Patient Encounter Part 2 Medical History Physical Exam and ADHD Evaluation

AD's baseline physical examination is unremarkable. Family history is negative for cardiovascular disease, and there is no documented history of ADHD in the family.

Allergies: None known

AD's mother does not qualify for medical assistance, and she can hardly afford their monthly expenses.

What stimulants and/or nonstimulants are available that might control AD's symptoms?

Which medications will maximize efficacy, facilitate adherence, minimize potential side effects, and offer an acceptable cost for AD's mother?

What other information do you need before starting stimulant therapy?

What are important counseling points to discuss with AD's mother?

Table 42-4 30-Day Cost0 of Selected ADHD Medication Regimens twMfc (Brandl hghnwIOnndl

Coir

Shaft-Acting flapid-O-nsit Stimulantj

Mettljdpheflfcktti Genetic Metfiytin DeKmeitylpheniddle

Gmk Gartfric

Df?*(rai»nfi>e(jiTiiiif GsiotC

I ntBrmidi at«- Acting IlavifrOnirl Stimulant;

MetffylphetiitfaW

wwfyin rfi Dctimanfittuiiiiic' OtwK

UrxTi oampheramjntftinphietarntne Ceneiit

EKtertdtd-Actlng Rapld-0-nset Stimulanti

Mr.'lhylptn'nidtiH' Goncwta' Hj« ids re C& Ritalin LA* [)e*(rDainpinSamiiWanipl*?1amine

Addeiall XP Dcsmt.'iliyliil'iL'nidjlc Focalin KR*

E«(«idnl'A(ling ilnhti-Dnict Sdmulinb

UsdcKJpiltflimiW

wyvanse M^tylphenidatF Dayiran.i i antdtrnal parch

Noriitinuiaiui

Atomowetine

Strinn kTipfonire

Generic t tnidinr Generic Guanfacine CjWtric Generic EUpfüptöli ijfrlirit Generic £>?neri( Generic

¡r, 1 ■ J-, a 20-nng tablet twice daily 5 ino/i mL scdiixi t™« iJüiiv

J-j-nng l.dhlri twice daily

[Q- nf JD-nig ift rahlftt daily

16„27', , or £<t nig (AloLdady ¡0-, liO-.or 3D-nng capsule dally P0-. JO-mg capsule da^y

M-, 30-, 40-, SO-, W-, of /D-nig capsule dady Ii)-, lS-.iil-, Of 3D nig patch dally

10-, IS-. 25-, iO-.SO-.SO-.of I no-mij c&pftjfe

10-, 2S-,or Siting tablet twice dally

0.1, . or 0.3 rng LabW twice-daily i-mgiatiieT tmice deiiiy i-mg lablet twice daily

75- or 100 nvj liWtt Iw^C iJiily 100- of ISO-ing Sfl lablet twice daily 300-nrig IjKiviLAil iwix daily 150 mg en 300 mg XL tiblet -daily

i IS

Chew übkM. f hewabfc (aLilelr CG extended (jbiph^uc imm«liiKlelnH with exlended leteasclr EHextendud release LA bn<i-acting

■^mt ttfiedcn b"iind ".'gimcn ¡pecified withcuH 0 di^i H'niJng ft* pf diKOuM icf11 50-djy (upply.C«BareiurrWt aso' Stpnemb« 7WJ

"BinrixJiliileiiielHily thirl IWf; mimiis twkf U^ily dJiina <if shontr-xting s.iniyL*riK0ur\ieiJWfl).

'Av!T>:lui[j l^.iily IN.^ qjr.tJi^ll/CffLlirirj^j';.,Iftl (htn f ^VJf Siii SlZft 5Sif^ $'<Mtlf lluiiilffl

Clonidine and Guanfacine

Clonidine and guanfacine are central a2-adrenergic agonists that inhibit the release of norepinephrine presynaptically. Both these agents are less effective than stimulants in treating symptoms of ADHD but typically are used as adjuncts to stimulants to con trol disruptive or aggressive behavior and alleviate insomnia. Guanfacine will last 3 to 4 hours longer than clonidine and requires less frequent dosing. Common side effects with clonidine and guanfacine are low blood pressure and sedation. Sedation is transient and generally subsides after 2 to 3 weeks of therapy.30 Rarely, severe side effects such as bradycardia, rebound hypertension, irregular heart beats, and sudden death have been reported.

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