update on new psychiatric medications...major depressive disorder and generalized anxiety disorder....

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Update on Newer Psychiatric Medications

Teresa (Tess) Judge-Ellis

DNP, FNP-BC, PMHNP-BC, FAANP Associate Lecturer, Fitzgerald Health Education Associates,

North Andover, MA

Clinical practice, FNP/PMHNP Winfield Community Clinic, Winfield, IA

PMHNP Meadowlark Psychiatric Services, North Liberty, IA

Clinical Associate Professor, University of Iowa College of Nursing, Iowa City, IA

Fitzgerald Health Education Associates 1

Disclosure

• No real or potential conflict of interest to disclose.

• No off-label, experimental or investigational use of drugs or devices will be presented.


Objectives

• Upon completion of the learning activity the participant will be able to:

– Recognize clinical scenarios when newer and second line medications should be considered in the management of major depressive disorder (MDD).


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Objectives (continued)

• Upon completion of the learning activity the participant…: (cont.)

– Identify the mechanism of action of newer medication for the treatment of MDD.

– Describe the mechanism of action of newer agents for insomnia.


Major Depressive Disorder SIG E CAPS + Mood

DSM-5 criteria

• Sleep

• Interest*

• Guilt

• Energy

*Gateway symptoms

• One must be present + 4 other symptoms present for 2 weeks

• Not due to other psychiatric or medical condition or substance use disorder


• Concentration

• Appetite

• Psychomotor

• Suicidal thoughts

• + mood*

Psychotropic Options for Major Depressive Disorder


3

Generic Selective Serotonin Reuptake Inhibitors (SSRI)

• The first-line medications for most

mood disorders

– Citalopram (Celexa®)

– Escitalopram (Lexapro®)

– Fluoxetine (Prozac®)

– Fluvoxamine (Luvox®)

– Paroxetine (Paxil®)

– Sertraline (Zoloft®)


Serotonin Norepinephrine Reuptake Inhibitors (SNRI)

Generic SNRI

• Venlafaxine (Effexor®)

• Duloxetine (Cymbalta®)

Branded SNRI

• Desvenlafaxine (Pristiq®)

• Levomilnacipran (Fetzima®)


Other Antidepressants

Generic

• Norepinephrine-dopamine reuptake inhibitor

–Bupropion (Wellbutrin®)

•Noradrenergic and specific serotonergic antidepressant

–Mirtazapine (Remeron®)

Trade/Branded

•Serotonin modulator and stimulator

−Vortioxetine (Trintellix®)

•Serotonin partial agonist/reuptake inhibitor

−Vilazodone (Viibryd®)


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Newer Antidepressants

Vilazodone (Viibryd®)

Vortioxetine (Trintellix®)

Levomilnacipran (Fetzima®)


What do they have in common? Serotonin

Adverse effects and cautions

Attributed to increased

serotonergic activity


Adverse Effects and Precaution

Common to all SSRI/SNRI

• Abnormal bleeding

– Caution about increased risk of bleeding with patients on NSAIDs, aspirin, warfarin and other anticoagulants

• Activation of mania/hypomania

– As with all antidepressants


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Common to all SSRI/SNRI (continued)

• Hyponatremia

– Especially with elderly patients and those on diuretics

• Angle closure glaucoma risk in patients with anatomically narrow angles due to pupillary dilation


• Contraindicated due to risk of serotonin syndrome

– With MAOI use and within 14 days of stopping an MAOI

– In patients being treated with linezolid or intravenous methylene blue




• Boxed warning for an increase risk of suicidal thinking and behavior (suicidality) in children, adolescents and young adults (age 18−24 years) with MDD and other psychiatric disorders.

• Pregnancy category C

• Breastfeeding risk: Acceptable for SSRIs




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Adverse Effects and Precaution Serotonin Syndrome

• What is it? – Over activation of the central and

peripheral serotonin receptors due to high level of serotonin

• Incidence is unknown. – Uncommon with low dose SSRI or SNRI

and occasional use of a triptan

• A diagnosis of exclusion


Risk of Serotonin Syndrome (continued)

•Caution with concomitant use of other serotonergic drugs – Examples: Triptans, TCAs, fentanyl, lithium,

tramadol, tryptophan, buspirone, St John’s Wort, antidepressants, MAOIs, SGAs, phentermine

•Alerts

–Chronic pain, migraine history, depression or anxiety, end-stage renal disease


Serotonin Syndrome

• Signs and symptoms

– Alteration in mental status

– Neuromuscular abnormalities

– Autonomic hyperactivity


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Boyer E and Shannon M. N Engl J Med 2005;352:1112-1120

Spectrum of Clinical Findings in Serotonin Syndrome

19 Fitzgerald Health Education Associates

Boyer E and Shannon M. N Engl J Med;352:1112-1120

Findings in a Patient with Moderately Severe Serotonin Syndrome


Intervention in Serotonin Syndrome

• Mildly ill

– Hyperreflexia, tremor, afebrile

• Supportive care

• Removal of precipitating drugs

• Benzodiazepines – Source: Boyer E and Shannon M. N Engl J Med

2005;352:1112-1120.


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Intervention in Serotonin Syndrome (continued)

• Moderately ill – Aforementioned findings, fever,

cardiorespiratory abnormalities • Aggressive correction of cardiorespiratory

and thermal abnormalities

• Administration of 5-HT2A antagonists such as cyproheptadine (Periactin®) with a dose range=12−32 mg/24h so that up to 95% of serotonin receptor sites are occupied

– Source: Boyer E and Shannon M. N Engl J Med;352:1112-1120.


Vilazodone (Viibryd®)

• Indication

– For the treatment of major depressive disorder in adults age ≥18 years

• Mechanism of action

– Increases CNS serotonergic activity

• SSRI

• Partial 5-HT1A receptor agonist

• Cost=$140 per month


• How supplied

– 10 mg, 20 mg, and 40 mg tablets

• Recommended daily dose

– Start with an initial dose of 10 mg once daily with food for 7 days

– Then increase to 20 mg once daily with food

– Increase up to 40 mg once daily with food after a minimum of 7 days between doses


Vilazodone (Viibryd®) (continued)

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Vilazodone (Viibryd®) (continued)

• Take with food

– Taking on an empty stomach can decrease availability by 50−60%


Vilazodone (Viibryd®) Adverse Effects

•Most common adverse effects

– Diarrhea, nausea, vomiting

– Insomnia

– Headache, dizziness

•No reported weight gain in clinical trials

•Minimal reported sexual adverse reactions


Vilazodone (Viibryd®) Niche

Comorbid depression and anxiety

Weight gain worriers

Sexual adverse effect concerns


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Case Example

•Mr. R., a 25-year-old graduate student, recently moved to your town to begin graduate studies. He has a history of major depressive disorder and generalized anxiety disorder. His anxiety is worse and he is feeling depressed. His current medication is sertraline 100 mg. PHQ-9=16; GAD-7=12


Case Example (continued)

• You increase his sertraline to 150 mg and recommend counseling.

• He returns in 2 months with continued mild depression (PHQ-9=14; GAD-7=12) and worsening anxiety symptoms of rumination, muscle tension and occasional difficulty with middle insomnia.



• He is also unhappy with the sexual adverse effects, specifically difficult and delayed orgasm, that he attributes to the sertraline.

• You start vilazodone 10 mg daily with breakfast and reduce the sertraline to 100 mg.


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• During week 2 you reduce the sertraline to 50 mg daily and increase vilazodone to 20 mg daily.

• During week 3 the sertraline was discontinued and the vilazodone was increased to 40 mg daily.



• Mr. R. tolerated this transition well. After a month his depression had improved (PHQ-9=10) and his anxiety symptoms were improved (GAD-7=7).

• While he still has some delay to orgasm, this is much improved and he opts to continue on vilazodone (Viibryd®) 40 mg.



Vortioxetine (Trintellix®)

• Indication

– For treatment of major depressive disorder in adults age ≥18 years

• Cost

– About $240/month


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Vortioxetine (Trintellix®) September, 2013

• What is it?

– “Multi-modal” antidepressant or a “serotonin modulator and stimulator”

• Selective serotonin reuptake inhibitor (SSRI)

• Serotonin receptor agonist (5-HT1A)

• Partial agonist (5-HT1B)

• Antagonist (5-HT3A, 5HT7, 5-HT1D)


Vortioxetine (Trintellix®) (continued)

•How supplied

– 5 mg, 10 mg, 15 mg, and 20 mg tablets

•Recommended daily dose

– 10 mg starting dose without regards to meals

• If 10 mg is tolerated, dosage can be increased to 20 mg/day.

• Consider 5 mg/day for those unable to tolerate higher doses


Vortioxetine (Trintellix®) (continued)

• Elderly study

– 155 adults age 64−88 years with MDD

• Diagnosed with MDD recurrent

• No comorbid cognitive impairment; MMSE score>24

– Vortioxetine 5 mg or placebo

– Significant improvement in the HAMD-24


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Vortioxetine (Trintellix®) Adverse Effects and Precaution

• Vortioxetine is metabolized by CYP2D6.

−Reduce vortioxetine dose by 50% when co-administrated with a strong CYP2D6 inhibitor (e.g., bupropion, fluoxetine, paroxetine, quinidine).

−Consider increasing the vortioxetine dose when co-administered with a strong CYP2D6 inducer (e.g., rifampicin, carbamazepine, phenytoin)



(continued)

• Vortioxetine is metabolized by CYP2D6. (cont.)

−Maximum recommended dose of vortioxetine is 10 mg/day in known CYP2D6 poor metabolizers.



• Most common adverse effects

– Nausea, constipation, vomiting, dry mouth

• Dose related

• Mostly in the first week

– Sexual dysfunction/adverse effects

– Dizziness

– Minimal reported weight gain


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(continued)

• Taper off vortioxetine is recommended to avoid transient discontinuation symptoms of headache and muscle tension.

• Individualize taper- generally 2‒4 weeks


Vortioxetine (Trintellix®) Niche

Elderly with depression

Concern will be with insurance coverage.

Depression where cognitive “fog” is a dominant concern


Case Example

• Norma is an 82-year-old woman with a history of major depressive disorder. She was hospitalized at age 70 and 76 years. Her symptoms had been managed well with citalopram 60 mg.


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• Past psychiatric medication tried and failed: Fluoxetine, citalopram, and bupropion.

• After FDA warnings about prolonged QT interval with citalopram, she was tapered off citalopram and onto sertraline. Currently she is on sertraline 150 mg daily.



• Depressive symptoms of decreased interest, lack of motivation and energy remain, which keep her from going out with friends and socializing. PHQ-9=17


•Norma agreed to a medication change.

–Week 1: Sertraline 100 mg daily

–Week 2: Sertraline 50 mg and vortioxetine 5 mg

–Week 3: Sertraline 25 mg and vortioxetine 5 mg

–Week 4: Vortioxetine 5 mg



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•She tolerated the switch without difficulty.

•Return visit at 2 months where she reported improvement in interest and “ambition.” PHQ=12

•Vortioxetine is increased to 10 mg. She returns in 6 weeks and feels “back to my old self.” PHQ=8



Levomilnacipran (Fetzima®) July, 2013

• Indication

– For the treatment of major depressive disorder in adults age ≥18 years

• Cost

– $200 per month



•Mechanism of action

–Serotonin and norepinephrine reuptake inhibitor

• Relatively more selective for norepinephrine reuptake inhibition (NRI) compared with serotonin reuptake inhibition (SRI)

–>10-fold greater selectivity for NRI than SRI compared with duloxetine or venlafaxine


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•Mechanism of action (cont.)

–Serotonin and norepinephrine...(cont.)

• Relatively more… (cont.)

–Could offer more targeted treatment of NE deficiency MDD symptoms (e.g., concentration, physical slowing, decreased self-care)

• Could be considered a NSRI


• How supplied – 20 mg, 40 mg, 80 mg, 120 mg ER capsules

• Recommended daily dose – Start at 20 mg daily, increase to 40 mg

daily after 2 days

– Based on efficacy and tolerability, increase by increments of 40 mg/d every 2 or more days up to a maximum dose of 120 mg daily

• Take with or without food Fitzgerald Health Education Associates 50

Levomilnacipran (Fetzima®) (continued)

Levomilnacipran (Fetzima®) Adverse Effects and Precaution

• Elevated blood pressure and heart rate – Measure blood pressure and pulse prior to

initiating levomilnacipran and periodically throughout treatment. • Mean change from baseline after one year

of levomilnacipran – SBP was 3.9 mm Hg

– DBP was 3.1 mm Hg

– Control pre-existing hypertension before starting levomilnacipran.


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Levomilnacipran (Fetzima®) Adverse Effects and Precaution

(continued)

• Urinary hesitancy or retention

– Use with caution in patients prone to obstructive urinary disorders.

– Consider new onset of urinary hesitancy, urinary retention or dysuria a possible drug-related effect.


Levomilnacipran (Fetzima®) (continued) • Do not exceed 80 mg once daily when

used with strong CYP3A4 inhibitors. – Ketoconazole, clarithromycin, ritonavir

• Renal dosing – Moderate renal impairment (GFR 30−59

mL/min/1.73 m2) • Dose should not exceed 80 mg once daily

– Severe renal impairment (GFR 15–29 mL/min/1.73 m2) • Dose should not exceed 40 mg once daily

– Not recommended with end-stage renal disease


• Most common adverse effects

– Nausea, constipation, vomiting

– Hyperhidrosis

– Heart rate increase, palpitations

– Erectile dysfunction

• Pregnancy category C

• Lactation risk unknown


Levomilnacipran (Fetzima®) (continued)

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Levomilnacipran (Fetzima®)Niche

Comorbid chronic pain and depression

Renal dosing


Case Example

•Marjorie, 53-years-old, has fibromyalgia and depression. Her previous antidepressants include fluoxetine, duloxetine, citalopram, and sertraline. She takes nortriptyline 20 mg at bedtime for fibromyalgia and sleep. Some days are better than others with regards to her fibromyalgia.



•She has not taken any antidepressants for several years, but would like to restart because of worsening depression symptoms. PHQ was 16.

•You recommend returning to her counselor and starting on levomilnacipran (Fetzima®).


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•She starts levomilnacipran 20 mg/d for 2 days, then 40 mg daily for 5 days.

•After one month she returns and her depression is improved but not 100% relieved. PHQ score is 12. She believes her pain is improving.



•You increase the levomilnacipran to 80 mg.

•One month later, PHQ is at 8. She feels happier and relates her pain is less of an issue.



New Second Generation Antipsychotic Indication for

MDD Augment

Brexpiprazole (Rexulti®)


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SGAs for MDD Augment

• Quetiapine XR (Seroquel XR®)

• Aripiprazole (Abilify®)


Brexpiprazole (Rexulti®) July, 2015

• Indication

– For schizophrenia and adjunctive treatment for major depressive disorder

• Cost

– $867 per month


Brexpiprazole (Rexulti®) (continued)


– 5-HT1A receptor partial agonist

– D2 receptor partial agonist

– 5-HT2A receptor antagonist

– α1A receptor antagonist

– α1D receptor antagonist


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• How supplied

– 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, and 4 mg tablets

•Recommended daily dose for MDD augment

– 0.5 mg or 1 mg daily

– Titrate increases at weekly interval to the patient’s clinical response and tolerability



•Recommended daily dose for MDD augment (cont.)

– Target dose 2 mg daily; maximum daily dose 3 mg

• Take with or without food



• Dose adjustments with moderate to severe hepatic impairment (<2 mg daily)

• Dose adjustments for renal impairment GFR≤60 mL/min/1.73 m2 (2 mg/day)



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• Dosing adjustments recommended

– Patients who are known CYP2D6 poor metabolizers

– Patients taking CYP3A4 inhibitors, or CYP2D6 inhibitors or strong CYP3A4 inducers



• In clinical trials, brexpiprazole dosing was not adjusted for strong CYP2D6 inhibitors: Paroxetine, fluoxetine

– However start low, 0.5 mg and wait longer between dosage adjustments



Brexpiprazole (Rexulti®) Boxed Warnings

• Increased mortality in elderly patients with dementia-related psychosis

– Common to all SGAs

• Suicidal thoughts and behaviors in children, adolescents, and young adults

– Common to all antidepressants


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Brexpiprazole (Rexulti®) Antipsychotic Adverse Effects

• Neuroleptic malignant syndrome

• Tardive dyskinesia

• Extrapyramidal adverse effects

• Metabolic changes

– Hyperglycemia/diabetes, dyslipidemia, weight gain


Brexpiprazole (Rexulti®) Antipsychotic Adverse Effects

(continued)

• Leukopenia, neutropenia, agranulocytosis

• Orthostatic hypotension/syncope

• Body temperature dysregulation

• Dysphagia

• Cognitive and motor impairment


Brexpiprazole (Rexulti®) Antipsychotic Metabolic Syndrome

Monitoring Recommendations

• Baseline

– BMI, waist circumference, Hgb A1C, fasting plasma glucose, fasting lipid profile

• 1 month

– BMI, waist circumference

• 2 months

– BMI, waist circumference


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Brexpiprazole (Rexulti®) Antipsychotic Metabolic Syndrome

Monitoring Recommendations (continued)

• 3 months – BMI, waist circumference, Hgb A1C, fasting

plasma glucose, fasting lipid profile

• 6 months – BMI, waist circumference

• Annually – BMI, waist circumference, Hgb A1C, fasting

plasma glucose, fasting lipid profile


Brexpiprazole (Rexulti®) Niche

Recurrent MDD

Adjunctive

System for monitoring


Suvorexant (Belsomra®)


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Sleep Architecture Naturally Occurring Sleep’s 2 Stages

1. Non-rapid eye movement (NREM)

– Stage 1 − Transitional

– Stage 2 − Light sleep

– Stage 3 − Deep sleep

– Stage 4 − Deepest sleep

2. Rapid eye movement (REM)


Non-REM: Stages 1 and 2

• Stage 1

– Easily awakened “muscle jump” (hypnic myoclonia)

• Stage 2

– Heart rate slows, body temperature drops

– 50% of total sleep time


Non-REM: Stage 3

• Stage 3

– Delta waves (slow waves)

– Moving to deeper sleep


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Stage 4: “Deep Sleep”

•Stage 4 – Delta waves exclusively

• Difficult to arouse • No eye movement or

muscle activities

– When interrupted • “Groggy and disoriented”

– Stage of bedwetting, night terrors or sleep walking occur during deep sleep


REM Sleep: 20% of Adult Sleep

• Rapid, irregular and shallow breathing

• Rapid eye jerks in various directions

• Temporary paralysis of limb muscles

• Increased HR, BP

• Penile erections

• Most vivid dreams


Sleep Stages Movement Through 5 Stages

• Adults actively move

through the sleep process from NREM stages 1−4 to REM

– Complete cycle typically 90−100 minutes

– Complete 4−5 cycles per night


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Sleep Stages

Movement Through 5 Stages (continued)

• Length of REM sleep becomes progressively longer and time in deep sleep decreases throughout the night


Potential Influence of Sleep Aids on Sleep Architecture:

Potential Increase in Stage 1, Stage 2, Sleep Potential Reduction in Stage 3,

Stage 4, REM Sleep

Consider as short-term therapy!

Source: http://www.medscape.com/viewarticle

/723907_2


Circadian Rhythm

•Biologic “internal clock”

–Housed in suprachiasmatic nucleus in anterior hypothalamus

–Fully developed by age 25 years

– Source: http://www.howsleepworks.com/how_circadian.html


http://www.medscape.com/viewarticle/723907_2

http://www.medscape.com/viewarticle/723907_2

http://www.howsleepworks.com/how_circadian.html

http://www.howsleepworks.com/how_circadian.html

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Sleep-Wake Homeostasis

• The pressure to sleep

– Also known as sleep drive

• Unable to overcome

– With use of stimulants, can only mask need to sleep

– With medications, can mildly promote or enhance sleep drive


Pharmacology of Insomnia Treatment Therapeutic Approaches

•Stimulate/activate sleep promoting system

– GABA

• Inhibitory neurotransmitter (NT)

• Main hypothalamic NT, projects to several sleep regulating centers of the brain

– Increase in GABA inhibits (“blocks”) the wake-promoting chemicals

– Melatonin


Pharmacology of Insomnia Treatment Therapeutic Approaches

(continued)

• Suppress the wake-promoting systems

– Histamine

– Cholinergic

– Serotonin

– Orexin


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Suvorexant (Belsomra®) Novel Mechanism of Action

• What is it?

– Orexin-receptor antagonist

• Any drug that occupies a receptor site and prohibits its activation is an antagonist.

• First drug in this class FDA approved to treat insomnia


Source of image: https://en.wikipedia.org/wiki/Orexin#/media/File:1CQ0_crystallography.png

Suvorexant (Belsomra®) Mechanism of Action

(continued)

• Blocking the binding of neuropeptides orexin A and orexin B to receptors OX1R and OX2R=Thought to suppress the wake drive


Suvorexant (Belsomra®) C-IV

• Indication

– For treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance in adults age ≥18 years

• What would you expect for PK?


https://en.wikipedia.org/wiki/Orexin/media/File:1CQ0_crystallography.png

https://en.wikipedia.org/wiki/Orexin/media/File:1CQ0_crystallography.png

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Suvorexant (Belsomra®) PK Information

• Peak plasma time

– 2 h post dose

– With high fat meal= 1.5 h delay

• T ½=12 h

– As a result, when taking at 10 PM, 50% of the dose still on board at 10 AM

• Zolpidem (Ambien®)

– T ½=2.6 h

• 2.6 h × 3=7.8 h, take at 10 PM, approx. 12.5% of dose on board at 6 AM

– Time to Cmax=1.6 h


Suvorexant (Belsomra®) Recommended Dose

• How supplied

– 5 mg, 10 mg, 15 mg, and 20 mg tablets

• Recommended daily dose

– 10 mg, taken ≥30 mins prior to bedtime, only if ≥7 h of sleep time available, only 1 dose per night

• If 10 mg dose is well-tolerated but not effective, dose can be increased up to a maximum dose of 20 mg daily.


Suvorexant (Belsomra®) Precaution Do we have this information on older meds?

• Per FDA required study

– Exposure to suvorexant increased in obese compared to nonobese patients

• AUC and Cmax increased by 46% and 25% respectively compared to nonobese females.

– Women compared to men

• Consistent with warnings about other sleep aids including zolpidem (Ambien®)


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Suvorexant (Belsomra®) Adverse Effects and Precaution

(continued)

• Patient advised about these in handout provided with medication.

– CNS depressant effects and daytime impairment

– Abnormal thinking and behavioral changes

– Worsening of depression/suicidal ideation

– Sleep paralysis, hallucinations, cataplexy-like symptoms


Newer ADHD Medications


ADHD Symptom Clusters DSM-5

• Inattention

– Off task, lacking persistence, difficulty sustaining focused, disorganized

• Hyperactivity

– Excessive motor activity when it is not appropriate, excessive fidgeting, tapping, talkativeness


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ADHD Symptom Clusters (continued)

• Impulsivity

– Hasty actions without forethought and with high potential for harm, desire for immediate rewards, inability to delay gratification


Stimulants: First-line Medication in the Treatment of ADHD Safe and Effective


– Increased norepinephrine and dopaminergic activity in the prefrontal cortex and other areas in the brain is thought to explain it’s efficacy.

• How they differ?


Stimulants: First-line Medication in the Treatment of ADHD Safe and Effective

(continued)

• Methylphenidate (e.g., Ritalin®, Methylin®, Ritalin® LA, Concerta®) – Inhibits the reuptake of dopamine and

norepinephrine

• Amphetamine salts (Adderall®) – Inhibits the reuptake of dopamine and

norepinephrine – Releases dopamine and norepinephrine from

the presynaptic neuron Fitzgerald Health Education Associates 99

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Dopamine and Norepinephrine Pathways and ADHD

Prefrontal cortex –Inhibitory control •Ability to block out irrelevant stimuli to focus on the relevant



(continued)

Executive function –Relates to task completion – Analyze, plan, organize, develop timelines, adjust or

shift, complete


Dorsal striatum and motor response in ADHD –ADHD variable reaction time • Quick motor and long-delayed motor responses • Results in trouble executing motor component of a task



(continued)

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Ventral striatum and response to reward in ADHD –ADHD and difficulty with delaying gratification –Arousal adjustment in response to the emotional



(continued)

Cerebellum and motor timing in ADHD

–Children with ADHD have a difficult time with tasks that require time estimation or time discrimination.



(continued)

Newest ADHD Medications “Me-too”

Methylphenidate ER (QuilliChew ER®, Quillivant XR®, Aptensio XR®)

Amphetamines (Adzenys XR-ODT®

Dyanavel® XR, Evekeo®)


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Methylphenidate Extended-Release All with IR/ER onset of action

Methylphenidate ER

medications with

IR/ER action

Administration

Once daily

Duration of

Action (approx.)

QuilliChew® ER Cherry tablet 8 hours

Quillivant® XR Oral suspention 12 hours Aptensio® XR Whole or sprinkled 12 hours Concerta® Whole 12 hours

Ritalin® LA Whole or sprinkled

on applesauce

6‒9 hours

Metadate® CD Whole or sprinkled

on applesauce

6‒9 hours


Amphetamines Amphetamines

ER

Administration

Once daily

Duration of

action (approx) Adderall® XR

(mixed

amphetamine

salts)

Whole or

sprinkled on

applesauce

10‒12 hours

Adzenys XR-

ODT®

(amphetamine)

Sublingual

orally

disintegrating

10‒12 hours

Dyanavel XR®

(amphetamine)

Suspension At least 12 hours


Amphetamines (continued)

Amphetamine Administration

1‒3 times per day

Additional doses at

4‒6 hours

Duration of

action

(approx.)

Adderall® IR

(mixed

amphetamine salts)

Whole 6 hours

Evekeo®

(mixed

amphetamine salts)

Whole At least 9.25

hours


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Decision Making in ADHD Medications

• Choice of medication

– Onset of action

– Duration of action

– Ease of taking medication

– Adverse effects

– Dosing

– Cost


Fitzgerald Health Education Associates

End of Presentation

Thank you for your time and attention.

Tess Judge-Ellis

DNP, FNP-BC, PMHNP-BC, FAANP

www.fhea.com [email protected]

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References

• Anderson, S. & VandeGriend, J (2014) Quetiapine for insomnia: A review of the literature. American Journal of Health-Syestem Pharmacists, 71, 394-402

• Coe, H. & Hong, I. (2012). Safety of Low Doses of Quetiapine when Used for Insomnia. The Annals of Pharmacotherapy;46:718-722.


http://www.fhea.com/

mailto:[email protected]

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References (continued)

• Belsomra (suvorexant) Product Insert, http://www.merck.com/product/usa/pi_circulars/b/belsomra/belsomra_pi.pdf

• Brintellix (vortioxetine) Product Insert, http://general.takedapharm.com/content/file.aspx?applicationcode=396066C6-E50F-4113-ABAD-54FE9525BF7E&filetypecode=BRINTELLIXPI&cacheRandomizer=3dae8368-2480-4331-bf59-1fe9c7f9eb54



• Dopheide, J. & Pliszka, S. (2009) Attention-Deficit-Hyperactivity Disorder: An Update. Pharmacotherapy, 29 (6); 656-679.

• Elmaadawi, A., Singh, N., Reddy, J., Nasr, S., (2015) Prescriber’s guide to using 3 new antidepressants: Vilazodone, levomilnacipran, vortioxetine. Current Psychiatry (2015) 14(2): 28-29, 32-36.

• Fetzima (levomilnacipran) Product Insert, http://www.allergan.com/assets/pdf/fetzima_pi#page=1



• Prescriber’s Letter; March 2016; Vol: 23. New ADHD Stimulant Formulations

• Prescriber’s Letter; September 2013; ADHD Stimulant FAQs

• Prescriber’s Letter: February 2015; Vol: 31. Role of Suvorexant (Belsomra) for Insomnia.

• Solanto, M. (1998) Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. Behavioural Brain Research 94 (1998), 127-152


http://www.merck.com/product/usa/pi_circulars/b/belsomra/belsomra_pi.pdf

http://www.merck.com/product/usa/pi_circulars/b/belsomra/belsomra_pi.pdf

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• Seier, K., Connell, R., Resche, W., Thomas, C. (2013). Recommendations for lab monitoring of atypical antipsychotics. Current Psychiatry, 12(9):51-54.

• http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm

• http://www.howsleepworks.com/types_rem.html

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• Volpi-Abadie, J., Kaye, A.M., Kaye, A.D. (2013). Serotonin Syndrome. The Ochsner Journal 13: 533-540


• Images/Illustrations: Unless otherwise noted, all images/ illustrations are from open sources, such as the CDC or Wikipedia or property of FHEA or author.

• All websites listed active at the time of publication.


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http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm

http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm

http://www.howsleepworks.com/types_rem.html

http://www.allergan.com/assets/pdf/viibryd_pi

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