What is the recommended treatment for Attention Deficit Hyperactivity Disorder (ADHD) in individuals assigned female at birth (AFAB) undergoing hormone therapy to transition?

ADHD Treatment in AFAB Individuals on Hormone Therapy for Transition

For AFAB individuals undergoing hormone therapy for transition, atomoxetine (Strattera) is recommended as first-line pharmacological treatment for ADHD due to its efficacy, safety profile, and lack of interaction with gender-affirming hormone therapy. 1

Treatment Algorithm

1. First-line treatment:

   • Non-stimulant: Atomoxetine (Strattera)
     • Starting dose: 40 mg daily
     • Titration: Increase every 7-14 days to 60 mg then 80 mg
     • Maximum dose: 1.4 mg/kg/day or 100 mg/day (whichever is less) 1, 2

2. Alternative options if atomoxetine is ineffective or not tolerated:

   • Bupropion (Wellbutrin)
     • SR formulation: Start 100-150 mg daily, maintenance 100-150 mg twice daily
     • XL formulation: Start 150 mg daily, maintenance 150-300 mg daily
     • Maximum dose: 450 mg per day 1

3. Stimulant options (if non-stimulants ineffective):

   • Methylphenidate (preferred over amphetamine derivatives)
   • Consider intermittent use or lowest effective dose 1

Rationale for Atomoxetine as First-Line

• Mechanism of action: Selective norepinephrine reuptake inhibitor that does not affect hormone levels 3, 4
• No abuse potential: Not a controlled substance, important for patients who may face additional scrutiny 3, 5
• Once-daily dosing: Convenient administration 6, 3
• Efficacy throughout the day: Effects extend through waking hours into late evening 5

Monitoring and Follow-up

• Initial phase: Weekly contact during dose titration
• Maintenance phase: Monthly appointments until symptoms stabilize 2
• Monitor for side effects:
  • Common: Dry mouth, insomnia, nausea, decreased appetite, constipation
  • Less common but important: Increased heart rate and blood pressure 6, 3

Special Considerations for AFAB Individuals on Hormone Therapy

• Cardiovascular monitoring: Check blood pressure and heart rate regularly, as both testosterone therapy and atomoxetine can affect cardiovascular parameters 1
• Hepatic function: Monitor liver function tests periodically, as both hormone therapy and atomoxetine can affect liver function 1, 6
• Mental health: Be vigilant for mood changes, as both gender-affirming hormone therapy and ADHD medications can impact mood 1

Non-Pharmacological Approaches

• Cognitive Behavioral Therapy (CBT): Most effective non-pharmacological treatment for ADHD 1
• Dialectical Behavior Therapy (DBT): Four modules addressing different aspects of ADHD:
  • Mindfulness skills for poor concentration
  • Distress tolerance for disorganization
  • Interpersonal effectiveness for relationship difficulties
  • Emotion regulation for affective lability 1

Important Caveats

• Switching medications: If transitioning from stimulants to atomoxetine, allow 6-8 weeks to evaluate full efficacy 5
• CYP2D6 metabolism: Approximately 7% of the population are poor CYP2D6 metabolizers who may require lower doses due to slower clearance of atomoxetine 2, 6
• Therapeutic expectations: Response rates to atomoxetine after failed methylphenidate treatment are approximately 50% 5

Pitfalls to Avoid

• Expecting immediate results: Unlike stimulants, atomoxetine may take 2-4 weeks to show full therapeutic effect 5
• Premature discontinuation: Inadequate trial periods may lead to incorrect conclusions about efficacy 5
• Overlooking side effects: Initial side effects often diminish over time but require monitoring 6, 3
• Neglecting non-pharmacological treatments: Medication works best when combined with appropriate behavioral strategies 1

By following this treatment approach, AFAB individuals on hormone therapy for transition can receive effective ADHD treatment while minimizing potential interactions with their gender-affirming care.