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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of attention deficit/hyperactivity disorder (ADHD) that respond to therapy

  • Select appropriate stimulant preparations for a patient with ADHD displaying an adverse effect to another stimulant preparation

  • Propose ways of improving the effectiveness and/or minimizing the cost of medications used for ADHD and other common comorbid childhood problems (i.e., encopresis/constipation, sleep latency problems, allergic rhinitis, asthma)

  • Recommend an appropriate monitoring plan for stimulant therapy on the basis of individual patient characteristics and past adverse side-effect profile

  • Properly educate a patient taking stimulants for ADHD therapy

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PATIENT PRESENTATION

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Chief Complaint

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"I still have this rash where I stick my Daytrana patch. Using my hay fever spray before I stick on the patch helps a lot but my mom says it is getting kind of expensive."

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History of Present Illness

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Rev Williams is a 12½-year-old male who presents with his mother to the pediatrician's clinic office for a refill request of Nasonex. His mother works as a receptionist at an adult medicine clinic in a neighboring town. One month ago, after reading a magazine advertisement for Daytrana and talking with various medical staff at her clinic, she requested that her pediatrician switch RW from Vyvanse to the patch. Her reasons for switching were that RW was a little more fidgety on Vyvanse (although this was tolerable), to take advantage of the flexibility in dosing of Daytrana according to her son's schedule, and that Daytrana costs about the same as Vyvanse. She incurs the same monthly $50 co-pay for both ADHD medications since they both are available only as brand name and nonpreferred tier 3 agents on her current prescription insurance plan. RW was switched to Daytrana and soon afterward began manifesting a bumpy red rash with slight swelling at the application site. RW's mother began applying Nasonex (also nonpreferred tier 3 agent on RW's prescription plan with a $50 co-pay) to her son's application site for the patch as a temporary measure until she could talk to her pediatrician. RW just finished the sixth grade and did very well in his charter school. His teacher says he has a high IQ, is on task, finishes his work quickly, and might benefit from the gifted program. Since beginning stimulant therapy over the last 4½ years (Ritalin LA → Concerta → Vyvanse → Daytrana + methylphenidate PRN), there has been a marked decrease in his level of forgetfulness (e.g., homework, lunch box), aggressiveness, temper tantrums, anger, frustration, and in hitting and kicking fellow classmates. Prior to stimulant therapy, RW hated to read but now has acquired a desire to read after years of treatment for ADHD and continues to read avidly at almost a ninth-grade level. His favorite class is physical education, especially when they play soccer. This occurs the first hour of the day, immediately after arriving at school. He ...

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