TRATTAMENTO DELL’ADHD NELL’ADULTOwork shop

Andreas Conca

Psichiatria di Transizione La complessità dell’ADHD

04-05-06.12.2016 - Eurac, Bolzano

rasssegna–ADHD non viene diagnosticato (la maggior parte dei casi)

–ADHD viene diagnosticato (raramente)

–non c´é il passaggio dalla NPI alla Psichiatria

• intervento multimodale

• trattamenti non farmacologici

• prescrizione farmaci

– realtá - probabilitá – possibilitá

– Evidenze scientifiche

– il farmaco non viene offerto al momento giusto

– prescrizione off label

objectives

• Respecting of specificity and responsibility in adults

• ADHD in adults demands a broad spectrum of bio-psycho-social interventions

• The treatment is orientated to real individual needs – single core symptoms– behavioral aspects– self-steem and affective aereas– employment – relationships

• A multimodal treatment programme must be individually tailored, continually monitored, and optimised1

• Ideally, the treatment plan would also involve the adult’s partner, family, or close relationship2

• Unlike in childhood, guidelines for treating adult ADHD with either moderate or severe levels of impairment, recommend that drug treatment be started first unless the person has a preference for a psychological approach3

1. Murphy et al. J Atten Disord. 2010;13(5):546–52.2. Murphy. J Clin Psychol. 2005;61(5):607–19.

3. http://www.nice.org.uk/nicemedia/live/12061/42059/42059.pdf

Multimodal Approach

• A multimodal treatment programme must be individually tailored, continually monitored, and optimised1

• Ideally, the treatment plan would also involve the adult’s partner, family, or close relationship2

• Unlike in childhood, guidelines for treating adult ADHD with either moderate or severe levels of impairment, recommend that drug treatment be started first unless the person has a preference for a psychological approach3

1. Murphy et al. J Atten Disord. 2010;13(5):546–52.2. Murphy. J Clin Psychol. 2005;61(5):607–19.

3. http://www.nice.org.uk/nicemedia/live/12061/42059/42059.pdf

Multimodal Approach

3,6 h

Atomoxetina e Metlfendidato

Bymaster et al 2002

-1 0 1 2 3 4

% D

opam

ine

Bas

elin

e

050

100150200250300350

Time h

-1 0 1 2 3 4

% D

opam

ine

Bas

elin

e

050

100150200250300350 *p <.05 vs. baseline

***

AtomoxetinaMetilfenidato

MET 3 mg/kg ip ATX 1 mg/kg ip

-1 0 1 2 3 40

-1 0 1 2 3 40

*p

***

StriatoCorteccia prefrontale

Nucleo accumbensStriatoCorteccia prefrontale

Nucleo accumbens

<.05 vs. baseline

Time h

Il „puro“ ADHD nell´adulto

inattenzioneimpulsivitá

nicotina/insonnia

atomoxetina/

bupropione

inattenzione

iperattivitá

nicotina/diresgulazion

e emotiva

metilfenidato

Conca & Giupponi 2014

Il „puro“ ADHD nell´adulto

inattenzioneimpulsivitá

nicotina/insonnia

Atomoxetia/Bupropione

inattenzione

iperattivitá

nicotina/diresgulazione

emotiva

metilfenidato

Conca & Giupponi 2

impulsivitá

iperattivitá

nicotina/diresgulazione

emotiva

Metilfenidatoe/o

atomexetina

Algoritmo alla prescrizione variabiligenerali

manifestazione

comobilitá

• etá• genere• familiaritá

• fenotipo• gravitá

• psichiatrica• somatica

Conca & Giupponi 2

ADHD as a Risk Factor for Development of Co-occurring Conditions Later in Life

Environmental and genetic risks:(maltreatment / COMT* genotype)

Risk Model

Adult with ADHD

• Antisocial behavior• Addiction• Depression/low self-esteem• Anxiety

*Catechol-O-methyl transferase

1. Asherson. 1st European Network Adult ADHD Conference. London, 2011.

ADHD Unipolar‐Bipolar DisorderEarly childhood onset1 Adolescent or adult onset1

Trait-like, no change from pre-morbid state1 Episodic course, change from pre-morbid state1

Excitable, but not grandiose/elated Grandiose/elated2

Reports being unable to function1 Reports high level function1

Chronic low self-esteem2 Episodes of depression1

Usually possesses insight, complains of changeable moods Trend to lack of insight1

Difficulty sleeping2 Reduced need for sleep2

Complains of being unable to concentrate/focus1 Subjective sense of sharpened mental abilities1

Restless (fidgety, difficult being still)1 Overactivity, often linked to unrealistic ideas/plans1

ADHD and Unipolar-Bipolar Disorder

ADHD Affective DisorderAtomoxetina Mood Stbilizer

MethylphenidatLitioVPACBZLTG

Bupropione*

VLX (?)*Sertralina (?)*

AntidepressivaSertralinaBupropione

Aripiprazolo (?)*

AtipiciAripiprazoloOlanzepinaPalliperidoneZiprasidone

Omega 3* Omega 3 * off label

ADHD in adults and Affective Disorder

scheda tecnicaetá evolutiva e adulta

scheda tecnicaetá evolutiva + adulta solo se precritto prima dei18 anni

ADHD and Bipolar Disorder

Cronic course

Episodic course

ADHDBipolar

Disorder

Euphoric mood

Megalomania

Psychotic symptoms

Talkativeness, inattention, hyperactivity, impulsivity,

poor insight

• Lifetime prevalence 9.5% (14.7% males, 5.8% Females

• Early onset of BD (5 years before)• Comorbid anxiety, alcohol and substance use

disorders

Nierenberg et al. 2005

Nierenberg et al. 2005

ADHD Anxiety Disorder

Ceaseless mental activity1 Anxious worrying (might look like obsessive thought processes [OCD])2

Motor restlessness1 Nervous tension2

Family history of ADHD2 Family history of anxiety–depression2

Avoids frustrating situations:Shopping, social situations, queueing, travelling

Phobic avoidance2

Easily feeling overwhelmed3 Easily becoming anxious2

Forgetfulness2 Hypervigilant

No somatic symptoms1 Somatic symptoms1

Improved by stimulants4 Exacerbated by stimulants4

ADHD and Anxiety

ADHD Anxiety DisorderAtomoxetine SSRI

In label EscitalopramParoxetine

Methylphenidate

off label NSSRI

DLXVLX

Pregabalin off labelAlprazolam

ADHD in adults and Anxiety

Adler et al 2009

Adler et al 2009

Terapie farmacologiche e eventi cardiovascolari (adulti)

Adjusted rate ratios for serious cardiovascular events associated with use vs non-use of ADHD medications

Habel et al 2011

0.2 1.0 5.0Rate Ratio (95% CI)

Current use 107322.4 234 0.83 (0.72–0.96) Amphetamines 46826.5 88 0.85 (0.68–1.05) Methylphenidate 47792.3 120 0.87 (0.72–1.04) Atomoxetine 8248.2 17 0.74 (0.46–1.19) Pemoline 2985.2 9 0.75 (0.39–1.45) Multiple 1470.1 0 NA

Indeterminate use 51709.6 125 0.94 (0.78–1.13) Former use 46120.8 121 0.86 (0.72–1.04) Remote use 67489.0 243 0.81 (0.70–0.93)

MI, SCD, or stroke

Outcome and ADHD Medication Use Person-Years

No. of Events

Rate Ratio (95% CI)

• Metilfenidato

– Ritalin ®, 10 mg cpr- (mass 1,01 mg/kg/corporeo)– Equasym®, 10 mg/ 20 mg/ 30 mg cps– Concerta ® 18mg/ 36 mg /72 mg (non in Italia)

• Atomoxetina

– Cps da 10mg, 25 mg, 40 mg, 60 mg, 80mg, 100 mg– inizialmente 40 mg/ 7 gg mass dagli 80 ai 100mg/d

Dosaggi nell´adulto

Farmacocinetica per ATX• Atomoxetine EM 3,6/PM 21h (semivita) 200-1000 ng/mL (TDM)

CYP2D6

• Inhibiting CYP 2D6

• Amiodarone• Bupropion• Chinidin• Duloxetine• Fluoxetine and norfluoxetine• Levomepromazine

• Melperone• Metoclopramide• Metoprolol• Paroxetine• Perphenazin• Propafenon• Propranolol• Terbinafin• Ritonavir

„Atomxetin ist nicht zugelassen für Impulskontrollstörungen im Rahmen des

M. Parkinson“