General

Pronunciation
am-FET-a-meen

Trade Name(s)

• Amphetamine Salt

• Adderall

• Adderall XR

Controlled Substance Schedule
II

Pregnancy Category
Category C

Ther. class.
central nervous system stimulants

Indications

• Narcolepsy

• ADHD

Action

Causes release of norepinephrine from nerve endings. Pharmacologic effects are

» CNS and respiratory stimulation

» Vasoconstriction

» Mydriasis (pupillary dilation)

Therapeutic Effect(s):

• Increased motor activity, mental alertness, and decreased fatigue in narcoleptic patients

• Increased attention span in ADHD

Pharmacokinetics

Absorption: Well absorbed after oral administration

Distribution: Widely distributed in body tissues, with high concentrations in the brain and CSF. Crosses 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: Children 6–12 yrs: 9–11 hr; Adults: 10–13 hr (depends on urine pH)

TIME/ACTION PROFILE (CNS stimulation)

ROUTE	ONSET	PEAK	DURATION
PO	tablet: 0.5–1 hr	tablet: 3 hr capsule: 7 hr	4–6 hr

Contraindication/Precautions

Contraindicated in:

• Hyperexcitable states including hyperthyroidism

• Psychotic personalities

• Suicidal or homicidal tendencies

• Chemical dependence

• Glaucoma

• Structural cardiac abnormalities (may increase the risk of sudden death)

• OB: Potentially embryotoxic

Use Cautiously in:

• Cardiovascular disease (sudden death has occurred in children with structural cardiac abnormalities or other serious heart problems)

• History of substance abuse (misuse may result in serious cardiovascular events/sudden death)

• Hypertension

• Diabetes mellitus

• Tourette's syndrome (may exacerbate tics)

• Geri: Geriatric or debilitated patients may be more susceptible to side effects

Adverse Reactions/Side Effects

CNS: hyperactivity, insomnia, restlessness, tremor, behavioral disturbances, dizziness, hallucinations, headache, mania, irritability, thought disorder.

CV: palpitations, tachycardia, cardiomyopathy (increased with prolonged use, high doses), hypertension, hypotension.

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

GU: erectile dysfunction, increased libido.

Derm: urticaria.

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

Misc: psychological dependence.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• Use with MAO inhibitors or meperidine can result in hypertensive crisis

• adrenergic effects with other adrenergics or thyroid preparations

• Drugs that alkalinize urine (sodium bicarbonate, acetazolamide) excretion, effects

• Drugs that acidify urine (ammonium chloride, large doses of ascorbic acid) excretion, effects

• risk of hypertension and bradycardia with beta blockers

• risk of arrhythmias with digoxin

• Tricyclic antidepressants may effect of amphetamine but may risk of arrhythmias, hypertension, or hyperpyrexia

Drug-Natural Products
Use with St. John's wort may serious side effects (avoid concurrent use)

Drug-Food
Foods that alkalinize the urine (fruit juices) can effect of amphetamine

Route/Dosage

• Dose is expressed in total amphetamine content (amphetamine + dextroamphetamine)

Narcolepsy

• PO (Adults and Children >= 12 yr): 10–60 mg/day in divided doses; start with 10 mg/day, increase by 10 mg/day at weekly intervals. Sustained-release capsules can be given once daily, tablets every 8–12 hr.

• PO (Children 6–12 yr): 5 mg once daily; may increase by 5 mg/day at weekly intervals to a maximum of 60 mg/day.

ADHD

• PO (Children >=6 yr): 5 mg/day 1–2 times daily; increase daily dose by 5 mg at weekly intervals. Sustained-release capsules can be given once daily, tablets every 8–12 hr. If starting therapy with extended release capsules, start with 10 mg once daily and increase by 10 mg/day at weekly intervals (up to 40 mg/day).

• PO (Adults): 20 mg/day initially (as extended-release product).

• PO (Children 3–5 yr): 2.5 mg/day in the morning; increase daily dose by 2.5 mg at weekly intervals not to exceed 40 mg/day.

Availability

Amount is expressed in total amphetamine content (amphetamine + dextroamphetamine

• Tablets: 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg

• Extended-release capsules: 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg

Assessment

• Monitor blood pressure, pulse, and respiration before and periodically during therapy. Obtain a history (including assessment of family history of sudden death or ventricular arrhythmia), physical exam to assess for cardiac disease, and further evaluation (ECG and echocardiogram), if indicated. If exertional chest pain, unexplained syncope, or other cardiac symptoms occur, evaluate promptly

• 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

• Monitor closely for behavior change

• Has high dependence and abuse potential. Tolerance to medication occurs rapidly; do not increase dose

ADHD

• Monitor weight biweekly and inform physician of significant loss. Pedi: Monitor height periodically in children; inform physician of growth inhibition

• Assess attention span, impulse control, motor and vocal tics, and interactions with others in children with ADHDs

Narcolepsy

• Observe and document frequency of narcoleptic episodes

Lab Test Considerations

• May interfere with urinary steroid determinations

» May cause plasma corticosteroid concentrations; greatest in evening

Potential Nursing Diagnoses

• Disturbed thought process (Side Effects)

Implementation

• PO: Use the lowest effective dose

» May be taken without regard to food

» Extended-release capsules may be swallowed whole or opened and sprinkled on applesauce; swallow contents without chewing. Applesauce should be swallowed immediately; do not store. Do not divide contents of capsule; entire contents of capsule should be taken

• ADHD: Pedi: When symptoms are controlled, dose reduction or interruption of therapy may be possible during summer months 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 at least 6 hr before bedtime to avoid sleep disturbances. Missed doses should be taken as soon as remembered up to 6 hr before bedtime. With extended release capsule, avoid afternoon doses to prevent insomnia. Do not double doses. Advise patient and parents to read the Medication Guide prior to starting therapy and with each Rx refill. Instruct patient not to alter dose without consulting physician. Abrupt cessation of high doses may cause extreme fatigue and mental depression

• 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

• Inform patient that periodic holidays from the drug may be used to assess progress and decrease dependence. Pedi: Children should be given a drug-free holiday each year to reassess symptoms and treatment. Doses will change as children age due to pharmacokinetic changes such as slower hepatic metabolism

• Advise patient and/or parents to notify health care professional of behavioral changes

• Advise patient to notify physician if nervousness, restlessness, insomnia, dizziness, anorexia, or dry mouth becomes severe. Pedi: If reduced appetite and weight loss are a problem, advise parents to provide high calorie meals when drug levels are low (at breakfast and or bedtime)

Evaluation/Desired Outcomes

• Improved attention span

• Decrease in narcoleptic symptoms

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