cancer that word you’d be like chad you want us to concern you just i’d be like i got this

Test coming out he like take a concern i’m like i’m good he was generous right so you gotta give me that here’s a character alright so anyway also performance arts arts and athletics a lot of sports regulatory organizations ban stimulants for that reason for obvious reasons right slower release of oral stimulants again doesn’t really produce a high so the reason

That this is the big controversy right so if somebody wants to use a drug that’s relatively safe it doesn’t really get you high to use it and low doses and are taking it orally if you’re not grinding up and starting it right i mean that’s obviously abuse but so if you’re taking it normally like what’s to stop somebody to say hey i want to do a little bit study

Harder and i want to take a five milligrams of adderall every well is that really wrong i don’t know that’s that’s a dilemma there’s a lot of ethical debate around that so interesting i’ll leave it at that i’m not really gonna get into it cuz i i don’t know if i have a strong opinion either way patients are at high risk for abuse if you do have these patients who

Have abused the drug or for these other drugs in the past i definitely consider adam ox a team or a tricyclics possibly as a first-line option alright okay so what about patients thought any she already talked about this how it happens like why would somebody get an effect if they don’t and yes they get a stimulant effect but it’s gonna work differently in their

Branded with somebody with the actual disease okay treatment strategy initial treatment no history of drug abuse you’re gonna usually start with the stimulant take a formulation if that doesn’t work switch consider mixing long-acting with short-acting you know if you wanted to go with atomoxetine right off the bat i would never fault somebody for doing that that’s

Fine too just the evidence body is great i think adam oxy teen for a long time we’ve kind of pushed it off but now that it’s generic i think it’s more affordable for a lot of people and it certainly could be maybe considered something to try starting with if you’re really uncomfortable with stimulant use in certain patients especially if you’re thinking they have

Adhd but are also maybe drug seeking a little bit getting that kind of spider sense tingling anyway if you have history abuse or second line options atomoxetine tc is guanfacine for kids should be probably your second line option or it first line for those aggressive patients or highly agitated kids not responding try different stimulants maybe combine classes

Look at your release mechanisms make sure you’re getting the optimal amount at the optimal times for the patient and then consider adding an antidepressant especially for adults sometimes in kids in adolescence – they might benefits from at like a necessary adjunct and these even if they don’t necessarily have depression per se sometimes it does help alright any

Questions on that alright i’ll give you 25 24 minutes left how’s that yes

Transcribed from video
ADHD By Chad Peterson