amphetamine

General

Pronunciation:
am-fet-a-meen


Trade Name(s)

  • Adzenys ER
  • Adzenys-XR ODT
  • Dyanavel XR
  • Evekeo
  • Evekeo ODT

Ther. Class.
central nervous system stimulants

Controlled Substance Schedule: II

Indications

  • ADHD.
  • Narcolepsy (Evekeo only).
  • Obesity (Evekeo only).

Action

Causes release of norepinephrine from nerve endings. Pharmacologic effects are:

  • CNS and respiratory stimulation,
  • Vasoconstriction,
  • Mydriasis (pupillary dilation).

Therapeutic Effect(s):

  • Increased attention span in ADHD.
  • Increased motor activity, mental alertness, and decreased fatigue in narcolepsy.
  • Weight reduction.

Pharmacokinetics

Absorption: Well absorbed after oral administration.

Distribution: Widely distributed in body tissues, with high concentrations in the brain and CSF. Crosses the placenta and enters breast milk.

Metabolism and Excretion: Some metabolism by the liver. Urinary excretion is pH-dependent. Alkaline urine promotes reabsorption and prolongs action.

Half-life: 10–15 hr.

TIME/ACTION PROFILE (CNS stimulation)

ROUTEONSETPEAKDURATION
PO1–2 hrunknown4–10 hr

Contraindication/Precautions

Contraindicated in:

  • Hypersensitivity;
  • Concurrent use of or within 14 days of discontinuing MAO inhibitor therapy;
  • Hyperexcitable states;
  • Hyperthyroidism;
  • Patients with psychotic personalities or suicidal or homicidal tendencies;
  • Personal or family history of Tourette's syndrome;
  • Glaucoma;
  • Motor tics;
  • Concurrent use or use within 14 days of MAO inhibitors;
  • Lactation: Lactation.

Use Cautiously in:

  • History of cardiovascular disease (sudden death has occurred in children with structural cardiac abnormalities or other serious heart problems);
  • Hypertension;
  • Diabetes mellitus;
  • Continual use (may result in psychological or physical dependence);
  • Seizure disorders (may lower seizure threshold);
  • OB:   Use during pregnancy only if maternal benefit outweighs potential fetal risk; use may lead to premature delivery, low birth weight infants, and withdrawal symptoms in newborns;
  • Pedi:  Growth suppression may occur in children with long-term use
  • Geri:  Initiate with lower dose in older adults due to age-related decline in organ function.

Adverse Reactions/Side Effects

CV: SUDDEN DEATH, hypertension, palpitations, tachycardia, cardiomyopathy (↑ with prolonged use, high doses), hypotension, peripheral vasculopathy

Derm: urticaria

Endo: growth inhibition (with long term use in children)

GI: anorexia, constipation, cramps, diarrhea, dry mouth, metallic taste, nausea, vomiting

GU: erectile dysfunction, ↑ libido

Neuro: hyperactivity, insomnia, restlessness, tremor, dizziness, headache, irritability

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS AND ANGIOEDEMA), fever, physical dependence, psychological dependence, tolerance

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

  • Use with  MAO inhibitors  or  vasopressors  may result in hypertensive crisis (concurrent use or use within 14 days of MAO inhibitors is contraindicated).
  • Drugs that affect serotonergic neurotransmitter systems, including  tricyclic antidepressants,  MAO inhibitors,  SSRIs,  SNRIs,  fentanyl,  buspirone,  lithium,  tramadol, and  triptans  ↑ risk of serotonin syndrome.
  • ↑ adrenergic effects with other  adrenergics  or  thyroid preparations.
  •  Drugs that alkalinize urine sodium bicarbonate,  acetazolamide ) ↓ excretion and may ↑ effects.
  •  Drugs that acidify urine  (large doses of  ascorbic acid ) may ↓ effects.
  • ↑ risk of hypertension and bradycardia with  beta blockers.
  • ↑ risk of arrhythmias with  digoxin.
  •  Tricyclic antidepressants  may ↑ effect of amphetamine and may ↑ risk of arrhythmias, hypertension, or hyperpyrexia.

Drug-Natural Products:

 St. John's wort  may ↑ risk of serotonin syndrome.

Drug-Food:

 Foods that alkalinize the urine (e.g., cranberry juice)  can ↑ effects.

Route/Dosage

ADHD

PO (Adults): Adzenys ER– 12.5 mg (10 mL) once daily;  Adzenys XR-ODT– 12.5 mg once daily;  Dyanavel XR– 2.5–5 mg once daily in AM; may ↑ by 2.5–10 mg/day every 4–7 days (max dose = 20 mg/day).

PO (Children  ≥6 yr): Adzenys ER– 6.3 mg (5 mL) once daily in the AM; may ↑ by 3.1 mg/day (2.5 mL/day) or 6.3 mg/day (5 mL/day) at weekly intervals (max dose = 18.8 mg/day [15 mL/day] for age 6–12 yr; 12.5 mg/day [10 mL/day] for age 12–17 yr);  Adzenys XR-ODT– 6.3 mg once daily in AM; may ↑ by 3.1 mg/day or 6.3 mg/day at weekly intervals (max dose = 18.8 mg/day for age 6–12 yr; 12.5 mg for age 12–17 yr);  Dyanavel XR– 2.5–5 mg once daily in AM; may ↑ by 2.5–10 mg/day every 4–7 days (max dose = 20 mg/day);  Evekeo or Evekeo ODT– 5 mg 1–2 times daily; may ↑ by 2.5–5 mg/day at weekly intervals until optimal response obtained (max dose = 40 mg/day).

PO (Children  3–5 yr): Evekeo or Evekeo ODT– 2.5 mg once daily; may ↑ by 2.5 mg/day at weekly intervals until optimal response obtained (max dose = 40 mg/day).

Narcolepsy

PO (Adults and Children ≥12 yr): Evekeo– 10 mg once daily; ↑ by 10 mg/day at weekly intervals (usual dose = 5–60 mg in divided doses).

PO (Children  6–12 yr): Evekeo– 5 mg once daily; may ↑ by 5 mg/day at weekly intervals (usual dose = 5–60 mg in divided doses).

Obesity

PO (Adults and Children ≥12 yr): Evekeo– Up to 30 mg/day in divided doses (5–10 mg per dose given 30–60 min before a meal).

Availability (generic available)

Immediate-release tablets (Evekeo): 5 mg, 10 mg

Immediate-release orally disintegrating tablets (Evekeo ODT): 2.5 mg, 5 mg, 10 mg, 15 mg, 20 mg

Extended-release orally disintegrating tablets (Adzenys XR-ODT): 3.1 mg, 6.3 mg, 9.4 mg, 12.5 mg, 15.7 mg, 18.8 mg

Extended-release oral suspension (Adzenys ER) (orange flavor): 1.25 mg/mL

Extended-release oral suspension (Dyanavel XR) (bubble-gum flavor): 2.5 mg/mL

Assessment

  • Assess for presence and family history of cardiac disease (sudden death, ventricular arrhythmia) prior to starting therapy.
  • Monitor blood pressure, pulse, and respiration before and periodically during therapy.
  • May produce a false sense of euphoria and well-being. Provide frequent rest periods and observe patient for rebound depression after the effects of the medication have worn off.
  • Assess for risk of abuse prior to starting therapy. Monitor during therapy. Has high dependence and abuse potential. Tolerance to medication occurs rapidly; do not increase dose.
  • Assess for serotonin syndrome (mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile BP, hyperthermia], neuromuscular aberrations [hyperreflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]), especially in patients taking other serotonergic drugs (SSRIs, SNRIs).
  • ADHD: Monitor weight biweekly for significant loss. Monitor height periodically in children; inform health care professional of growth inhibition.
  • Assess attention span, impulse control, motor and vocal tics, and interactions with others in children with ADHD.
  • Narcolepsy: Observe and document frequency of narcoleptic episodes.
  • May produce a false sense of euphoria and well-being. Provide frequent rest periods and observe patient for rebound depression after the effects of the medication have worn off.
  • Has high dependence and abuse potential. Tolerance to medication occurs rapidly; do not increase dose.

Lab Test Considerations:

  • May interfere with urinary steroid determinations.
  • May cause increased plasma corticosteroid concentrations; greatest in evening.

Implementation

  • To switch from  Adderall XR  to  Adzenys XR-ODT , use following equivalencies:  Adderall XR  5 mg =  Adzenys XR-ODT  3.1 mg; 10 mg = 6.3 mg; 15 mg = 9.4 mg; 20 mg = 12.5 mg; 25 mg = 15.7 mg; 30 mg = 18.8 mg respectively. To switch from other amphetamine products, discontinue therapy and titrate  Adzenys XR-ODT using titration schedule under Route/Dosage. Do not substitute on an mg/mg basis.
  • PO 

    Administer in the morning. May be taken without regard to food. Individualize dose to therapeutic needs and response of patient. Use the lowest effective dose. Keep tablet in blister pack until administration. Use dry hands to open blister. Do not push tablet through foil. Remove tablet and place on tongue; allow to disintegrate without chewing or crushing.

    • Shake solution well before administering. Use calibrated measuring device for accurate dose.
    • Orally disintegrating tablets should be left in the package until use. Remove from the blister pouch. Remove tablet by pushing it through back of foil-lined blister pack. Place tablet on tongue. Tablet will dissolve rapidly and be swallowed with saliva. No liquid is needed to take orally disintegrating tablet; may move tablet around mouth until it disintegrates.
  • ADHD: When symptoms are controlled, dose reduction or interruption of therapy may be possible during summer mo or may be given on each of the 5 school days, with medication-free weekends and holidays.

Patient/Family Teaching

  • Instruct patient to take medication once in the morning as directed. Do not double doses. Instruct patient not to alter dose without consulting health care professional. Abrupt cessation of high doses may cause extreme fatigue and mental depression. Advise patient to read the  Medication Guide  before starting medication and with each Rx refill in case of changes.
  • Inform patient that the effects of drug-induced dry mouth can be minimized by rinsing frequently with water or chewing sugarless gum or candies.
  • Advise patient to limit caffeine intake.
  • May impair judgment. Advise patient to use caution when driving or during other activities requiring alertness until response to medication is known.
  • Advise patient/parent to notify health care professional promptly if signs and symptoms of heart problems (chest pain, shortness of breath, fainting), mental problems (new or worsening behaviors, thought, or mental symptoms, hearing voices, believing things that are not true, being suspicious, new manic symptoms), serotonin syndrome or circulation problems in fingers and toes (numb, cool, painful, change from pale to blue or red, unexplained wounds on fingers or toes) occur.
  • Advise patient that amphetamine is a drug with known abuse potential. Store in safe place, protect it from theft, and never give to anyone other than the individual for whom it was prescribed.
  • Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially St. John's Wort.
  • Inform patient that periodic holidays from the drug may be used to assess progress and decrease dependence.
  • Advise patient to notify health care professional if nervousness, restlessness, insomnia, dizziness, anorexia, or dry mouth becomes severe.
  • Rep:  May cause fetal harm. Advise female patient to notify health care professional if pregnancy is planned or suspected or and to avoid breastfeeding during therapy. May increase risk or premature birth and low birth weight. Monitor infants born to mothers taking amphetamines for symptoms of withdrawal (feeding difficulties, irritability, agitation, excessive drowsiness). Encourage patients exposed to amphetamines during pregnancy to join the registry. Health care professionals may call the National Pregnancy Registry for Psychostimulants at 1-866-961-2388 or online at https://womensmentalhealth.org/clinical-and-research-programs/pregnancyreg... to register patients.

Evaluation/Desired Outcomes

  • Improved attention span. Therapy should be interrupted and need reassessed periodically.
  • Decrease in narcoleptic symptoms.
  • Weight reduction.
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Anesthesia Central is an all-in-one web and mobile solution for treating patients before, during, and after surgery. This collection of drugs, procedures, and test information is derived from Davis’s Drug, MGH Clinical Anesthesia Procedures, Pocket Guide to Diagnostic Tests, and PRIME Journals. .