ADHD Stimulants: Managing Adverse Effects, Monitoring, and Discontinuation

00:01 Now, how do you manage these adverse effects? Well, there's three main points.

00:05 And then the one at the bottom is the biggest thing.

00:08 So let me start right there.

00:10 If the client experiences severe psychiatric symptoms or has new or worsening tics, you've got to, at the very minimum, reduce the dosage or discontinue the medication completely depending on how severe it is.

00:24 So I want to highlight that first because that's incredibly important.

00:28 Your patient needs to understand what types of things you would be looking for so they can notify you.

00:34 And you can make a decision together.

00:36 Now the other adverse effects, the three that are they're problematic, but they're not as threatening as the severe psychiatric symptoms are suppressed appetite, poor growth and problems with their sleep and insomnia.

00:50 So these are going to be the three major categories that you'll see more common than severe psychiatric symptoms.

00:55 So with the suppressive appetite, think about administering the medication at or after meals.

01:01 Make sure when that any food that you can get in your child make it as nutrient dense as possible. Now, don't make this a battle zone.

01:09 Sometimes it's really hard to get kids to eat.

01:12 So if you can get some calories in, that's better than nothing.

01:15 But try and get as much nutrient dense foods in as you can.

01:19 This might be an opportunity to refer the client to a dietitian, particularly if it's a pediatric client, to encourage them to know what types of foods kids are most willing to eat. But this may also become a problem for adult clients.

01:32 Now, also keep in mind when it comes to food, high fat content may delay the medication absorption.

01:38 So you might have to adjust the timing.

01:40 The second category is poor growth.

01:43 So you're going to do some of the things that has crossover from the suppressed appetite. So you're going to consider drug holidays as appropriate.

01:50 You're going to optimize their nutrition and try to get the best food in them that you can. You may also consider an appetite stimulant.

01:58 Now I'm going to focusing on children.

02:00 But this can also happen with adults.

02:03 Now if they don't respond, you might consider alternative treatment options that aren't stimulants like non stimulants or behavioral therapy and just have to pull them off the stimulant medication.

02:14 Now the final one is insomnia.

02:15 Now look at the first tip there.

02:17 Encourage good sleep habits.

02:19 First of all, you need to be aware of what good sleep habits are, and hopefully you're practicing them yourself.

02:25 So you want a consistent bedtime.

02:27 You want to limit screen time right before they go to sleep.

02:31 You want to change the lighting.

02:32 All the things that you can do to help them develop good sleep habits.

02:37 Now for this, you also want to consider if they're having problems with insomnia.

02:40 Consider changing from a long acting to a short acting preparation.

02:45 So hopefully backing off that time that they'll be affected by those neurotransmitters that could be keeping them awake.

02:50 Also, think about reducing or eliminating the last dose of the day if they're taking short acting agents.

02:57 What we're trying to do is back up the effects of that medication so they have an easier time of getting to sleep.

03:03 Now, so a general overall suggestion to be thinking about the last dose of the immediate release stimulant no later than 3 p.m.

03:10 in the day is an easy framework.

03:12 You can you can teach your clients to have a frame of reference.

03:17 Now, the long term monitoring that you'll be doing as a provider during the maintenance phase is still just as important, but not as intense as when you're initiating and titrating the medications.

03:26 Once you get to a stable maintenance phase, you can follow up every 3 to 6 months, depending on these following factors.

03:34 How are the client's symptoms? What side effects are they experiencing? Are they able to adhere to the medication regimen, and what are the other coexisting conditions and how are those going? Now your assessments should always include height and weight, particularly for children, but for also for adults.

03:51 You want to look at their heart rate and their blood pressure because of that sympathetic nervous system stimulation, and make sure their vital signs are within a normal range. Now, if you're going to discontinue this medication, you could try a trial of stimulants.

04:05 And this might be appropriate in cases where you're trying to do an assessment of some new adverse effects that have appeared and you're not exactly sure what's causing them, or the client may be experiencing some Intolerable adverse effects.

04:18 And so you want to try a trial off the stimulus.

04:22 You may also consider, hey, things are getting better.

04:24 Remember, not everyone needs lifetime medication for ADHD.

04:28 So you can use a trial off the stimulants.

04:30 If you want to assess whether the treatment is still necessary after they've had long term stable improvement.

04:37 Also, unfortunately, if you suspect cases of diversion and misuse, you're going to have to try a trial off the stimulants.

04:44 And I would also involve social worker or other interdisciplinary measures to help make the best decision to keep your clients safe in the home and for the client.

04:56 Now, if you have to, abrupt discontinuation is an option because most of the stimulants have a relatively short half life.

05:03 But you know, the patients may prefer a more accelerated taper, too.

05:06 So you could do that if the client says, I want off of this.

05:10 The withdrawal symptoms you need to teach them to watch for are fatigue, depression and irritability. Remember the stimulant.

05:18 They're at this really high level when you take them off that their symptoms are going to be the opposite of that.

05:24 So they're going to feel really tired.

05:25 They may feel kind of sad or low mood, and they might just be irritable, kind of like how you feel when you're really sleep deprived.

05:33 Remember, the core symptoms and the functioning should be monitored closely throughout this time period by both you as the provider, the client and the family members. Now the good news is we touched on it.

05:45 But just remember, approximately 30% of the children with ADHD don't show symptoms in adulthood. So you can try discontinuation during a summer vacation and see how they do.

05:56 Let your family and clients know this that for the children, hey, we're going to try this. It's going to be focused on helping you succeed in school because you've shared with us. That's your goal.

06:06 And then we know that you may not have to be on this medication for the rest of your life.

06:11 So that wraps up how you should know the adverse effects, how you can titrate and initiate the medications, and what you should be watching for in monitoring for both safe and effective care.