2. ADHD AND STIMULANTS PART 2 Stephen Soltys MD Professor and Chair SIU Department of Pyschiatry Double click on the speaker on following slides

3. STIMULANTS Long acting preparations developed Methylphenidate (Concerta) was developed with a capsule that had a coating of regular methylphenidate. When the coating was dissolved, moisture absorbed in one end of the capsule caused inert material in capsule to expand at a steady rate, causing release of methylphenidate over twelve hours. Available in 18 mg, 27 mg, 36 mg,and 54 mg tablets.

4. STIMULANTS Methylphenidate marketed as Concerta 18 mg = 10-15 mg/day regular or 20 mg methylphenidate-SR 36 mg = 20-30 mg/day regular or 40 mg methylphenidate-SR 54 mg = 30-45 mg/day regular or 60 mg methylphenidate-SR Also available in 27 mg

5. OROS METHYLPHENIDATE Wilens et al JAACAP 2003 OL study on Concerta 71% completed one year Start 18mg (29%), 36mg (47%), 54mg (24%). End 18mg (15%), 36 mg (40%), 54mg (45%) No tolerance to beneficial effects 6.9% discontinued because of adverse effects. Most common tics, decreased appetite, insomnia

6. NEW PREPERATIONS Other long acting methylphenidate preparations developed that have variable sized coatings on granules (Metadate, Ritalin LA) Methylphenidate patch which bypasses GI absorption and hepatic first pass inactivation (Daytrana)

7. STIMULANTS The long acting preparation of mixed amphetamine salts comes in a capsule that dissolves releasing rapid acting and delayed release beads that delivers two pulses of medication. Marketed as Adderall XR. Capsule can be opened and mixed with apple sauce for those with trouble swallowing pills Available in 5 mg, 10 mg, 15 mg, 20 mg, 25 and 30 mg. Not recommended in children under 6.

8. STIMULANTS Decreased appetite is a major problem. Need to monitor height, weight and follow growth chart. Spencer et al 1996 found untreated ADHD children have slower growth rate advances than normal children If taken with food will decrease chance of stomach upset. Headache Document presence or absence of tics Dysphoria

9. LISDEXAMFETAMINE 20 mg to 70 mg capsules. Marketed as Vyvanse Inactive until converted to dextro- amphetamine in gut Longer length of action because of conversion process Ineffective if taken by other routes than oral

10. STIMULANT ABUSE May be abused orally, internasally, parenterally 2-3% of high school seniors annually use recreationally with 13% using at sometime in their lives 16% of all ADHD patients are asked to sell March 2003 JAACAP article suggested a 7X increase in MPH abuse

11. AMPHETAMINE TOXICITY Irritability, hyper-vigilance, situational reactivity, stereotyped behaviors, euphoria, impaired judgment, motor agitation Tachycardia, dilation of pupils, elevated BP, perspiration, nausea/vomiting Severe: weakness, respiratory depression, cardiac arrhythmias, confusion, coma