Pharmacological Treatment Of Attention Deficit Disorders

Since medication is frequently used in the treatment of ADHD, it is important to have reasonable expectations regarding its effectiveness and to be aware of potential side effects.

General Medication Information

• Each person responds uniquely to medication.
• Medications in children are very safe. More studies have been done about children taking stimulant medications than any other medications including
• nonprescription drugs. Prescribed and taken correctly, they are not addictive. Individuals do not have a physical craving for medication. When stimulant
• medication is out of the blood stream, the individual goes back to exhibiting full-blown ADHD symptoms.
• Both hyperactive and nonhyperactive individuals with attentional problems can benefit from medications.
• Medication is effective for 54% of nonhyperactive children and 80-90% of hyperactive children.
• Medications are prescribed for adults with ADHD in the same small dosages given to children.
• When taking the appropriate dosage, medication usually doesn't affect personality.
• Dosages should never be changed without discussion with the prescribing doctor.

Medication Does Not:

• cure ADHD.
• teach the ADHD individual how to cope and compensate for difficulties.
• imply a "magic pill".
• just treat hyperactivity. Medication also helps with impulsivity, attention difficulties, and aggression.
• cause addiction. Long-term studies show that children who have taken stimulant medication are not more prone to substance abuse but rather, less so.
• have a permanent effect on a child's growth, if carefully monitored and weight is not effected.
• sedate children so that their behavior improves.
• lead to aggressive, dangerous behavior.
• create personality changes.
• cause seizures.
• cause tics but may bring them out in patients with Tourette's Disorder. Stimulants may increase the tics.

Medication Does:

• treat ADHD symptoms.
• influence long-term progress and prognosis of ADHD children, when utilized in conjunction with treatment modalities specific for ADHD.
• stimulate the attention center of the brain to function more normally.
• affect impulsivity, attention and behavior positively. More specifically, stimulants can increase attention span, concentration and compliance; improve
• handwriting and fine motor skills; and allow improved peer relationships. Also, a decrease in impulsivity, aggressiveness, and hyperactivity can occur.

Medications Frequently Used In Treating Adhd

I. Psychostimulants:

Psychostimulants stimulate the release of norepinephrine and dopamine from the nerve terminals in the attention center of the brain. Of the pharmacologic options available for ADHD, stimulants are the most studied, most commonly used, most effective, and are usually the first used agents for treatment.

Stimulants Improve:

• Core Symptoms
• Inattention
• Impulsivity
• Hyperactivity

AND

• Impulsive aggression
• Social interactions
• Academic productivity accuracy

Advantages of Stimulants:

• Specifically treat ADHD core symptoms of inattention, overactivity, and impulsiveness
• Largest effect on ADHD of any drug class, especially for children
• Significant benefit in 90% of ADHD if two or more tried in succession and titrated carefully
• Calms comorbid aggression and oppositional-defiant behavior
• Results of given dose seen immediately; relatively easy titration

Stimulant Side-effects (most common):

• Insomnia
• Loss of appetite
• Rebound of hyperactivity after medication wears off
• Irritability
• Stomachache
• Headache
• Over focusing, compulsive behaviors
• Weight loss

Signs of over dosage:

• Increased hyperactivity
• Overly obsessive behavior or anxiety
• Social withdrawal
• "Zombie-like" appearance or sedation
• Increased blood pressure and pulse

Potential Side Effects:

• Proven safer than most psychiatric medications
• None of these side effects are dangerous for healthy children
• Side effects are usually experienced when medication is started and decrease over time
• Tics: There is an increased risk that children will develop these symptoms if there is a familial predisposition to Tourette's Disorder. Children who have undetected Tourette's may develop tics and the full-blown symptoms of the disorder. Less than 5% have tics and the incidence of Tourette's is very rare.
  Symptoms of Tourette's are more pronounced under stress.
• Appetite Suppression: This may be more of a problem if medication is given before meals. Appetite will usually return when the effects of the medication have worn off. Approximately 50-60% complain of appetite loss; 50-60% of difficulties falling asleep; and 20-40% of stomach cramps and headaches when first starting the medication. There may be mild increases in heart rate and blood pressure. Mild weight loss may occur in the initial first or second month, but no overall effect on skeletal growth. Rarely, children can experience a growth slow down if they continue to lose weight. There are easy methods to deal with this such as adjusting medications, allowing time periods where appetite is not suppressed, and using protein drinks at bedtime.
• Behavioral Rebound: Increased excitability, talkativeness, impulsivity, or insomnia may appear 5 to 20 hours after the last dose treatment. Rebound resembles a return of the original symptoms after the medication wears off, except that the magnitude of symptoms actually increases above the baseline. Rebound has been clearly demonstrated in normal children and has been described, but less well documented, as a clinical problem.
• Impaired Cognitive Performance: Mainly observed at high doses and probably represents the toxicity of over medication. Single doses of methylphenidate above 1mg/kg have been repeatedly found to impair cognitive functioning. In predisposed children who may have Bipolar Disorder, psychotic or psychotic-like symptoms which include hallucinations or delusions, mania, stereotyped or compulsive behavior, and self-biting may occur.
• Neuropsychiatric Effects: Include tics or other abnormal movements, night terrors, and lip-licking or biting. Occasional adverse effects include dizziness, nausea, nightmares, constipation, lethargy, fatigue, anxiety, fearfulness, hypercusis (increased acuity of hearing), rash, hives, and a sensation of "ants crawling on skin." However, these effects are uncommon.

Relative Contraindications:

• Amphetamines should not be used in patients with known psychosis, a history of symptoms suggestive of a risk for psychosis, or a history of substance abuse in an adolescent or adult patient, peers, or immediate family members without careful monitoring. Other contraindications include a child with a family history of tics or Tourette's Disorder, cardiac abnormalities or high blood pressure abnormalities, seizure disorder, or severe side effects in a previous stimulant trial.

Psychostimulants Used in ADHD

Short Acting Duration Duration of effect in hours

Methylphenidate (Ritalin, Methylin) 1-4
Dextroamphetamine (Dexedrine) 1-6
Dextroamphetamine (DextroStat) 1-6
Dexmethylphenidate (Focalin) 4-6
Dextroamphetamine Sulfate (Zenzedi) 1-6

Intermediate Acting Duration Duration of effect in hours

Methylphenidate (Ritalin LA) 4-8
Methylphenidate ER (Metadate ER, Methylin ER) 4-8
Methylphenidate (Metadate CD) 6-8
Pemoline (Cylert) 7-9
Amphetamine-dextroamphetamine (Adderall) 6-8
Dextroamphetamine (Dexedrine Spansule) 6-8
Dextro-Methylphneidate (Focalin) 6
Amphetamine Sulfate (Evekeo) 6
Methylphenidate (Quillivant XR- Liquid) 8

Long Acting Duration Duration of effect in hours

Methylphenidate (Concerta) 10-12
Amphetamine-Dextroamphetamine (Adderall XR) 10-12
Dextromethylphenidate XR (Focalin XR) 10-12
Methylphenidate (Daytrana) 9-12
Vyvanse Dextroamphetamine Prodrug 12
Methylphenidate Hydrochloride (Aptensio XR) 12
Amphetamine (Adzenys XR) 10-12
Amphetamine (Dyanavel XR) 13

Amphetamine Based Stimulants

Adderall

• Capsules contain a mixture of different amphetamine salts
• Usually taken once a day; lasts 12 hours
• Dose is split into 2 separately timed releases which prevents a peak/valley effect
• Capsule
• A single product made up of 4 different amphetamine salts: Dextroamphetamine Sulfate, Dextroamphetamine Saccharate, Amphetamine Sulfate, and Amphetamine Aspartate.
• Usually taken once or twice a day.

Adderall XR

• Capsules contain a mixture of different amphetamine salts
• Usually taken once a day; lasts 12 hours
• Dose is split into 2 separately timed releases which prevents a peak/valley effect
• Capsule may be opened and given as "sprinkles" for young children

Evekeo (Amphetamine Sulfate)

• Evekeo is an amphetamine sulfate similar to Adderall, but with a different composition: whereas Adderall is 75% dextroamphetamine and 25% levoamphetamine, Evekeo is an even 50% of each. Evekeo is an immediate-release, short-acting medication.

• Not recommended for children under 3 years of age. Available in 5 and 10 mg tablets.
• In children 3-5 years of age, start with 2.5mg daily; daily dosage may be raised in increments of 2.5mg at weekly intervals until optimal response is obtained.
• In children 6 years of age and older, start with 5mg once or twice daily; daily dosage may be raised in increments of 5mg at weekly intervals until optimal response is obtained. Only in rare cases will it be necessary to exceed a total of 40 mg per day.

Adzenys XR-ODT (Amphetamine extended-release orally disintegrating tablets)

• Orange-flavored tablet that dissolves in the mouth when taken with or without water.
• Adzenys XR-ODT is formulated for once daily dosing using tow different kinds of "micro-particles" that dissolve at different rates. Fifty percent dissolve immidiately upon the medication's administration, while the other 50% dissolve slowly to release the medication steadily throughout the day.
• Patients taking ADDERALL XR may be switched to ADZENYS XR-ODT at the equivalent dose taken once daily. Click here to review dosage equivalency chart at www.adzenysxrodt.com

Zenzedi (Dextroamphetamine Sulfate)

• For pediatric patients age 3 to 16 years as an integral part of a total treatment program for ADHD that may include counseling or other therapies.
• 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, and 30 mg immediate-release dextroamphetamine tablets available. This incremental dosing allows a physician to customize therapy with preceise dosing adjustments.
• Zenzedi may help manage symptoms throughout the day with flexible dosing.
• Not recommended for pediatric patients under 3 years of age.

Dyanavel XR (Amphetamine Extended-Release Liquid)

• Extended-release amphetamine oral suspension of 2.5mg/ml (liquid) for children aged 6 years and older
• It has been reported to provide control of ADHD symptoms for up to 13 hours and starts working one hour after taking.
• In children 6 years of age and older, recommended starting dose is 2.5mg or 5mg once daily in the morning.

Concerta

• Extended release formulation of methylphenidate which is designed to last 12 hours with just one dose
• Helps maintain focus without in-school and after-school dosing
• The medication is released gradually in a smooth pattern minimizing the peaks/valleys associated with short-acting medication
• Capsule may not be opened or broken

Daytrana

• A methylphenidate patch which works for about 10 hours
• It takes about 1-2 hours to start working
• The patch gives more control to decide when to stop the stimulant effect or for children who have difficulty taking medication

Dexedrine or Dextrostat (Dextroamphetamine)

• Dexedrine spansule is given once per day. 50% of beads dissolve immediately and 50% in four hours
• Dexedrine/Dextrostat tablets can be taken two or three times a day

Metadate

• 10, 20, and 30mg extended-release methylphenidate capsule, which may be opened and used as "sprinkles"
• Offers extended-release strength of methylphenidate and may eliminate the need for midday dosing
• Effects last 8 hours which may be helpful because it covers the school day and may then wear off to improve appetite during after school hours
• A generic tablet is available

Focalin (dexmethylphenidate HCI)

• A refined filtered formulation of methylphenidate (dextrosteroisomer)
• Available in 2.5, 5, and 10mg tablets. The recommended dose will be half the dose of Ritalin
• Taken twice daily
• Short-acting benefit is that the side effects should wear off quickly

Focalin XR (Dextromethylphenidate)

• Extended release capsule
• Comes in 5mg, 10mg, 15mg, 20mg, 30mg, 40mg capsules
• Dosing once per day in the morning with a 10-12 hour effect
• Capsule can be opened and sprinkled on food for children who cannot swallow pills
• Less side effects because stereoisomer of Methylphenidate • dextro only
• For ADHD with anxiety

Ritalin (Methylphenidate)

• Usually taken twice a day; a third dose may also be prescribed to help the child participate in after-school activities, do homework, and interact with the family
• Also available in sustained release form, Ritalin SR or Ritalin LA, which is taken once in the morning eliminating the need for a noon dose

Vyvanse (Dextroamphetamine)

• New delivery system. Dextroamphetamine is attached to the amino acid Lysine. In the blood stream an enzyme that separates the medication and makes it available in the Dextroamphetamine form. This offers a smoother blood level than Adderall XR. The other advantage is that this medication cannot be snorted or injected, thereby decreases it's potential for abuse.
• Dosing once daily in AM.
• Capsule can be opened and powder mixed with liquid for children who cannot swallow pills. This also allows making varying doses by amount of solution given.

Aptensio XR (Methylphenidate Hydrochloride)

II. Non Stimulant

Strattera (atomoxetine) A Selective Norepinephrine Reuptake Inhibitor

• Dosing 1 or 2 times per day
• Relatively mild side effects
• No life threatening side effects
• May cause slight (1-3mm) rise in blood pressure, which is equal to stimulants
• 2 cases of liver reactions

Most Common Side Effects:

• Sedation/Insomnia
• Nausea
• Decreased appetite for first month in 15% of cases
• Tremor
• Blurry vision
• Itching

Catapress (Clonidine) or Tenex (Guanfacine)

• May be prescribed for ADHD children who have difficulty with aggression, impulsivity, insomnia, and/or severe hyperactivity
• May have a sedation effect
• Is utilized with Tourette's Syndrome and ADHD children with tics.
• Usually taken up to 3-4 times a day
• A 5-day patch is available for Clonidine called catapres TTS
• Targets hyperactivity and impulsivity more than attention
• Not approved for children

Common side effects include:

Dry mouth, irregular heart rate, hypotension, headache and dizziness, stomachache, and vomiting

Uncommon side effects include:

Depression, nightmares, anxiety and rebound hypertension if patient suddenly stops taking the medication

Kapvay (Clonidine) (Alpha 1 Agonist)

• Kapvay is the sister drug to quanfacine
• Similar effects and side effects
• Not approved for children 6 and under

Catapres Patch (Clonidine)

• For ages 18 and up

Intuniv ( guanfacine) Extended Release Tablets - Alpha 1 Agonist

• Improves functioning in Prefrontal Cortex by effect on Norepinephrine neurotransmitter System
• Very helpful for hyperactivity and impulsivity
• Especially helpful in oppositional/defiant, conduct type problems
• No known potential for abuse or dependency
• No effects on height or weight
• Can lower blood pressure but usually only temporarily
• Start with 1mg daily and titrate weekly in 1mg increments to achieve to desired balance of efficacy and tolerability
• Dosages above 4mg/day have not been studied
• Tablets should not be crushed, chewed, or broken before swallowing

Most Common Side Effects:

• Tiredness, fatigue
• Headache
• Abdominal Pain
• Dizziness on standing
• Dry mouth
• Constipation

III. Tricyclic Antidepressants

Elavil (Amitriptyline)
Pamelor (Nortriptyline)
Norpramin (Desipramine)
Tofranil (Imipramine)

Common Characteristics of these older medications:

• Prescribed for ADHD children who are also experiencing anxiety and/or enuresis.
• Elicits mild improvements in attention and activity level, and decreased impulsivity, irritability, aggressiveness, and temper outburst
• May be given 1-3 times a day
• May become less effective over time
• May improve sleep onset

Side Effects:

• Side effects are numerous, including cardiac side effects such as irregular heartbeat, dry mouth, sedation, constipation, and hypertension or hypotension

Medications Used In Treating Comorbid Disorders With Adhd

Other Medications:

These medications are considered "3rd line". They are often prescribed when the other more commonly used medications have proven ineffective or if special problems or comorbid conditions exist that are associated with ADHD.

I. SSRIs-Antidepressants (no evidence of effectiveness in ordinary ADHD)

Brand	Generic
Prozac	(Floxetine)
Luvox	(Fluvoxamine)
Remeron	(Mirtazapine)
Lexapro	(Escitalopram Oxalate)
Paxil	(Paroxetine)
Zoloft	(Sertraline)

 

 

 

 

 

 

ADHD children and adolescents may get agitated and sometimes more hyperactive at high doses (greater than 150mg).

Dosing:

• Usually once a day
• Don't need blood levels
• Fewer side effects than tricyclic antidepressants
• Not lethal in overdose
• Don't interfere with heart function

Adverse Effects:

• Nausea, vomiting, upset stomach
• Insomnia
• Agitation
• Restlessness
• Weight loss
• Sexual dysfunction

II. (SSRI and SNRI) Selective Norepinephrine Reuptake Inhibitor

Effexor (Venlafaxine)

Preliminary reports in adults indicate that Effexor may be useful in decreasing ADHD symptoms, particularly in ADHD adults who are also experiencing anxiety and/or depression. These preliminary reports have not held up in research

Common side effects include:

• Nausea
• Somnolence
• Dry mouth
• Dizziness
• Constipation
• Nervousness
• Increased sweating
• Sexual dysfunction

Uncommon side effect:

• Increased blood pressure (greater chance of occurrence at dosages above 200mg/day) blood pressure will normalize with dose reduction

Cymbalta (Duoxetine)

III. Antidepressant (Dopamine Reuptake Inhibitor)

Wellbutrin (Bupropion)

• Antidepressant unrelated to all the others
• Central nervous system stimulant effects
• More frequently prescribed for ADD adults
• Contraindicated in patients with seizure disorder, bulimia, or anorexia nervosa
• Usually given once a day (XR) or twice a day (SR)

Common side effects include:

• Agitation
• Dry mouth
• Insomnia
• Headache/migraine
• Nausea
• Vomiting
• Constipation
• Tremor

Uncommon side effects include:

• Seizures (4/1000)
• Swelling
• Chest pain
• Shortness of breath
• Liver damage
• Urinary symptoms
• Lack of coordination
• Hypertension

IV. Mood Stabilizers

In the past 10 years I have been doing research into trying to understand why some children do not benefit from our typical treatments for ADHD. what I and others have found is that some children have abnormal electrical rhythms in their brains that react atypically. I have called those children "Neuroatypical." This is a name that has been used previously to describe children that have neuropsychiatric abnormalities. Some of these children have subclinical "spike and wave" activity that in my experience respond to anti-seizure medications. In psychiatry we classify them as mood stabilizers because of their stabilizing effects on mood disordered children such as Bipolar Disorder.

Swatzyna Rj, Kozlowski GP, Tarnow JD: Pharmaco-EEG; A Study of Individualized Medicine in Clinical Practive. Clin EEG Neurosci; 2015 Jul;46(3):192-6

Further research is needed to understand these children's brains. However, I have listed those medications for completeness just as including anti-psychotic medications. They are not for your typical ADHD child. ADHD has a 30-50% comorbidity with other psychiatric disorders.

Carbatrol or Tegretol (Carbamazepine)

• The most responsive symptoms include Bipolar Disorder, aggressive behaviors, low frustration tolerance, and impulsivity
• Usually given 2-3 times a day

Common side effects include:

• Stomachaches, dizziness, sedation, blurred vision and low blood count. A complete blood count should be done periodically especially when patient has repeated or severe infections

Adverse effects:

• Upset stomach
• Nausea, vomiting
• Decreased white blood cell count, if gets fever, sore throat, infection, may need to consider agranulocytosis (medical emergency involving stopping Tegretol)
• Rash
• Avoid in pregnancy
• Sedation
• Weight gain
• Ataxia
• Hair loss
• Low platelet count
• Chemical Hepatitis
• Pancreatitis

Monitoring:

• Needs blood levels and CBC monitoring

Dosing:

• Begin 200mg BID to TID up to 1500mg or so based on blood levels

Toxicity:

• Drowsiness, ataxia, muscle weakness, confusion
  Avoid in pregnancy: Valproic Acid (Depacote) Gabapentin (Neurontin) Lamitrogene (Lamictal) Topamax

Depakote (Valproic Acid)

• Indicated for treatment of manic episodes associated with bipolar disorder
• Also usedwhen mood disorders co-exist withADHD

Common side effects include:

Acid or sour stomach, body aches or pain, change in vision, congestion, ringing or buzzing noise in the ears, hair loss or thinning of the hair, hearing loss, heartburn, impaired vision, lack or loss of strength, loss of memory, rash, tender, swollen glands in the neck, trouble with swallowing, uncontrolled eye movements, voice changes, weight gain, or weight loss.

Adverse effects:

Black, tarry stools, bleeding gums, bloating or swelling of the face, arms, hands, lower legs, or feet, blood in the urine or stools, confusion, cough or hoarseness, crying, delusions, dementia, depersonalization, diarrhea, difficult or labored breathing, dysphoria, euphoria, fever or chills, general feeling of discomfort or illness, headache, joint pain, loss of appetite, lower back or side pain, mental depression, muscle aches and pains, nausea, nervousness, painful or difficult urination, paranoia, pinpoint red spots on the skin, quick to react or overreact emotionally, rapid weight gain, rapidly changing moods, runny nose, shakiness in the legs, arms, hands, or feet, shivering, sleepiness or unusual drowsiness, sore throat, sweating, tightness in the chest, tingling of the hands or feet, trembling or shaking of the hands or feet, trouble sleeping, unusual bleeding or bruising, unusual tiredness or weakness, unusual weight gain or loss, and vomiting.

Monitoring:

Needs Blood Levels and CBC Monitoring

Dosing:

Recommended initial dose is 750mg daily in divided doses.

Toxicity:

Somnolence, heart block, deep coma, and hypernatremia (high concentration of sodium in the blood.

Avoid in pregnancy

Lamictal (Lamitrogene)

Anticonvulsant

Common side effects include:

Dizziness, drowsiness, headache, nausea, and vomiting.

Adverse effects:

Drowsiness, tremor, blurred vision, skin rash, nausea, ataxia, vomiting, diplopia, insomnia, rhinitis, dizziness, headache, abdominalpain, and fever. Dyspepsia, dysmenorrhea, vaginitis, weakness, abnormal gait, pain, constipation, pruritus, bronchitis, and emotional lability.

Monitoring:

Needs blood levels and CBC monitoring

Dosing:

The target dose of LAMICTAL is200 mg/day

Toxicity:

Severe clumsiness or unsteadiness, severe continuous, uncontrolled back and forth or rolling eye movements, severe dizziness, drowsiness, dryness of the mouth, headache or slurred speech. Increased heart rate and coma.

Avoid during pregnancy.

Keppra (Levetiracetam)

Anticonvulsant

Common side effects include:

Drowsiness, weakness, infection, loss of appetite, stuffy nose, tiredness, and dizziness.

Side effects in children include sleepiness, accidental injury, hostility, nervousness, and weakness.

Adverse effects:

Hallucinations, unusual thoughts or behavior; bruising, severe tingling, numbness, pain, muscle weakness; feeling very weak or tired; fever, chills, body aches, flu symptoms, sores in your mouth and throat; problems with walking or movement; the first sign of any skin rash, no matter how mild; fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain, followed by a red or purple skin rash that spreads and causes blistering and peeling.

Monitoring:

Needs blood levels and CBC monitoring

Dosing:

Dosing in pediatric patients weighing 40 to 80 lbs, treatment should be initiatedwith a daily dose of500 mggiven as twice daily dosing (250 mg twice daily).

Toxicity:

Somnolence, heart block, respiratory depression, coma, agitation, agression, ataxia and abdominal complaints.

Avoid in pregnancy

Neurontin (Gabapentin)

Anticonvulsant

Common side effects include:

Dizziness, drowsiness, weakness, tired feeling; nausea, diarrhea, constipation; blurred vision; headache; breast swelling; dry mouth; or loss of balance or coordination.

Adverse effects:

Clumsiness or unsteadiness and continuous, uncontrolled, back-and-forth, or rolling eye movements. More common in children - Aggressive behavior or other behavior problems, anxiety, concentration problems and change in school performance, crying, depression, false sense of well-being, hyperactivity or increase in body movements, rapidly changing moods, reacting too quickly, too emotional, or overreacting, restlessness, suspiciousness or distrust.

Monitoring:

Needs blood levels and CBC monitoring

Dosing:

12 years and above – Starting dose is 300mg three times a day

3 to 11 years – starting dose range is 10mg to 15mg a day given in 3 divided doses

Toxicity:

Severe weakness or tiredness; upper stomach pain; chest pain, new or worsening cough with fever, trouble breathing; severe tingling or numbness; rapid back and forth movement of your eyes; little or no urination, painful or difficult urination, swelling in your feet or ankles, feeling tired or short of breath; or severe skin reaction--fever, sore throat, swelling in your face or tongue, burning in your eyes, skinpain followed by a red or purple skin rash that spreads and causes blistering and peeling.

Avoid during pregnancy

Topamax (Topiramate)

Anticonvulsant

Common side effects include:

Numbness or tingling in your arms and legs; flushing (warmth, redness, or tingly feeling); headache, dizziness, drowsiness, tired feeling; mood problems, confusion, feeling nervous, problems with thinking or memory; changes in your sense of taste; nausea, diarrhea, stomach pain, loss of appetite, indigestion, weight loss; or rapid back-and-forth movements of the eyes.

Adverse effects:

vision problems, eyepainor redness, sudden vision loss; confusion, slowed thinking, memory problems, trouble concentrating, problems with speech; dehydration symptoms - decreased sweating, high fever, hot and dry skin; severepainin your side or lower back, painful or difficult urination; irregular heartbeats, feeling tired, loss of appetite, trouble thinking, feeling short of breath; or vomiting, unexplained weakness, feeling like you might pass out.

Monitoring:

Needs blood levels and CBC monitoring

Dosing:

The recommended dose for in adults and pediatric patients 10 years of age and older is 400 mg/day in two divided doses.

Toxicity:

Decreased awareness or responsiveness, dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position, severe sleepiness, unusual drowsiness, dullness, tiredness, weakness, or feeling of sluggishness.

Avoid during pregnancy.

Trileptal (Oxcarbazepine)

Anticonvulsant

Common side effects include:

Abdominal or stomach pain, burning feeling in the chest or stomach, nausea and vomiting, sleepiness or unusual drowsiness.

Adverse effects:

Change in vision, change in walking or balance, clumsiness or unsteadiness, cough, fever, sneezing, or sore throat, crying, dizziness, double vision, false sense of well-being, feeling of constant movement of self or surroundings, mental depression, sensation of spinning, uncontrolled back-and-forth and/or rolling eye movements

Monitoring:

Needs blood levels and CBC monitoring

Dosing:

Treatment with Trileptal should be initiated with a dose of 600 mg/day, given in a twice-a-day regimen.

In pediatric patients aged 4-16 years,treatmentshould be initiated at a daily dose of 8-10 mg/kg generally not to exceed 600 mg/day, given in a twice-a-day regimen.

Toxicity:

Somnolence, heart block, coma, and hypernatremia (high concentration of sodium in the blood, ataxia and abdominal complaints.

Avoid in pregnancy

V. Atypical Anti-pyschotics

Abilify (Aripiprazole)Approved for children
Geodon (Ziprasidone)
Seroquel (Quetiapine)
Risperdal (Risperidone Approved for children
Zyprexa (Olanzapine)

Common Characteristics:

• Prescribed for the management of manifestations of Schizophrenia, Bipolar Disorder
• Improves a full range of psychotic symptoms including positive symptoms, negative symptoms, uncontrolled hostility/excitement, and disorganized thought
  Usually given 2-3 times a day
• Has been shown to improve impulsive aggression in children and adolescents May also improve sleep and symptoms associated with severe anxiety and depression
• Helps tics, severe Obsessive Compulsive Disorder

Common side effects include:

• Sedation
• Dizziness
• Constipation
• Nausea
• Indigestion
• Runny nose
• Rash
• Rapid heartbeat

Uncommon side effects include:

• Restlessness
• Tremors
• Involuntary slow or jerky facial or body movements (Tardive Dykinesia)
• Muscle stiffness

VI. Neuroleptics

• Haldol
• Prolixin
• Thorazine
• Mellaril

Common Characteristics:

• Antipsychotics used in Schizophrenia, Bipolar Disorder
• Anti tic effects
• Tranquilizing effect
• Anti-aggression

Adverse Effects:

• Blurred vision
• Dry mouth
• Constipation
• Urinary retention
• Decreased sweating
• Memory impairment
• Impotence
• Increased heart rate
• Drowsiness
• Weight gain
• Low blood pressure
• Skin rashes
• Photosensitive
• Lowered seizure threshold
• Restlessness
• Muscle stiffness
• Tightness
• Abnormal motor movements (Tardive Dyskinesia - usually involves mouth first)
• Neuroleptic malignant hypertension (medical emergency severs rigidity, change in mental status, abnormal vital signs-increased temperature, autonomic instability)

Toxicity:

• Sedation
• Low blood pressure
• Extrapyramidal Symptoms (muscle stiffness, rigidity, abnormal motor movements)
• Tardive Dyskinesia - mouth tic

VII. Catapres (Clonidine) or Tenex (Guanfacine)

• May be prescribed for ADHD children who have difficulty with aggression, impulsivity, insomnia, and/or severe hyperactivity
• May have a sedation effect
• Is utilized with Tourette 's syndrome and ADHD children with tics
• Usually taken up to 3-4 times a day
• A 5-day patch is available for Clonidine called Catapress TTS
• Targets hyperactivity and impulsivity more than attention
• Not approved for children

Common side effects include:

• Dry mouth
• Irregular heart rate
• Hypotension
• Headache and dizziness
• Stomachache
• Vomiting

Uncommon side effects include:

• Depression
• Nightmares
• Anxiety and rebound hypertension if patient suddenly stops taking the medication
  
  

VIII. Provigil (Modafinil)

• Used in Narcolepsy
• Stimulant effects on the brain
• Not approved for children
• Not approved for ADHD

There are other medications, diets and chemical, herbal products that have been tried or are being investigated for their use in the treatment of ADHD symptoms. A physician who is familiar with the treatment of ADHD in children, adolescents, and adults should be consulted for medication and treatment decisions.

Jay Dennis Tarnow, M.D., Diplomate of the American Board of Psychiatry and Neurology Certified in General Psychiatry and Child and Adolescent Psychiatry Clinical Associate Professor of Psychiatry Baylor College of Medicine University of Texas Medical School at Houston and Nancy L. Eisenberg, MSW, LCSW, LMFT

 

Copyright -Tarnow Center for Self-Management 2010

Revised November 2016