A referral was made for a comprehensive assessment of Jacob Martinez is a 10 yo Hispanic male to determine if there was a need to initiate medication management. He was seen in the office to follow up with a diagnosis of ADHD (Attention Deficit Disorder) to receive his first medication management. Martinez was observed to have and stated by his caregivers, behaviors which included problems at school, displaying poor attention and focus, constantly distracted, and not completing his assignments. His teacher recommended evaluation for ADHD because of his distraction of classmates with his frequent movement from his desk requiring redirection. He was diagnosed with ADHD hypersensitivity disorder.
After a two-week of observational evaluation, the following recommendations for medication management was Concerta (methylphenidate), or Intuniv (Guanfacine), and Adderall (dextroamphetamine amphetamine). Concerta Concerta (Methylphenidate), is a central nervous system stimulant that contains the same ingredient found in Ritalin, its difference is the method of delivery, and it is effective in the body for 12 hours, it was FDA approved as a longer -acting stimulant to eliminate the need to take medication during the school day in children to treat ADHD, (Drug.com,2018). Its dosage for a child older than 6 years of age is 18-72 mg. q am, may increase by 18 mg/day q 7days, for a max. 2 mg /kg/day up to 54 mg/day in duration q 12 hrs., and do not crush, chew tab, (Daughton, & Kratochvil (2009). Its mechanism of action is that it stimulates CNS activity, blocks reuptake and increase the release of norepinephrine and dopamine, it is excreted in urine and feces, and have a half-life of 3.6 hrs.
The side effects include headaches, upper respiratory infections, stomachache, loss of appetite, and weight loss. It is contraindicated in children with agitation, hypersensitivity to methylphenidate, TICS, psychosis, Tourette’s, use of MAOs and seizures, (Daughton, & Kratochvil (2009). Concerta has the potential for drug dependence, psychosis, mania, aggressive behavior, and sudden death from cardiac. The monitoring of Concerta It requires the same baseline labs and vital signs as Adderall with the inclusion of CBC with diff, and platelets annually with prolonged treatment, (Drug.com.2018). As explained the third potential medication is Intuniv. Intuniv Intuniv (Guanfacine) is a sympatholytic drug used to treat ADHD, it is a selective alpha 2 adrenergic receptor agonist in the CNS. Its mechanism of action in ADHD works by strengthening the regulation of attention and behavior in the prefrontal cortex.
Pediatric dosing for Jacob weight is 56.81 kg and his age is 6-17 yo, 49.5-58.4 kg his dose would be 3-6 mg po qd, starting with 1 mg po qd increasing by 1 mg/day q wk.: alt 0.05-0.12 mg/kg/po qd in monotherapy or adjunctive treatment not to be given with fatty meats, nor crushed or chewed (Epocrates,2018). There is no clear evidence of first-pass metabolism, it is assumed metabolism in the liver CYP450, it is excreted in the renal with a half-life of 17 hrs. (Kiechel,1980). The side effects drowsiness, dizziness, dry mouth, constipation, stomach pain, and headache, (Drug.com,2018). Serious reactions are hypotension, syncope, bradycardia, AV block, and hallucinations. Contraindications are cardiac disease, hypersensitivity, kidney disease, liver disease, and low blood pressure. Monitoring includes all baseline labs and vital signs with cardiac conduction. monitoring periodically. No black box warnings, prescriptions not controlled (Drug.com,2018).
Many providers prescribe Adderall as a first-line pharmacological treatment for ADHD as an FDA approved short -acting stimulants, known as mixed amphetamine salt, that has an immediate release with a duration of action for a period of four hours, it is a central nervous system stimulant of the phenethylamine that increases the activity of the neurotransmitters dopamine and norepinephrine in the brain, as its mechanism of action, it also can be prescribed for a longer action period as Adderall XR, (Drug.com,2018). The prescription of Adderall to Jacob will assist in decreasing his hyperactivity, impulsivity, as an effort to decrease impairment in his social, academic, and occupational functioning, (Sadock, Sadock, & Ruiz,2014). The pediatric dose of Adderall starts at 5 mg daily for a week, then 5 mg po bid q week increments with a duration of 5-8 hrs. given divided doses for bid not to exceed 40 mg /daily for optimal response, (Daughton, & Kratochvil (2009). Adderall is metabolized in the liver by the CVP450:2D6 substrate and excreted in the urine with a half-life of 9-14 hrs., (Drug.com,2018).
Side-effects that require immediate attention are allergic reaction noted as hives, cardiovascular finding, facial and neck edema, increase psychosis, hostility, and aggression. The provider should also instruct the family to observe for lack of appetite, weight loss, stomach pain constipation, dry mouth, and trouble sleeping. Jacob will require monitoring of labs plasma corticosteroid levels on initiation of medication and with every dose adjustment and as needed with the change in behaviors, as well as baseline cardiac, Bp, height and weight, and periodically, (Drug.com,2018). I am also ordering labs and monitoring for cardiovascular disease, hypertension, hyperthyroidism, allergies to amphetamines, as well as to assure no substance abuse because Adderall can be addictive, (Drug.com,2018).
Summary We have reviewed all the potential medications that can be prescribed to Jacob and it is my recommendation that we try Concerta as our first line of treatment. This is due to most of his behaviors are occurring in school and affecting his social, and academic performance that is impacting the success of himself and his classmates due to his distractions. I prefer the long- acting stimulant because of longer effective response that limits the need for multiple daily dosing, resulting in better adherence, (Daughton, & Kratochvil (2009). This will also decrease the stigma imposed on a child that has to receive medication in the school setting.
Concerta may be costly however there are economic supplemental resources available to assist with the purchasing of the medication. I would start Jacob on Concerta 18 mg po daily in the am and titrate by 5 mg a week to achieve optimum management not to exceed 54 mg/day in divided doses (Daughton, & Kratochvil (2009). I would monitor weekly for side effects, and because they are not as extreme as the other ADHD medications Concerta can be prolonged treatment that can be used as Jacob grows. This would increase compliance with medication and behavioral therapy resulting in the effective change in the patient’s behavior and be supportive to the stabilization of the family unit in the patient’s care. If aggressive symptoms or other adverse effects occur Concert can be reduced and discontinued without adverse effects (Drugs.com,2018). This will still provide me with medications to try until stabilization is met.
