Tiffany Budzinski,  FNP-BC

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurobehavioral disorder in the United States,

with about 9.4% of children aged 2 to 17 years having received a diagnosis, according to the CDC.

ADHD prevalence increased by 57% from 2007-2008 to 2011-2012, according to the results of a recent study in the

Journal of Developmental & Behavioral Pediatrics

ADHD left untreated can negatively affect patients both academically and socially. Primary care providers (PCPs) should take note of this astounding increase in prevalence and aid with early recognition of symptoms to provide a concise management plan for these patients.

ADHD is marked by 3 key behaviors: hyperactivity, impulsivity, and inattention.

Hyperactivity is when a patient moves about constantly, including in situations when it is not appropriate. A patient may even excessively fidget, talk, or tap. For preschool-aged children, hyperactivity is the most common symptom of ADHD.

Impulsivity in patients may cause them to act in the moment without first thinking. This may have a potential for harm. A patient with impulsivity may have a desire for instant gratification. Sometimes an impulsive patient may make important decisions without considering the long-term consequences or interrupt others.

Inattention can mean that the patient is disorganized, has difficulty sustaining focus, lacks persistence, and wanders off task. In elementary grades, patients may be described as lazy.

In young children with ADHD, hyperactivity and impulsivity are the most prevalent presenting behaviors. The

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

(DSM-5) criteria can support PCPs in making a diagnosis of ADHD. Diagnosis can be made using only these DSM-5 criteria, based on patients’ exhibiting a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with development and functioning.

Management can be determined by referencing the American Academy of Pediatrics (AAP) clinical practice guideline for ADHD, which provides detailed, evidence-based information regarding managing patients aged 4 to 18 years and treatment recommendations.

Experts are unsure of what causes ADHD but have concluded that many factors should be considered, such as brain injuries, cigarette smoking and/ or drug use during pregnancy, exposure to environmental toxins, genes, and low birth weight.

Study results have shown that ADHD is diagnosed more in men than in women. In addition, non-Latino white patients have a higher prevalence of ADHD than other ethnic and racial groups. Most patients receive a diagnosis between 3 and 6 years of age, with a median age of onset at 6 years old.

Children with ADHD symptoms should be comprehensively evaluated as early as 4 years old by a licensed pediatrician, psychiatrist, or psychologist with expertise in the condition. Professionals should gather information from at least 2 different environments (home and school) and perform a comprehensive developmental, educational, family, and medical history.

ADHD can be successfully managed with the appropriate plan provided by the PCP. ADHD management consists of behavioral therapy (BT) and medications. For children older than 6 years, the AAP recommends BT and medication as part of the management plan. In children younger than 6 years, BT is indicated as the first line of treatment.

BT is a treatment option that can reduce the behaviors prominent in patients with ADHD.

There are 2 types of BT: BT with children and parent training in BT. Having a child with disruptive behaviors can create stress for the entire family.

The child—parent relationship is affected by ADHD because of the disruptive behaviors. It is important for not only the child to be involved in BT but the parents as well.

In BT with children, the therapist helps the child convey improved behaviors to replace unfavorable behaviors.

In parent training in BT, parents learn skills to guide and teach their children to better control their behavior.

Four programs for parents of young children with ADHD that have been shown to significantly help behavior and symptoms include the Forest Parenting Programme, the Incredible Years parenting programs, the Parent-Child Interaction Therapy, and the Triple P (Positive Parenting Program).

Medications can be used in combination with BT or initiated alone in children older than 6 years. ADHD medications include stimulants and nonstimulant medications.

Stimulants are the first-line treatment for ADHD, with 75% to 90% of children taking them.

Stimulants improve focus because they increase dopamine and norepinephrine, which play an essential role in attention and thinking. Stimulants commonly prescribed include dexmethylphenidate (Focalin), dextroamphetamine (Dexedrine, Dextrostat, ProCentra, and Zenzedi), dextroamphetamine/amphetamine (Adderall), methamphetamine (Desoxyn), and methylphenidate (Methylin and Ritalin). Methylphenidate (Ritalin) is the cheapest stimulant medication, costing about $33.55 for 60 days’ worth of 5-mg tablets. Dextroamphetamine/ amphetamine (Adderall) is approved by the FDA for children 3 years and older.

Stimulants come in several different preparations (short acting, intermediate acting, and long acting) to treat ADHD. There are no clear benefits of one preparation over another. The choice depends on how the child responds to each individually.

Nonstimulants take longer to work than stimulants. They can be effective when used alone or in combination with a stimulant. PCPs may prescribe a nonstimulant because of possible adverse effects or contraindications of stimulants or use one in combination with a stimulant for increased effectiveness. Nonstimulants include atomoxetine (Strattera), clonidine extended release (Kapvay), and guanfacine (Intuniv).

PCPs must determine what is best for the patient: BT, medication, or both.

PCPs provide a fundamental role in assessing key behaviors to lead to a diagnosis of ADHD. Through early recognition of these behaviors, PCPs can provide appropriate management for children with BT and/or medications. Ultimately, the goal of management is to improve these behaviors to help children progress academically, developmentally, and socially.

Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management; Wolraich M, Brown L, Brown RT, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.

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CDC. Attention-deficit/hyperactivity disorder (ADHD). cdc.gov/ncbddd/adhd/. Updated February 14, 2018. Accessed April 11, 2018.

Danielson ML, Visser SN, Gleason MM, Peacock G, Claussen AH, Blumberg SJ. A national profile of atten- tion-deficit hyperactivity disorder diagnosis and treatment among US children aged 2 to 5 years.

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Luthy K, David R, Macintosh J, et al. Attention-deficit hyperactivity disorder: comparison of medication efficacy and cost.

2015;11(2):226-232. doi: 10.1016/j.nurpra.2014.07.026.

Attention deficit hyperactivity disorder. National Institute of Mental Health website. nimh.nih.gov/health/topics/ attention-deficit-hyperactivity-disorder-adhd/index.shtml. Updated March 2016. Accessed April 11, 2018.

Pericak A. Diagnosing attention-deficit hyperactivity disorder using the DSM-5 criteria.

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Articles

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurobehavioral disorder in the United States, with about 9.4% of children aged 2 to 17 years having received a diagnosis. The prevalence increased by 57% from 2007-2008 to 2011-2012, according to the results of a recent study.

ADHD Symptoms and Treatment

Asthma is a major health concern in the United States due to poor disease control. An estimated 23 million Americans have asthma, of whom 12 million experience an asthma exacerbation annually.

Many patients with asthma are not being prescribed or actively taking a long-term controller medication, even though they are needed to manage asthma effectively and prevent exacerbations. Promoting the use of long-term controller medications as part of a patient’s management plan is key to managing this disease.

Lack of health care access, insufficient education, medication side effects, poor provider management, and lack of patient follow-up are the main reasons for the inadequate use of long-term controller medications. Lack of asthma control leads to an increased number of asthma exacerbations, which account for an estimated 1.8 million emergency room visits each year in the United States.

Astonishing study results suggest that only 35.4% of the current asthma population uses a long-term controller for prevention of asthma exacerbations.

In order to decrease the occurrence of asthma exacerbations and improve disease control, practitioners should become more familiar with long-term controller medications.

Long-Term Controller Medications for Asthma Management

The goal of asthma disease management is to control the patient’s asthma in order to decrease the number of exacerbations. Guides are available to assist practitioners in classifying asthma severity in patients aged 12 years and older (

). Using these guides as a foundation, a practitioner can use the stepwise approach to manage a patient’s asthma efficiently with selected long-term controller medications (

According to asthma guidelines from the National Heart, Lung, and Blood Institute (NHLBI), the new focus in monitoring asthma control is based on distinguishing between asthma severity and asthma control:

Asthma severity is defined as the “intrinsic intensity of the disease process.”

Practitioners should evaluate asthma severity before initiating therapy.

Asthma control is defined as the “degree to which the manifestations of asthma…are minimized by therapeutic interventions and the goals of therapy are met.”

Practitioners should then assess and monitor asthma control in order to adjust therapy based on the stepwise approach.

Within severity and control, the NHLBI focuses on 2 key domains: impairment and risk

Impairment is the “frequency and intensity of symptoms and functional limitations the patient is experiencing currently or had recently experienced.”

Risk is the “likelihood of either asthma exacerbations, progressive decline in lung function (or, for children, reduced lung growth), or risk of adverse effects from medication.”

Based on symptom severity and control, including the domains of risk and impairment, a practitioner can either step up or step down when adjusting a patient’s daily long-term controller medication. This updated stepwise approach now includes age-specific guidelines (ages 0-4, 5-11, and 12+) to aid with a more focused treatment plan. Several classes of medication are included in the stepwise approach used to manage asthma control.

Inhaled corticosteroids (ICSs) are the mainstay long-term medication for asthma control. Results of recent studies have shown that consistent use of ICSs will improve asthma symptoms more so than with any other long-term controller medication available for patients of any age.

ICSs work by inhibiting inflammatory cytokines, thereby decreasing inflammation.

This prevents and reduces airway swelling and reduces mucus in the lungs.

Experts advise that ICSs are the first-line choice for controlling asthma because they decrease the number of asthma exacerbations, symptom frequency, and oral steroid use.

Examples of ICSs include beclomethasone (QVAR), budesonide (Pulmicort), ciclesonide (Alvesco), flunisolide (Aerospan), fluticasone (Flovent), and mometasone furoate (Asmanex Twisthaler).

The only ICS that is classified as pregnancy category B is budesonide.

ICSs can be used long term as a safe and effective treatment for persistent asthma in patients of all ages.

Leukotrienes are chemicals in the body that are released when a patient breathes in an allergen such as pollen. When leukotrienes are released into the body, swelling in the lungs and vasoconstriction of the airway can occur, potentially precipitating asthma symptoms.

Blocking the leukotriene response terminates this reaction in the body. The 2 available leukotriene receptor antagonists are montelukast (Singular) and zafirlukast (Accolate). Montelukast is given once a day and can be given to children older than 12 months. Zafirlukast is given twice daily and can be given to children older than 7 years.

Both are rated as pregnancy category B and are suitable for managing mild persistent asthma. Leukotriene receptor antagonists have a high rate of compliance because of their ease of use, and they also provide great control of asthma symptoms.

-agonists (LABAs) include salmeterol (Serevent) and formoterol (Foradil). These medications are bronchodilators that selectively stimulate the beta

adrenergic receptors, allowing the airways to vasodilate by relaxing the smooth muscles around them.

adrenergic receptors, associated rates of tremor and tachycardia are low.

LABAs should never be used as monotherapy for asthma control. As a result of increased asthma exacerbations and a rise in related deaths when LABAs were used alone, the FDA reviewed these medications and determined that they should be used only as part of combination therapy with an ICS.

LABAs now require a black-box warning and are categorized as pregnancy class C. Pregnant patients should be advised by their practitioner about whether the benefit of taking a LABA outweighs the risk. LABAs should be considered for combination therapy when ICSs alone are not improving asthma symptoms.

Cromolyn sodium is an inhaled nonsteroidal medication that stabilizes mast cells to prevent the airways from swelling when they come in contact with an asthma trigger.

Although cromolyn sodium is used as an alternative medication option for asthma control, it is not an ideal medication. Newer medications are available that can better control asthma.

Omalizumab (Xolair) is an immunomodulator medication that is used as additive therapy for patients aged 12 years and older who have severe persistent asthma and demonstrated immediate hypersensitivity to inhaled allergens.

It prevents binding of immunoglobulin E to mast cells and basophils, thereby inhibiting the body from reacting to allergic triggers.

Omalizumab is administered as a subcutaneous injection every 2 to 4 weeks. At a cost of approximately $1048 for a single injection, however, the medication is expensive.

In addition, it is advised that this medication be administered and monitored by an asthma specialist because of the black-box warning regarding the high risk for anaphylaxis.

Theophylline is a methylxanthine that is used as an alternative medication in patients with asthma, most effectively in combination with an ICS. Theophylline serum levels need to be monitored in patients taking this methylxanthine because toxicity can occur.

Although theophylline is still used in some clinical situations, it is no longer the preferred asthma control treatment because patients do not often comply with monitoring serum theophylline levels. Newer, more effective medications are available.

Combination therapy in patients with asthma consists of an ICS combined with an LABA. Examples include budesonide/formoterol (Symbicort), fluticasone/salmeterol (Advair), and mometasone/formoterol (Dulera).

Combination therapy is convenient for patients because it decreases the need for 2 separate inhalers. It is also safer for patients because the medications are already combined, decreasing potential side effects and lowering the incidence of black-box warning side effects with LABAs. Results from various studies have shown outstanding asthma control with combination therapy for moderate persistent asthma in patients aged 12 years and older.

Oral steroid treatment is recommended not only for moderate to severe asthma exacerbations, but also for step 6 in the stepwise approach to asthma management (

). Dosing for oral steroid treatment is 1&shy; mg/kg/day to 2 mg/kg/day for 3 to 10 days in children, or 40 mg/kg/day to 60 mg/day in 1 or 2 divided doses for 5 to 10 days in adults. Tapering is not necessary because of the short course of treatment.

Important Controller Medication Interactions

When taking a patient’s history, practitioners should ask several questions regarding current medications because many of them can interact with long-term asthma controller medications. In particular, any beta-blocker or angiotensin-converting enzyme (ACE) inhibitor use should be evaluated. A risk for bronchospasm is associated with nonselective beta-blockers due to the involvement of beta

-receptor blockers cause bronchoconstriction and should be used with caution in patients with asthma. Additionally, ACE inhibitors should be used with caution because many patients present with coughing as a common side effect. Other medications that can cause bronchospasm in an older asthmatic patient and should be given with caution include nonsteroidal anti-inflammatory drugs and cholinergic agents.

These and many other factors should be considered when prescribing medications for patients with asthma. Practitioners should always weigh benefits and risks when prescribing long-term control medications because treatment is ultimately about deciding what is best for the patient.

Although long-term controller medications are the foundation for asthma control, it is imperative for patient education to be provided, as well. In order to optimize asthma control, patients need to be educated about an asthma action plan, peak flow use, severity of dyspnea, the need for follow-up, and recommended vaccines.

To effectively use an asthma action plan, a patient must be educated on how to perform a PFM. Peak flow averages are based on gender, age, and height or a patient’s “personal best” effort,

which is determined when the patient is asymptomatic and his or her asthma is under control. With a combination of a patient’s averages and personal best, an asthma action plan can be created (

The asthma action plan used most commonly involves the traffic light model of green, yellow, and red zones. Using this model, patients can identify that they are within the green zone when they are not having any symptoms and their PFM is 80% or greater of their personal best. Meanwhile, patients in the yellow zone have some symptoms and a PFM that is 50% to 80% of their personal best, while those in the red zone are severely short of breath with critical asthma symptoms and a PFM less than 50% of their personal best.

Patient self-monitoring with PFMs and symptoms using an asthma action plan allows for superior asthma control and improved patient outcomes.

It is important for practitioners to follow up and recommend vaccines for patients to better control their asthma, as this follow-up can produce better health outcomes. It is recommended that patients be reevaluated 2 to 6 weeks after the introduction of a new medication.

Patients with controlled persistent asthma should have scheduled biannual follow-up visits.

Asthma control can be stepped down at this time in patients who are very well controlled for at least 3 months at their current step using the stepwise approach. During these visits, practitioners can also encourage patients to obtain recommended vaccines.

The CDC recommends that asthma patients receive the influenza vaccine annually. It also recommends that patients aged 19 to 64 years, and all adults aged 65 years and older, receive the pneumococcal polysaccharide vaccine.

Improved asthma control requires a foundation of long-term controller medications alongside patient education and self-monitoring. When the pieces of asthma control are all put into place, practitioners can beyond a doubt provide exceptional care for their patients.

Tiffany Budzinski is a board-certified family nurse practitioner specializing in retail health. She currently works for CVS MinuteClinic. She earned her bachelor of science in nursing degree at University of Illinois in Chicago and her master’s of science in nursing at Saint Xavier University in Evergreen Park, Illinois.

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Asthma action plans with peak flow ranges are vital in order to improve patient outcomes. Patients with asthma frequently misperceive the severity of dyspnea because they have a longstanding history of shortness of breath which makes it difficult for them to realize when their asthma symptoms are worsening.

Results from a recent study show that only 19.1% of asthma patients reported having a peak flowmeter at home,

which further proves the need for education with an asthma action plan and use of peak flowmeter measurements (PFMs).

Asthma is a major health concern in the United States due to poor disease control.

Tiffany Budzinski, FNP-BC

Articles

ADHD Symptoms and Treatment

Managing Asthma with Controller Medications