Recommended Treatment Approach for ADHD Medications
Stimulant medications, particularly methylphenidate (MPH), should be used as first-line pharmacological treatment for ADHD in most patients, with atomoxetine, guanfacine extended-release, or clonidine extended-release as appropriate alternatives in specific clinical scenarios. 1
First-Line Pharmacological Treatment
Stimulant Medications
Methylphenidate (MPH) formulations are the mainstay treatment for ADHD in most Asian countries 2
Dosing recommendations for children and adolescents up to 70 kg:
- Start at approximately 0.5 mg/kg/day
- Increase after minimum 3 days to target dose of 1.2 mg/kg/day
- Maximum dose: 1.4 mg/kg/day or 100 mg (whichever is less)
- Can be administered as single morning dose or divided doses (morning and afternoon) 3
Dosing for children/adolescents over 70 kg and adults:
- Start at 40 mg/day
- Increase after minimum 3 days to target dose of 80 mg/day
- Maximum dose: 100 mg/day 3
Non-Stimulant Alternatives
When to Consider Non-Stimulants
- For patients with:
- History of substance abuse
- Significant anxiety comorbidity
- Tic disorders
- Intolerable side effects from stimulants
- Patient/family preference to avoid controlled substances 1
Atomoxetine
Dosing for children and adolescents up to 70 kg:
- Starting dose: 0.5 mg/kg/day
- Target dose: 1.2 mg/kg/day
- Maximum dose: 1.4 mg/kg/day or 100 mg 3
Dosing for children/adolescents over 70 kg and adults:
- Starting dose: 40 mg/day
- Target dose: 80 mg/day
- Maximum dose: 100 mg/day 3
Alpha-2 Agonists
- Extended-release guanfacine (Intuniv): Start at 1 mg daily 1
- Extended-release clonidine (Kapvay): Start at 0.1 mg daily 1
Regional Variations in Treatment Approaches
Japan differs from other Asian countries and Western guidelines:
- Non-stimulants (atomoxetine and guanfacine) are first-line treatments
- MPH-immediate release is not approved due to stimulant abuse concerns
- OROS-MPH and lisdexamfetamine (LDX) have strict prescription controls 2
Most Asian countries follow a similar approach to Western guidelines:
- MPH as first-line treatment
- Atomoxetine as second-line 2
Monitoring and Safety
Regular monitoring should include:
- Vital signs (blood pressure, heart rate)
- Weight and growth in children
- Symptom response
- Potential adverse effects 1
Additional monitoring:
Common Side Effects to Monitor
Stimulants (methylphenidate):
- Loss of appetite (approximately 20%)
- Dry mouth (15%)
- Heart palpitations (13%)
- Gastrointestinal issues (10%)
- Agitation/restlessness (10%) 1
Atomoxetine:
- Drowsiness
- Gastrointestinal upset
- Potential for increased blood pressure and heart rate 4
Maintenance Treatment
- Pharmacological treatment of ADHD often needs to continue for extended periods
- Periodically reevaluate the need for continued medication
- Benefits of maintaining treatment have been demonstrated in controlled trials 3
- Long-term studies show that benefits may diminish after medication is discontinued 5
Special Considerations
- Screen for bipolar disorder before starting atomoxetine 3
- For patients with hepatic impairment on atomoxetine:
- Moderate impairment: reduce dose to 50% of normal
- Severe impairment: reduce dose to 25% of normal 3
- For patients taking strong CYP2D6 inhibitors (paroxetine, fluoxetine, quinidine) or who are CYP2D6 poor metabolizers:
- Start at lower doses and titrate more cautiously 3
Combination Therapy
- For partial response to stimulants, consider adding:
- Alpha-2 agonist (guanfacine ER)
- Adjunctive risperidone in specific cases 1
Pitfalls to Avoid
- Discontinuing treatment too early - ADHD is typically a chronic condition requiring long-term management 1
- Excessive polypharmacy - increases risk of side effects and interactions
- Overlooking comorbid conditions - treating comorbidities simultaneously with ADHD often leads to better outcomes 1
- Using medication without appropriate behavioral and educational supports - medication should be part of a comprehensive treatment program 3