32. Meds for ADHD and anxiety: What to treat first, which med to use

Send us Fan MailIs there a go-to medication to treat a child with both ADHD and anxiety?  Join us as we continue the conversation with Dr. Jeffrey Strawn from Cincinnati Children's Medical Center to discuss how to approach medication treatment for a child with ADHD and anxiety.  We talk about which stimulants are better tolerated, when to use alpha 2 agonists (like clonidine and guanfacine), and finally what to know about the norepinephrine reuptake inhibitors, Viloxazine (Qelbree) and atomoxetine (Strattera). Key Points:1 – treat ADHD first, then address residual anxiety (unless anxiety is Severe)2 – When treating ADHD, start with stimulants;  Methylphenidate (MPH) stimulants are less likely to cause mood/anxiety sxs than mixed-amphetamine salts; MPH stimulants also have  ½ incidence of appetite suppression relative to the mixed-amphetamine salts3 – When to use alpha 2-agonistso   Clonidine is “a little messier” – hits multiple receptors (alpha 2a, 2b, 2c; hits imidazoline receptor), more likely to affect BP, sedation; best for problems initiating sleep o   Guanfacine – “much more selective for alpha 2 A receptor”,o   Guanfacine XR can be dosed once daily (vs. clonidine xr which is still BID) o   Dosing and titration of Guanfacine XR stay below 6mg, 0.1 mg/kg/dayo   Guanfacine XR considered as adjunctive med in addition to SSRI for anxietyo   Good to help w/ impulsivity4 – Viloxazine/Qelbree (NRI) “what’s hype vs. what’s clinically relevant pharmacology?”o   Works more rapidly than atomoxetine: Even within first couple of weeks, noticing improvement in symptomso   Little 2D6 metabolism, but not affected by 2D6 metabolizer status like atomoxetine (did you know fda recommends different dosing/titration based on metabolizer status in atomoxetine)o   Potent CYP 1A2 inhibitor (which metabolizes caffeine/energy drinks)  increase caffeine exposure (blood level over time) six fold ** ADR2A genetic polymorphism means 2/3 people do NOT experience anxiety when they consume caffeineDr. Jeff Strawn is a Professor of Psychiatry and Behavioral Neuroscience at the University of Cincinnati College of Medicine.  Dr. Strawn directs the Anxiety Disorders Research Program and conducts clinical trials and neuroimaging studies in patients with anxiety and related disorders.  He is an internationally recognized expert int he field of child and adolescent anxiety disorders.Check out our website PsychEd4Peds.com for more resources!Follow us on Instagram @psyched4pedsCheck out our NEW CME Audio-based, on-demand CME Course online at:Pediatric Mental Health CME Toolkit - Cracking the ADHD Code: Essentials for Pediatric Clinicians. https://ce.nemours.org/content/podcast-series-cracking-adhd-code-essential-skills-pediatric-clinicians#group-tabs-node-course-default1