00:01
Hi, I'm Doctor Rhonda Lawes, and in this
discussion we're going to look at the adverse
effects contraindications and how you should
monitor for those for your patients.
00:10
You've prescribed stimulants to treat ADHD.
00:13
Now first let's go back and do a quick
review of the mechanism of action.
00:16
That's going to be a strong link to
remembering the adverse effects.
00:20
So stimulants block the reuptake of the
neurotransmitters dopamine and
norepinephrine. Now because these
medications block the reuptake of these
neurotransmitters, that leads to a higher
concentration of dopamine and norepinephrine
in the synaptic cleft.
00:35
That's a good thing because that will move
the levels of dopamine and norepinephrine in
critical brain regions.
00:41
You're trying to address for ADHD to help
alleviate those symptoms.
00:46
Remember, the goal of treatment of ADHD is
to restore normal levels or closer to normal
levels of dopamine and norepinephrine.
00:54
So we reviewed the mechanism.
00:56
Now let's talk about what the problem is.
00:58
Why is there an adverse effect.
01:01
Well this increased neurotransmission in
other areas of the brain and body can also
lead to the adverse effects.
01:08
So let's take a look at what happens when
you have extra dopamine and norepinephrine.
01:13
So the general adverse effects.
01:16
Just think about it under the category of
sympathetic nervous system stimulation.
01:20
Right. You've got those extra
neurotransmitters.
01:22
So you would expect tachycardia.
01:25
They're going to have a really fast heart
rate.
01:27
Remember sympathetic nervous system
stimulation.
01:31
They're going to have vasoconstriction.
01:33
Therefore an increased blood pressure
they're going to be sweaty.
01:36
They can be a little jittery and anxious as
you would be when your sympathetic nervous
system is overstimulated.
01:41
And they're going to have difficulty with
sleeping.
01:44
So when you're thinking about prescribing a
stimulant for your client, these are the
things you want to educate them to let you
know about if they're experiencing them.
01:53
Now, also keep in mind another adverse
effect is the increase in the dopamine
levels. This is because the patient can feel
this euphoria.
02:01
Now that may cause the patient to struggle
with addiction.
02:05
But when these drugs, these stimulants are
used as prescribed for ADHD.
02:09
It typically helps normalize the dopamine
levels without producing a euphoria.
02:16
Now think about the overall effect.
02:18
Because the adverse effect we're talking
about those extra dopamine and
norepinephrine. You've got that extra
stimulation of the sympathetic nervous
system. So you have this heightened arousal
and alertness which is what your sympathetic
nervous system is supposed to do.
02:32
So what it does that's well for the ADHD
client is it can improve their attention and
their focus. If they have ADHD and they're
taking stimulants, that's the therapeutic
effect we're looking for.
02:44
But even in our clients with ADHD who need
the medication, this can lead them to be
restless and irritable and they can have
difficulty in sleeping.
02:53
It's all back to those extra
neurotransmitters.
02:56
Now, there are some other adverse effects
we'd like you to keep in mind, but the most
common ones are it really goes after
appetite.
03:02
It suppresses their appetite.
03:04
Now, this is particularly problematic for
children because we want to watch to make
sure that it doesn't impact their growth and
development and cause them to lose weight and
weight and become underweight, particularly
during their childhood.
03:16
It can also make people a little emotionally
labile, so that's something that you really
have to work with your client.
03:21
Because remember, in ADHD, emotional
regulation is also a challenge.
03:26
So sometimes the symptoms of the treatment
look a lot like the actual ADHD.
03:31
Also this may cause the client to want to
have social withdrawal.
03:35
So you want to have a conversation with them
and see how things are going in the
psychosocial area.
03:41
I wanted to revisit the concept of addiction
and stimulants.
03:45
Now keep in mind, as a provider, you need to
be aware and help educate your clients that
ADHD stimulants do not increase their risk
of developing a substance use disorder if
they don't already have a comorbid conduct
disorder or a substance use disorder.
04:01
Now, that's why you as a clinician, you've
got to remain alert to this and keep an eye
on assessment.
04:06
Watch for signs of potential problem of
stimulant misuse and diversion.
04:10
Okay. That's the basics.
04:12
But also if you're dealing with a child and
you're dealing with parents, you want to
explain to Explain to them that this is a
much less common risk and how this comes to
be, and that you will partner with them and
to remain alert and watch for those signs
together. Now, the other contraindications
are going to go back to what we know about
the overload of norepinephrine and dopamine.
04:34
So if a client has already has symptomatic
cardiovascular disease they've got moderate
to severe hypertension.
04:40
We don't want them to take a stimulant that
will make those problems worse.
04:45
Same thing with hyperthyroidism.
04:46
Right. They're already there.
04:48
Sympathetic nervous system is already
cranking.
04:51
So we want to be really careful with
stimulant use with someone with
hypothyroidism. Now obviously if we know
they have some hypersensitivity or some
idiosyncrasy to sympathomimetic amines, we
don't want them to have a stimulant.
05:05
Anything that raises the blood pressure can
also raise the pressure in the eyes.
05:09
So if the client has glaucoma that's another
contraindication.
05:13
If the patient has anxiety or they have
agitated states, giving them a stimulant
could also make those worse.
05:20
So as you do as a provider, you have to
weigh out the benefits and the risks.
05:24
And this may be an additional problem.
05:26
Why you want to look for a different type of
medication to address the symptoms of ADHD.
05:31
Now, if the client has a history of drug
abuse, that's like what we just talked about.
05:36
This client is at an increased risk for
addiction.
05:39
This would involve a very therapeutic
conversation and a thorough assessment.
05:44
Now the last one is MAOIs.
05:46
But you know the MAOIs don't play well with
any other medications it seems like.
05:50
So you don't want someone taking a stimulant
and an maoi at the same time.
05:55
So you want it to be at least two weeks
since the last administration of an maoi
before they would take a stimulant safely.
06:02
Now, how do you choose an agent?
Well, here's the things you want to
consider.
06:06
You want to think about the desired onset of
action.
06:09
Remember, they have right away a little bit
longer and then extended.
06:13
So you have to look at what the needs are.
06:15
You have to figure out how long do you want
it to act.
06:18
What are we trying to treat here.
06:19
Is this just during school?
What is the time frame that the patient with
ADHD?
Or it Or it could even be for work.
06:26
What's the time frame?
They need the medication to be effective.
06:29
Also, the patient has to be able to swallow
if you're going to prescribe some of these
medications, as are pills or tablets.
06:36
Okay. So first thought is what are we trying
to do with this medication.
06:40
When is it most important to control these
symptoms.
06:43
That's your desired onset and duration.
06:46
Now you want to be sure that they're able to
swallow pills.
06:48
And don't just assume that they will be able
to do that.
06:51
Make sure you do an assessment for that.
06:53
Then we're next to drug palatability.
06:56
Tolerability. How does the individual
patient do with it.
06:59
What are their preferences and concerns.
07:01
And that's also including the onset of
action and the duration of the action.
07:06
Then this next point I'm not a fan of, but
it's reality.
07:10
Insurance coverage and costs are things that
you have to consider and what the patient has
available to them and what they can get in
their area from their pharmacy.
07:18
Unfortunately, ADHD medications can often be
in short supply, so that's something that you
need to be prepared for and have a backup
plan for your patient.
The lecture ADHD Stimulants: Adverse Effects and Contraindications by Rhonda Lawes, PhD, RN is from the course ADHD Treatment Guidelines.
Which adverse effect requires closest monitoring in pediatric patients?
Which condition is an absolute contraindication for stimulant therapy?
When is addiction risk highest with stimulant therapy?
What primary factor guides stimulant medication choice?
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