Class

• Neuroscience-based Nomenclature: dopamine, norepinephrine multimodal stimulant (DN-MM)

SERDEXMETHYLPHENIDATE commonly prescribed for

(Bold for FDA approved)

How SERDEXMETHYLPHENIDATE works

• Azstarys consists of serdexmethylphenidate, a prodrug of d-methylphenidate, co-formulated with immediate-release d-methylphenidate

• Serdexmethylphenidate is not active until after it has been absorbed by the lower intestinal tract and converted to d-methylphenidate (active component)

• d-methylphenidate increases norepinephrine and especially dopamine actions by blocking their reuptake

• Enhancement of dopamine and norepinephrine in certain brain regions (e.g., dorsolateral prefrontal cortex) may improve attention, concentration, executive function, and wakefulness

• Enhancement of dopamine actions in other brain regions (e.g., basal ganglia) may improve hyperactivity

• Enhancement of dopamine and norepinephrine in yet other brain regions (e.g., medial prefrontal cortex, hypothalamus) may improve depression, fatigue, and sleepiness

How long until SERDEXMETHYLPHENIDATE works

• Some immediate effects can be seen with first dosing

• Can take several weeks to attain maximum therapeutic benefit, especially as dose is being titrated

Notable Side Effects

Insomnia, headache, exacerbation of tics, nervousness, irritability, overstimulation, tremor, dizziness

• Anorexia, nausea, abdominal pain, weight loss, dry mouth

• Peripheral vasculopathy, including Raynaud’s syndrome

• Can temporarily slow normal growth in children (controversial)

Life Threatening Side Effects

• Psychotic episodes

• Rare priapism

• Seizures

• Palpitations, tachycardia, hypertension

• Rare neuroleptic malignant syndrome

• Rare activation of hypomania, mania, or suicidal ideation (controversial)

• Cardiovascular adverse effects, sudden death in patients with preexisting cardiac structural abnormalities

weight gain

unusual

sedation

unusual

What to do about SERDEXMETHYLPHENIDATE side effects

• Wait

• Adjust dose

• Switch to another long-acting stimulant

• Switch to another agent

• For insomnia, avoid dosing in afternoon/ evening

usual dosage range

• Ages 6–12: 26.1 mg/5.2 mg, 39.2 mg/7.8 mg, or 52.3 mg/10.4 mg

• Ages 13 and older: 39.2 mg/7.8 mg or 52.3 mg/10.4 mg

Dosage Forms

• Capsule (serdexmethylphenidate/d- methylphenidate) 26.1 mg/5.2 mg, 39.2 mg/7.8 mg, 52.3 mg/10.4 mg

long term use

• Methylphenidate is often used long-term for ADHD when ongoing monitoring documents continued efficacy

• Dependence and/or abuse may develop

• Tolerance to therapeutic effects may develop in some patients, in which case a dose increase should be considered

• Long-term stimulant use may be associated with growth suppression in children (controversial)

• Periodic monitoring of weight, blood pressure, heart rate, complete blood count, platelet counts, and liver function may be prudent

habit forming

• d-methylphenidate is a Schedule II drug; serdexmethylphenidate is under review by the DEA for scheduling

• Patients may develop tolerance, psychological dependence

Renal Impairment

• No dose adjustment necessary

Hepatic Impairment

• No dose adjustment necessary

Cardiac Impairment

• Use with caution, particularly in patients with recent myocardial infarction or other conditions that could be negatively affected by increased blood pressure

• Do not use in patients with structural cardiac abnormalities, cardiomyopathy, serious heart arrhythmias, or coronary artery disease

Elderly

• Some patients may tolerate lower doses better

Children and Adolescents

• Safety and efficacy not established in children under age 6

• Use in young children should be reserved for the expert

• Methylphenidate has acute effects on growth hormone; long-term effects are unknown but weight and height should be monitored during long-term treatment

• Half-life and duration of clinical action tend to be shorter in younger children

• Usual dosing has been associated with sudden death in children with structural cardiac abnormalities

• Current recommendations from the American Heart Association are that it is reasonable but not mandatory to obtain an ECG prior to prescribing a stimulant to a child; the American Academy of Pediatrics does not recommend an ECG prior to starting a stimulant for most children

Pregnancy

• Controlled studies have not been conducted in pregnant women

• Infants whose mothers took methylphenidate during pregnancy may experience withdrawal symptoms

• In animal studies, d-methylphenidate caused delayed skeletal ossification and decreased postweaning weight gain in rats; no major malformations occurred in rat or rabbit studies

• Racemic methylphenidate has been shown to have teratogenic effects in rabbits when given in doses of 200 mg/kg/day throughout organogenesis

• No evidence of developmental effects was found in an embryofetal development study with oral administration of serdexmethylphenidate in rabbits during organogenesis at doses of up to 374 mg/ kg/day

• Use in women of childbearing potential requires weighing potential benefits to the mother against potential risks to the fetus

• For ADHD patients, methylphenidate should generally be discontinued before anticipated pregnancies

Breast Feeding

• Unknown if methylphenidate is secreted in human breast milk, but all psychotropics are assumed to be secreted in breast milk

• Recommended either to discontinue drug or formula feed

• If infant shows signs of irritability, drug may need to be discontinued