1. Management and Diagnosis of ADHD Learning Collaborative Webinar #1 Medication management: Q&A February 16th, 2016, 12:15pm -1:00pm

2. Kristi Kleinschmit, MD Dr. Kleinschmit is an Assistant Professor, in the Department of Psychiatry, Division of Child Psychiatry, and is the medical director of the Teenscope and Kidstar day treatment programs at the University of Utah Neuropsychiatric Institute. She is also the program director for the Triple Board and Child Psychiatry Residencies. Dr. Kleinschmit graduated from Tulane University School of Medicine in New Orleans, Louisiana. She completed a Triple Board residency at the University of Utah School of Medicine. She holds American Board certifications in Pediatrics, Adult Psychiatry, and Child and Adolescent Psychiatry. kristi.kleinschmit@hsc.utah.edu

3. Disclosures Funding from: nothing to disclose Institutional support from: nothing to disclose

4. CME Credit Accreditation: This activity has been planned and implemented in accordance with the essential areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Primary Children’s Hospital, the Department of Pediatrics at the University of Utah School of Medicine, and UPIQ. Primary Children’s Hospital is accredited by the ACCME to provide continuing medical education for physicians. AMA Credit: Primary Children’s Hospital Designates this live activity for a maximum of 8 AMA PRA Category 1 Credit(s)™. Physicians should only claim the credit that commensurate with the extent of their participation in the activity.

5. Disclaimer Most of the information today is based on clinical practice of myself and my colleagues, based on evidence when available, but also gleaning from the “art” of psychiatry. I am using brand names at times for clarification, not to promote any specific one.

6. Objectives Review initial medication choices, titration, and follow up. Generic versus non-generic medications Stimulants versus non-stimulant medications Special Populations Comorbid disorders Rapid Metabolizers When to refer to psychiatry

7. Initial Choice Stimulants unless prior adverse effect Caution with anxiety, autism I usually start with methylphenidate family ** Family history guides choice I usually start with long-acting, to minimize daily dosing. I will start short-acting if really young, worries about adverse effects As a general rule, will start 0.5 mg/kg for Amphetamine family and 1 mg/kg for methlyphenidates. I titrate fairly quickly, to minimize feelings of hopelessness with treatment, as long as meds are tolerated **Plenty of my colleagues start with amphetamine family

8. Follow up and Titration Usually have them follow up by phone, often will plan a titration schedule with them, increasing every 1-3 weeks, anticipatory guidance for side effects Follow up in office in 1 month I feel like adequate trial is 3-4 weeks on a reasonable dose.

9. Managing side effects Appetite/weight Eat breakfast before/while taking morning dose Drug holidays on weekends and summers if able Power pack for lunch Short-acting to help lunch appetite Sleep Melatonin for sleep, or if very bad, will use clonidine Consider alternate preparation Pro-drug, Isomer

10. Generics versus non-generics I almost always start with generic medications Exceptions: Methylphenidate patch (Daytrana) for rapid metabolizers, need for longer length of action, concerns about substance abuse/diversion Lisdexamfetamine (Vyvanse): Prior effectiveness but adverse effects to mixed amphetamine salts (Adderall products), concerns about substance use/diversion Atomoxetine (Strattera): Intolerance to stimulants, comorbid anxiety, substance use concerns, need for 24 hour coverage/diversion Guanfacine and Clonidine XR (Intuniv and Kapvay): Insurance will cover (otherwise I use short-acting) Need for liquid (Quillivant) or dissolvable (Methylin) I haven’t used either)

11. Special populations Comorbid substance use Kids with treated ADHD less likely to abuse substances Consider methylphenidate patch, lisdesamfetamine, atomoxetine Hyperactivity, oppositionality, aggression Alpha Agonists Comorbid Anxiety I try to address the anxiety first (therapy +/- SSRI) If severe, could try stimulant, may make anxiety worse Strattera, alpha agonists Comorbid Depression Stimulants are approved adjunctive medications for depression Teenagers and driving: want to maximize coverage for when driving

12. Autism and ADHD General folklore rule: 1/3 of kids get worse, 1/3 have no effect, 1/3 get better with meds More sensitive and resistant to medications Start lower, go slower May need extra high doses I use alpha agonists quite a bit, for impulsivity/hyperactivity and aggression, perseveration, sleep

13. Rapid Metabolizers Try longer acting meds I’ve even given BID methylphenidate LA, at 6 am and noon to try to cover Short-acting medication after long-acting wears off TID dosing of short acting med Some success with methylphenidate patch Anecdotal reports of quickly metabolized Lisdexamfetamine. Consider Atomoxetine Clonidine or guanfacine in afternoon to bridge into evening (for hyperactive kids)

14. Other thoughts Nutrition- I often have nutrition talks with ADHD families, minimizing simple sugars, maximizing snacks Sleep- Remember comorbidity but also mimicking of sleep disorders with ADHD Complementary/alternative medications-This was a question. I don’t have much experience with this. Diagnostic imaging/testing- Nothing has enough evidence for me to recommend

15. When to refer to psychiatry Very young children (< 6 y/o) Multiple trials without success Looking for diagnostic clarification Concerning adverse reactions to stimulants Mania, psychosis Comorbid conditions that aren’t responding to treatment as expected Severe comorbid conditions (likely already in the care of psychiatrists) Bipolar, psychosis

16. Comments/Questions Reminder: 2 nd Team Lead Call, Tuesday, February 23 rd @ 12:30 Reminder: 2nd Webinar, Tuesday, April 19 th @12:15pm