What is the recommended treatment for Attention Deficit Hyperactivity Disorder (ADHD) in adults?

Recommended Treatment for ADHD in Adults

For adults with ADHD, first-line treatment is stimulant medication (methylphenidate or amphetamine preparations) with an effect size of approximately 1.0, indicating very strong evidence of efficacy. 1

Medication Options

First-Line Treatments

• Stimulant medications:
  • Methylphenidate preparations (e.g., OROS methylphenidate/Concerta)
  • Amphetamine preparations (e.g., lisdexamfetamine/Vyvanse)
  • Starting dose for lisdexamfetamine: 30 mg once daily in the morning 2
  • Titration: Increase by 10-20 mg at weekly intervals to maximum 70 mg daily 2

Second-Line Treatments

• Non-stimulant medications (effect size ~0.7, less strong but sufficient evidence) 1:
  • Atomoxetine (Strattera)
    • Starting dose: 0.5 mg/kg/day
    • Target dose: 1.2 mg/kg/day
  • Extended-release guanfacine (Intuniv): 1 mg daily
  • Extended-release clonidine (Kapvay): 0.1 mg daily

Medication Selection Algorithm

1. Start with stimulants unless contraindicated

   • Begin with low dose (e.g., methylphenidate 10-15 mg/day) 3
   • Increase by 10-15 mg at weekly intervals to maximum 60 mg/day 3
   • For lisdexamfetamine, start at 30 mg/day and increase by 10-20 mg weekly to maximum 70 mg/day 2

2. Consider atomoxetine instead of stimulants if patient has:

   • History of substance abuse
   • Significant anxiety comorbidity
   • Tic disorders
   • Preference to avoid controlled substances 1

3. Consider extended-release formulations for improved adherence

   • OROS methylphenidate (Concerta): 12-hour duration 3, 4
   • Metadate CD or Ritalin LA: 8-hour duration 3
   • Lisdexamfetamine (Vyvanse): long-acting 2

Monitoring and Follow-up

• Regular assessment of:

  • Blood pressure and heart rate (modest increases may occur: ~2-3 mmHg in BP, ~4 BPM in heart rate) 4
  • Weight (average decrease of 2.3 kg may occur) 4
  • Treatment response using standardized scales
  • Side effects

• Common side effects to monitor:

  • Decreased appetite (26.7%)
  • Headache (24.0%)
  • Insomnia (20.7%)
  • Dry mouth 4

Adjunctive Treatments

• Cognitive-behavioral therapy (CBT) focused on:

  • Time management
  • Organization
  • Planning
  • Emotional self-regulation 1

• Combination therapy may be considered for partial response:

  • Stimulant + alpha-2 agonist
  • Adjunctive risperidone for specific symptoms 1

Special Considerations

• Dosing flexibility: Once-daily dosing is generally preferred for convenience, but twice-daily dosing may reduce side effects like nausea 5

• Long-term treatment: Studies show continued efficacy and safety of stimulants like methylphenidate for up to 1 year 6

• Substance abuse risk: Assess risk before prescribing stimulants, educate patients about risks, and monitor for signs of misuse 2

• Comorbid conditions: Treating both ADHD and comorbid conditions simultaneously often leads to better outcomes 1

Pitfalls to Avoid

• Underdosing: Due to variability in response, adequate dose titration is essential for optimal efficacy 3

• Poor timing of doses: Avoid afternoon doses of stimulants to prevent insomnia 2

• Inadequate monitoring: Regular follow-up is essential to assess efficacy and side effects

• Ignoring non-pharmacological interventions: CBT significantly enhances medication effectiveness 1

• Discontinuing too early: Long-term treatment is often necessary as ADHD is typically a chronic condition 7, 6