What non-stimulant medication can be prescribed for Attention Deficit Hyperactivity Disorder (ADHD)?

Non-Stimulant Medications for ADHD

Atomoxetine (Strattera), extended-release guanfacine (Intuniv), and extended-release clonidine (Kapvay) are the FDA-approved non-stimulant medications that can be prescribed for ADHD, with atomoxetine being the preferred second-line option after stimulants. 1

Available Non-Stimulant Options

First Choice: Atomoxetine (Strattera)

• Mechanism: Selective norepinephrine reuptake inhibitor
• Dosing:
  • Starting dose: 0.5 mg/kg/day
  • Target dose: 1.2 mg/kg/day 1
• Efficacy:
  • Effect size of approximately 0.7 (medium range)
  • Effective for both inattentive and hyperactive/impulsive symptoms
  • Effects extend into evening hours with morning dosing 1
• FDA-approved for both children and adults with ADHD 2
• No abuse potential, making it suitable for patients with substance use concerns 1, 3

Alternative Options:

1. Extended-release guanfacine (Intuniv)

   • Alpha-2A adrenergic receptor agonist
   • Starting dose: 1 mg daily
   • Efficacy rate: 58.5% vs. 29.4% for placebo
   • Particularly effective for hyperactivity symptoms
   • Better evidence in children than adults 1

2. Extended-release clonidine (Kapvay)

   • Alpha-2 adrenergic receptor agonist
   • Starting dose: 0.1 mg daily
   • Often used as adjunctive therapy
   • May be beneficial for patients with comorbid sleep disturbances 1

Clinical Considerations

When to Consider Non-Stimulants

• Second-line treatment after stimulants (which have superior efficacy with effect size ~1.0) 1
• When stimulants are ineffective or poorly tolerated
• In patients with:
  • Substance use concerns (atomoxetine preferred)
  • Tics or Tourette syndrome
  • Anxiety disorders
  • Hypertension (guanfacine may be beneficial due to BP-lowering effects) 1

Important Differences from Stimulants

• Delayed onset of action:
  • Atomoxetine: 6-12 weeks for full effect
  • Guanfacine/clonidine: 2-4 weeks for full effect 1
• No abuse potential (unlike stimulants)
• Different side effect profiles

Monitoring and Side Effects

Atomoxetine

• Common side effects: appetite loss, abdominal pain, headaches, somnolence, nausea
• Cardiovascular: mild increases in heart rate and blood pressure
• Black box warning for suicidal ideation
• Monitoring needed: vital signs, growth parameters, liver function 1

Guanfacine/Clonidine

• Common side effects: somnolence, headaches, fatigue
• Cardiovascular: decreased heart rate and blood pressure
• Risk of rebound hypertension with abrupt discontinuation (requires tapering)
• Monitoring needed: blood pressure, heart rate, sedation levels 1

Treatment Approach

1. Start with atomoxetine as the first non-stimulant choice in most cases
2. Begin at lower doses and titrate gradually to minimize side effects
3. Allow adequate time (6-8 weeks) to evaluate full efficacy 4
4. Consider combination therapy with stimulants for partial responders
5. Monitor functional outcomes beyond symptom control

Common Pitfalls to Avoid

• Discontinuing too early before full therapeutic effect is achieved
• Abrupt discontinuation of guanfacine/clonidine (can cause rebound hypertension)
• Inadequate monitoring of side effects
• Expecting immediate results (unlike stimulants, non-stimulants have delayed onset)
• Failing to consider atomoxetine's potential benefits on quality of life and functional outcomes 1

Remember that non-stimulant medications are part of a comprehensive treatment program for ADHD that may include psychological, educational, and social interventions 2.