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Stimulant medications used to treat attention-deficit hyperactivity disorder (ADHD): Nursing Pharmacology



amphetamine (Adzenys, Adzenys ER-ODT, Dyanavel XR, Evekeo ODT), 
dextroamphetamine (Dexedrine, ProCentra, Zenzedi), 
lisdexamfetamine (Vyvanse), 
methylphenidate (Concerta, Ritalin, Ritalin LA, Daytrana)
CNS stimulants
Inhibit norepinephrine and dopamine reuptake → ↑ free concentration of norepinephrine and dopamine → ↑ focus, ↓ impulsivity
  • All: PO
  • Methylphenidate: transdermal
  • Weight loss, anorexia
  • Insomnia, irritability, headache, dizziness, seizures
  • Tachycardia, palpitations, chest pain
  • Boxed warnings:
    • Potential abuse and dependence
    • Severe cardiovascular disease (e.g., myocardial infarction, sudden death)
  • Arteriosclerosis, severe cardiovascular disease, moderate to severe hypertension
  • History of substance abuse, hyperthyroidism, agitation, anxiety, glaucoma
  • During / within 14 days of MAO inhibitor administration
  • Pregnancy and breastfeeding
  • Children younger than 6 years of age
  • History of seizures or myocardial infarction
  • Psychiatric conditions (e.g., anorexia nervosa, depression, bipolar disorder)
  • Focused baseline assessment; height, weight, vital signs; baseline mental status, sleep patterns, and nutritional history; dietary habits; e.g., consumption of cola or other caffeinated beverages
  • Laboratory tests: CBC, liver and renal function
  • Diagnostic tests: ECG
  • Monitor: effects on heart rate, blood pressure, sleep, nutrition; social and academic functioning
  • Purpose of medication: helps to decrease symptoms of ADHD; help improve functioning in school, social interaction, and family relationships
  • Self-administration
    • Immediate-release medication twice daily after breakfast and in the early afternoon
    • Extended release medication: once daily after breakfast
    • Transdermal patch
      • Apply a new patch at the same time each day
      • Ensure skin is clean, dry, and intact
      • Alternate hips, avoid waistline area
      • Remove patch after nine hours
      • Wash their hands after handling the patch
      • Monitor the application site for redness, blister formation, edema, or other signs of irritation
    • Do not discontinue abruptly
  • Common side effects
    • Headaches, dizziness, tremors, a fast heartbeat, and palpitations
      • Contact pediatrician promptly
    • Monitor appetite and weight
      • Provide appealing, nutritious meals; avoid caffeinated beverages
    • Monitor mood; hyperactivity, impulsivity, aggressiveness; sleep patterns
      • Seek assistance for management
  • Keep medications in a safe, secure place; prevent use by others

Attention Deficit Hyperactivity Disorder, or ADHD for short, refers to a range of behaviors characterized by inattention, hyperactivity, and impulsivity. Now, pharmacological treatment of ADHD can involve several medication groups, the main ones being central nervous system or CNS stimulant medications.

Additional medication groups that can be used to treat ADHD include norepinephrine reuptake inhibitors, such as atomoxetine; and alpha 2 adrenergic agonists, like guanfacine.

Finally, adjuvant medications include antidepressants, such as serotonin-norepinephrine reuptake inhibitors like venlafaxine, and tricyclic antidepressants, like imipramine; as well as antipsychotics, such as risperidone.

Alright, now CNS stimulants include amphetamine, dextroamphetamine, lisdexamfetamine, and methylphenidate. All of them are taken orally, while methylphenidate can also be applied transdermally.

Once administered, these medications are absorbed into the bloodstream, and travel to the brain. Here, they work at the synaptic cleft by inhibiting the reuptake of the neurotransmitters norepinephrine and dopamine.

This results in an increased concentration of these neurotransmitters within the synaptic cleft, subsequently increasing focus and attention while decreasing impulsivity.

Now, it’s important to note that CNS stimulants are highly addictive, therefore they have a boxed warning for potential abuse and dependence. In addition, these medications can often cause side effects like hyperactivity, irritability, insomnia, anorexia, and weight loss.

Also, clients often develop tachycardia and palpitations, while some may present hypertension or even arrhythmias; in fact, some of these medications have a boxed warning for serious cardiovascular disease, such as myocardial infarction, and even sudden death.

Finally, some clients may also experience headaches, dizziness, tremors, and on rare occasions, CNS stimulants can cause seizures.

Now, CNS stimulants are contraindicated in clients with severe arteriosclerosis, symptomatic cardiovascular disease, and moderate to severe hypertension. Other important contraindications include glaucoma, hyperthyroidism, and a history of substance abuse.

In addition, these medications are contraindicated during or within 14 days of treatment with monoamine oxidase inhibitors or MAOIs for short, which may trigger a hypertensive crisis.

Now, precautions should be taken during pregnancy and breastfeeding, as well as in children younger than 6 years of age.

Finally, CNS stimulants should be used with caution in clients with a history of seizures or myocardial infarction, as well as cardiovascular disease, and psychiatric conditions like anorexia nervosa, depression, and bipolar disorder.

Okay, when a pediatric client with ADHD is prescribed a CNS stimulant like methylphenidate, first, perform a focused baseline assessment, including height, weight, cardiac assessment and vital signs, as well as their baseline mental status, sleep patterns, and nutritional history, including consumption of cola or other caffeinated beverages.

Then, review their laboratory test results, including CBC, liver and renal function tests, as well as other diagnostic tests, such as ECG.

Next, explain to your client and their caregiver how methylphenidate helps to decrease symptoms of ADHD and help improve functioning in settings like school, social interaction, and family relationships.

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