What are the common medications for Attention Deficit Hyperactivity Disorder (ADHD)?

Common Medications for ADHD

Stimulant medications, particularly methylphenidate and amphetamine-based medications, are the first-line pharmacological treatment for ADHD due to their strong efficacy in reducing core ADHD symptoms and improving quality of life. 1

First-Line Medications

Stimulants

Stimulants have the strongest evidence base and are recommended as first-line treatment for ADHD in most cases:

1. Methylphenidate (MPH)

   • Available in immediate-release (IR) and extended-release (ER) formulations
   • Common brands: Ritalin, Concerta (OROS-MPH), Metadate CD
   • Dosing:
     • Starting dose: 5 mg twice daily for IR, 10-18 mg once daily for ER 1
     • Maximum dose: Up to 60 mg/day or 1.0 mg/kg 1
   • Duration: IR formulations last ~4 hours; ER formulations last 8-12 hours 2

2. Amphetamine-based medications

   • Mixed amphetamine salts (Adderall)
   • Lisdexamfetamine dimesylate (LDX)
   • Dosing:
     • Starting dose: 5-10 mg daily
     • Maximum dose: 50 mg daily for mixed amphetamine salts 1

Age-Based Recommendations

• Ages 4-5: Behavior therapy is first-line; methylphenidate may be prescribed if behavior interventions are insufficient 3
• Ages 6-11: FDA-approved medications (preferably with behavior therapy) 3
• Ages 12-18: FDA-approved medications with adolescent assent (may include behavior therapy) 3

Second-Line Medications (Non-Stimulants)

When stimulants are ineffective, poorly tolerated, or contraindicated:

1. Atomoxetine

   • Selective norepinephrine reuptake inhibitor
   • Dosing:
     • Starting dose: 1.2 mg/kg/day in patients ≤70 kg or 80 mg/day in patients >70 kg
     • Maximum dose: 1.4 mg/kg/day or 100 mg/day, whichever is lower 1, 4
   • FDA-approved for ADHD treatment 4

2. Extended-release guanfacine

   • Alpha-2 adrenergic agonist
   • Dosing:
     • Typical dose: 0.1 mg/kg once daily
     • Maximum dose: 6 mg daily 1

3. Extended-release clonidine

   • Alpha-2 adrenergic agonist
   • Dosing:
     • Starting dose: 0.1 mg at bedtime
     • Maximum dose: 0.4 mg/day 1, 3

Medication Selection Algorithm

1. First attempt: Trial of methylphenidate (MPH)

   • If effective with tolerable side effects → continue
   • If ineffective or intolerable side effects → try amphetamine-based medication

2. Second attempt: Trial of amphetamine-based medication

   • If effective with tolerable side effects → continue
   • If ineffective or intolerable side effects → try non-stimulant

3. Third attempt: Trial of atomoxetine

   • If ineffective → try extended-release guanfacine or clonidine

Important Clinical Considerations

Efficacy

• Stimulants have medium to large effect sizes compared to placebo 1
• 70-90% of patients respond to either methylphenidate or amphetamine 1
• Extended-release formulations provide continuous coverage throughout the day 1, 2

Side Effects Management

• Common stimulant side effects: insomnia, headaches, anxiety, appetite suppression 1, 2
• Monitor blood pressure, heart rate, height, and weight regularly 1
• Start at low doses and titrate gradually to minimize side effects 3, 1

Contraindications

• Advanced cardiovascular disease, high blood pressure, hyperthyroidism, glaucoma, agitation 1
• History of psychosis or mania (for stimulants) 1
• Caution with substance use disorders 1, 5

Regional Availability Considerations

Different countries have varying medication availability:

• India: MPH, atomoxetine, and clonidine are approved; guanfacine and extended-release clonidine are not available 3
• Japan: OROS-MPH, lisdexamfetamine, atomoxetine, and guanfacine extended-release are approved 3
• Republic of Korea: Various MPH formulations, atomoxetine, and extended-release clonidine are available 3
• Taiwan and China: MPH and atomoxetine are available, with MPH being first-line 3

Monitoring and Follow-Up

• Weekly contact during initial titration 1
• Regular monitoring of weight, appetite, vital signs, and height 1
• Titrate doses to achieve maximum benefit with minimum adverse effects 3

Remember that medication should be part of a comprehensive treatment plan that may include behavioral interventions, educational accommodations, and parent training 3, 1, 6.