Examine Case Study: A Young Caucasian Girl With ADHD You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
- Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? - Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? - Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
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Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD
BACKGROUND
Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.
The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.
Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.
SUBJECTIVE
Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.
MENTAL STATUS EXAM
The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.
Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation
RESOURCES
§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners’ Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.
Decision Point One
Select what the PMHNP should do:
Begin Wellbutrin (bupropion) XL 150 mg orally daily
Begin Intuniv extended release 1 mg orally at BEDTIME
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
//
Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD
Decision Point One
Begin Wellbutrin (bupropion) XL 150 mg orally daily
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Katie’s parents inform you that they stopped giving Katie the medication because about 2 weeks into the prescription, Katie told her parents that she was thinking about hurting herself. This scared the parents, but they didn’t want to “bother you” by calling the office, so they felt that it would be best to just stop the medication as they would be seeing you in two weeks
Decision Point Two
Select what the PMHNP should do next:
Select what the PMHNP should do next:
Educate the parents that Bupropion sometimes causes suicidal ideation in children and that this is normal, and re-start the drug at the previous dose
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parents again report that after about a week of treatment with the Bupropion, Katie began telling her parents that she wanted to hurt herself and began having dreams about being dead. This scared her parents and they stopped giving her the medication
- At this point, they are quite upset with the results of their daughter’s treatment and are convinced that medication is not the answer
Decision Point Three
Select what the PMHNP should do next:
Refer the parents to a pediatric psychologist who can use behavioral therapy to treat Katie’s ADHD
Guidance to Student
Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.
At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.
In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.
The PMHNP should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow the PMHNP to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.
Start Over
Do nothing, and explain to the parents that Katie’s ADHD will most likely improve with age as her prefrontal cortex grows and matures
Guidance to Student
Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.
At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.
In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.
The PMHNP should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow the PMHNP to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.
Start Over
Discuss the use of a medication such as Adderall and its evidence for treating ADHD
Guidance to Student
Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.
At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.
In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.
The PMHNP should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow the PMHNP to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.
Start Over
Discontinue Wellbutrin and begin Strattera (atomoxetine) 10 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are getting a bit better
- They are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of Strattera and reevaluate side effects at next office visit in 4 weeks
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but the PMHNP will need to monitor it. Keep in mind that if the PMHNP decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
Start Over
Discontinue Strattera and begin Intuniv extended release, 1 mg orally daily
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but the PMHNP will need to monitor it. Keep in mind that if the PMHNP decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
Start Over
Increase Strattera to 25 mg orally daily and reevaluate at next office visit in 4 weeks
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but the PMHNP will need to monitor it. Keep in mind that if the PMHNP decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
Start Over
Discontinue Wellbutrin and begin Adderall (amphetamine d, l) extended release 5 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- They are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are getting a bit better
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of Adderall and re-evaluate side effects at next office visit in 4 weeks
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Adderall, a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but the PMHNP will need to monitor it.
Increasing the dose of Adderall may worsen this side effect; however, if symptoms are still severe enough, an increase in dose may be warranted. At this point, the PMHNP needs to know what symptoms have improved and—based on overall functioning—must then determine whether or not there is an indication to increase the current dose of the medication.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
Start Over
Discontinue Adderall and begin Intuniv extended release, 1 mg orally daily
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Adderall, a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but the PMHNP will need to monitor it.
Increasing the dose of Adderall may worsen this side effect; however, if symptoms are still severe enough, an increase in dose may be warranted. At this point, the PMHNP needs to know what symptoms have improved and—based on overall functioning—must then determine whether or not there is an indication to increase the current dose of the medication.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
Start Over
Adderall to 10 mg extended release daily and reevaluate at next office visit in 4 weeks
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Adderall, a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but the PMHNP will need to monitor it.
Increasing the dose of Adderall may worsen this side effect; however, if symptoms are still severe enough, an increase in dose may be warranted. At this point, the PMHNP needs to know what symptoms have improved and—based on overall functioning—must then determine whether or not there is an indication to increase the current dose of the medication.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
Start Over
//
Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD
Decision Point One
Begin Intuniv extended release 1 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Katie’s teacher reports no change in her classroom behaviors
- Katie’s parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”
Decision Point Two
Select what the PMHNP should do next:
Select what the PMHNP should do next:
Increase Intuniv to 2 mg orally at BEDTIME
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- katie’s parents report that Katie is even more sedate and has been refusing to get out of bed in the morning. Her teacher reports that she has gone from being a “daydreamer” in class to being on the “verge of falling asleep.”
- Katie’s parents state that there were two instances where Katie fell asleep on the school bus on her way to school in the morning prompting the school nurse to call Katie’s parents
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of Intuniv
Guidance to Student
Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.
Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.
Start Over
Decrease Intuniv to 1 mg orally daily at BEDTIME
Guidance to Student
Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.
Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.
Start Over
Discontinue Intuniv and begin Strattera (atomoxetine) 10 mg orally daily
Guidance to Student
Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.
Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.
Start Over
Discontinue Intuniv and begin Dexedrine (dextroamphetamine) 5 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are better, but that she can be a bit “hyper” at times. Katie’s parents report that Katie is sometimes too “wound up” to go to bed and bedtime has become a “difficult” time in the house
- Katie’s parents are also concerned about her appetite, which has decreased since beginning the Dexedrine. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of Dexedrine and reevaluate in 4 weeks
Guidance to Student
Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. The PMHNP should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily.
Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.
Start Over
Increase Dexedrine to 10 mg extended release
Guidance to Student
Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. The PMHNP should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily.
Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.
Start Over
Discontinue Dexedrine and begin Concerta (methylphenidate) 18 mg orally daily
Guidance to Student
Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. The PMHNP should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily.
Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.
Start Over
Discontinue Intuniv and begin Focalin (dexmethylphenidate) XR 10 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better, and that her academic performance has improved considerably
- Katie’s parents are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of Focalin XR and re-evaluate at next clinic visit in 4 weeks
Guidance to Student
Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.
Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).
Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.
Start Over
Increase Focalin XR to 20 mg orally daily
Guidance to Student
Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.
Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).
Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.
Start Over
Discontinue Focalin XR and begin Strattera (atomoxetine) 10 mg orally daily
Guidance to Student
Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.
Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).
Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.
Start Over
//
Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD
Decision Point One
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
- Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
Decision Point Two
Select what the PMHNP should do next:
Select what the PMHNP should do next:
Continue same dose of Ritalin and re-evaluate in 4 weeks
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s academic performance is still improved, but her attention continues to worsen throughout the school day
- Katie is still reporting that her heart feels “funny.” Today’s pulse rate is 122 beats per minute, regular rhythm
Decision Point Three
Select what the PMHNP should do next:
Change to Ritalin LA 20 mg orally daily in the morning
Guidance to Student
Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.
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Obtain a STAT EKG
Guidance to Student
Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.
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Discontinue Ritalin and begin Adderall (amphetamine d, l) 10 mg orally daily
Guidance to Student
Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.
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Change to Ritalin LA 20 mg orally daily in the MORNING
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s academic performance is still improved, and the switch to the LA preparation is lasting Katie throughout the school day
- Katie’s reports of her heart feeling “funny” have gone away. Pulse was 92 during today’s office visit
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of Ritalin LA and reevaluate in 4 weeks
Guidance to Student
At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.
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Increase Ritalin LA to 30 mg orally daily
Guidance to Student
At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.
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Obtain EKG based on current heart rate
Guidance to Student
At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.
Start Over
Discontinue Ritalin and begin Adderall XR 15 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s academic performance is still improved, and the XR preparation has helped sustain her attention throughout the school day, however, you also learn that Katie is having tachycardia with this medication, too
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of medication and re-evaluate in 4 weeks
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.
Start Over
Decrease to Adderall XR 10 mg orally daily
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.
Start Over
Discontinue Adderall XR and begin Strattera 10 mg orally daily
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.
Start Over