What is the recommended treatment for Attention Deficit Hyperactivity Disorder (ADHD) in a patient with a previous diagnosis and a trial of Concerta (methylphenidate) and Ritalin (methylphenidate)?

From the Guidelines

For a patient with ADHD who has previously tried Concerta and Ritalin, I recommend considering alternative stimulant medications such as Adderall (mixed amphetamine salts) or Vyvanse (lisdexamfetamine) as the first-line treatment option, given their large effect sizes for reducing ADHD core symptoms and rapid onset of treatment effects 1.

Key Considerations

• The patient's previous trials of Concerta and Ritalin suggest that methylphenidate-based medications may not be effective, so alternative stimulant medications should be considered.
• Adderall could be started at 5-10mg once or twice daily, gradually increasing to an effective dose (typically 10-30mg daily), while Vyvanse might begin at 30mg once daily, potentially increasing to 50-70mg daily as needed.
• If stimulants remain ineffective or cause intolerable side effects, non-stimulant options like atomoxetine (Strattera) starting at 40mg daily and increasing to 80-100mg daily, or alpha-2 agonists such as guanfacine ER (Intuniv) at 1mg daily, gradually increasing to 1-4mg daily, should be considered.

Rationale

• Different medication classes work through distinct mechanisms, and patients often respond differently to each class 1.
• A comprehensive treatment approach should include behavioral therapy, organizational skills training, and regular follow-up appointments to monitor effectiveness and side effects, adjusting treatment as necessary.
• The choice of medication should be individualized based on factors such as severity of symptoms, presence of comorbidities, and patient preferences 1.

Potential Benefits and Drawbacks

• Stimulants have large effect sizes for reducing ADHD core symptoms and a rapid onset of treatment effects, but may have limitations such as a controlled substance status and potential for rebound of symptoms when the effect wears off 1.
• Non-stimulants, such as atomoxetine, may have a slower onset of action but can provide "around-the-clock" effects and may be a better option for patients with certain comorbidities, such as substance use disorders or tic/Tourette's disorder 1.

From the FDA Drug Label

Methylphenidate hydrochloride oral solution is indicated for the treatment of: • Attention Deficit Hyperactivity Disorder (ADHD) in adults and pediatric patients 6 years of age and older The recommended starting dosage is 5 mg orally twice daily before breakfast and lunch (preferably 30 to 45 minutes before meals). Increase the dosage gradually, in increments of 5 mg to 10 mg weekly.

The patient has already had a trial of Concerta and Ritalin, which are both methylphenidate-containing medications.

• Re-evaluation of the patient's condition and response to previous treatments is necessary.
• Alternative treatments or adjustments to the current treatment plan may be considered.
• It is essential to consult the patient's healthcare provider to determine the best course of action. 2

From the Research

Treatment Options for ADHD

Given the patient's previous diagnosis and trial of Concerta and Ritalin, the following treatment options can be considered:

• Non-stimulant medications such as viloxazine, atomoxetine, guanfacine, and clonidine, which have minimal adverse effects compared to stimulants 3
• Viloxazine, a selective norepinephrine reuptake inhibitor, which has been shown to be effective in treating ADHD with decreased chance of substance abuse, drug dependence, and withdrawal symptoms 3
• Guanfacine extended release, which has been found to be more efficacious than atomoxetine for the treatment of ADHD in children and adolescents 4
• Atomoxetine, which has been shown to improve executive functions in adults with ADHD, particularly in spatial planning 5

Combination Therapy

Combination therapy of methylphenidate and atomoxetine can also be considered, as it has been found to be effective in improving symptoms of ADHD in some patients 6

• However, the efficacy and safety of combination therapy should be carefully evaluated, as it may increase the risk of side effects such as irritability, appetite reduction, and palpitations 6

Treatment Recommendations

The choice of treatment should be based on the individual patient's needs and response to previous treatments. Extended-release methylphenidate and amphetamine formulations, atomoxetine, and extended-release guanfacine have been found to be effective in improving symptoms of ADHD in adolescents 7

• Psychosocial treatments, such as behavioral, cognitive behavioral, and skills training techniques, can also be considered, particularly for improving academic and organizational skills 7