From the Guidelines
The first-line non-stimulant treatment option for ADHD is atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor, due to its efficacy in reducing core symptoms and improving functional impairment and quality of life 1.
Key Considerations
- Atomoxetine is typically started at 0.5 mg/kg/day for children and adolescents, gradually increasing to a target dose of 1.2-1.4 mg/kg/day, with a maximum of 100 mg daily.
- For adults, starting doses are usually 40 mg daily, potentially increasing to 80-100 mg daily.
- Other first-line non-stimulant options include alpha-2 adrenergic agonists such as guanfacine extended-release (Intuniv) and clonidine extended-release (Kapvay).
Benefits and Side Effects
- Non-stimulants are particularly useful for patients who experience adverse effects from stimulants, have comorbid anxiety, tics, or substance use disorders, or when there are concerns about stimulant misuse.
- Unlike stimulants, these medications provide 24-hour coverage and don't have controlled substance restrictions, though they typically take 2-4 weeks to reach full effectiveness.
- Common side effects of atomoxetine include initial somnolence, gastrointestinal tract symptoms, and decreased appetite, while guanfacine and clonidine may cause somnolence, dry mouth, dizziness, and hypotension 1.
Patient Selection
- Non-stimulants may be considered as first-line treatment options in patients with certain comorbidities, such as disruptive behavior disorders, tic disorder, Tourette's syndrome, or substance use disorders 1.
- Clinicians should carefully evaluate the patient's medical history and perform additional evaluation if risk factors are present before starting non-stimulant medications, including obtaining an electrocardiogram (ECG) and possibly referring to a pediatric cardiologist if the ECG is not normal 1.
From the FDA Drug Label
1.1 Attention-Deficit/Hyperactivity Disorder (ADHD) Atomoxetine capsules are indicated for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) The efficacy of atomoxetine capsules was established in seven clinical trials in outpatients with ADHD: four 6 to 9-week trials in pediatric patients (ages 6 to 18), two 10-week trial in adults, and one maintenance trial in pediatrics (ages 6 to 15)
The first-line non-stimulant treatment options for Attention Deficit Hyperactivity Disorder (ADHD) include:
- Atomoxetine: a non-stimulant medication that has been shown to be effective in the treatment of ADHD in pediatric and adult patients 2, 2, 2. Key points to consider when prescribing atomoxetine include:
- It is indicated as an integral part of a total treatment program for ADHD that may include other measures (psychological, educational, social) for patients with this syndrome.
- The decision to prescribe atomoxetine will depend upon the physician’s assessment of the chronicity and severity of the patient’s symptoms.
From the Research
Non-Stimulant Treatment Options for ADHD
The first-line non-stimulant treatment options for Attention Deficit Hyperactivity Disorder (ADHD) include:
- Atomoxetine, a selective norepinephrine reuptake inhibitor, which has been shown to be effective in controlling ADHD symptoms in both children and adults 3, 4, 5
- Guanfacine, an antihypertensive, which has been found to be effective in treating adult ADHD 6, 7
- Other non-stimulant medications, such as antidepressants with noradrenergic or dopaminergic components, including tricyclic compounds, bupropion, and viloxazine, which have shown efficacy in treating adult ADHD 7
Mechanism of Action
The mechanism of action of atomoxetine is thought to be related to its selective inhibition of presynaptic norepinephrine reuptake in the prefrontal cortex 4, 5
- Atomoxetine has a high affinity and selectivity for norepinephrine transporters, but little or no affinity for various neurotransmitter receptors 4
- Guanfacine, on the other hand, is an alpha-2 adrenergic agonist, which decreases the release of norepinephrine and increases the activity of inhibitory neurons in the prefrontal cortex 6, 7
Efficacy and Safety
Atomoxetine has been shown to be effective in maintaining control of ADHD symptoms and preventing relapse without an increase in adverse effects 3
- Common adverse events associated with atomoxetine include headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea 4, 5
- Guanfacine has also been found to be effective and well-tolerated in adults with ADHD, with common adverse events including somnolence, fatigue, and dry mouth 6, 7
Treatment Considerations
Non-stimulant medications may be recommended for patients who do not respond or poorly tolerate stimulants 7
- Atomoxetine may be used as a second-line option in adults with ADHD, while other non-stimulant compounds may be used to personalize treatment based on comorbid conditions and ADHD features 7