A Young Girl With ADHD

Decision Point One

Decision Point One

Select what the PMHNP should do:

Begin Wellbutrin (bupropion) XL 150 mg orally daily

Begin Intuniv extended release 1 mg orally at BEDTIME

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

This is the optionBegin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
• Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute

Decision Point Two

Decision Point Two

Select what the PMHNP should do next:

Continue same dose of Ritalin and re-evaluate in 4 weeks

Change to Ritalin LA 20 mg orally daily in the MORNING

Discontinue Ritalin and begin Adderall XR 15 mg orally daily

This is the option:Discontinue Ritalin and begin Adderall XR 15 mg orally daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Katie’s academic performance is still improved, and the XR preparation has helped sustain her attention throughout the school day, however, you also learn that Katie is having tachycardia with this medication, too

Decision Point Three

Decision Point Three

Select what the PMHNP should do next:

Maintain current dose of medication and re-evaluate in 4 weeks

Decrease to Adderall XR 10 mg orally daily

Discontinue Adderall XR and begin Strattera 10 mg orally daily

This is the option:Decrease to Adderall XR 10 mg orally daily

Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.