What alternative treatments are available for an 18-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD) who has ulcerative colitis and is on Tumor Necrosis Factor (TNF) blockers, and has experienced severe reactions to bupropion (Wellbutrin) and Strattera (atomoxetine)?

From the Guidelines

For an 18-year-old ADHD patient with ulcerative colitis on TNF blockers who has had severe reactions to bupropion and Strattera, I strongly recommend trying guanfacine (Intuniv) at a low initial dose of 1mg daily, gradually titrating up to 1-4mg daily as tolerated. This approach is based on the most recent and highest quality study available, which highlights the importance of individualizing treatment for ADHD patients with comorbidities 1. Given the patient's history of severe reactions to bupropion and Strattera, it is crucial to prioritize medications with minimal gastrointestinal effects and low risk of ischemic colitis. Guanfacine, a non-stimulant medication, has been shown to have "around-the-clock" effects and is an uncontrolled substance, making it a suitable alternative for this patient 1.

Key considerations for this patient include:

• Avoiding stimulants due to the potential risk of exacerbating intestinal blood flow issues associated with ulcerative colitis and TNF blocker therapy
• Selecting medications with minimal gastrointestinal effects to reduce the risk of worsening ulcerative colitis symptoms
• Regular monitoring of both ADHD symptoms and gastrointestinal status, with follow-up appointments every 2-4 weeks during initial treatment adjustments
• Potential augmentation with cognitive behavioral therapy specifically designed for ADHD to help develop coping strategies and organizational skills

It is essential to note that medication adherence is a common problem in ADHD treatment, and factors such as patient attitudes, physician-patient relationship, family support, and knowledge about the disorder and medication can significantly impact adherence 1. By carefully selecting a suitable medication and closely monitoring the patient's response, we can optimize treatment outcomes and improve quality of life for this patient.

From the Research

Treatment Options for ADHD

• Atomoxetine is a selective norepinephrine reuptake inhibitor that is not classified as a stimulant, making it a potential option for patients with ADHD who cannot take stimulants due to certain medical conditions, such as ulcerative colitis 2, 3, 4, 5, 6.
• Atomoxetine has been shown to be effective in reducing ADHD symptoms in both children and adults, with a negligible risk of abuse or misuse 2, 3, 4, 5, 6.

Efficacy and Safety of Atomoxetine

• Studies have demonstrated that atomoxetine is effective in reducing ADHD symptoms in adults, with significant improvements in symptoms and quality of life 3, 5, 6.
• Atomoxetine has been shown to be generally well tolerated, with common adverse events including headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea 2, 3, 4, 5, 6.
• The most common adverse events in adults taking atomoxetine were nausea, dry mouth, decreased appetite, insomnia, and fatigue 5.

Considerations for Patients with Comorbidities

• Atomoxetine may be a useful option for patients with ADHD and comorbidities, such as anxiety or tics, as it has been shown to be effective in reducing symptoms of these conditions 2, 4.
• Patients with hepatic insufficiency may require dose adjustments, as atomoxetine exposure may be increased in these patients 2.

Dosage and Administration

• Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses, with a recommended clinical dose selection based on both CYP2D6 genotype and peak concentration 4.
• The dosage regimen of atomoxetine may need to be adjusted based on individual patient response and tolerability 2, 3, 4, 5, 6.