What are the treatment options for Attention Deficit Hyperactivity Disorder (ADHD) without using stimulants?

Non-Stimulant Treatment Options for ADHD

Atomoxetine is the first-line non-stimulant medication for ADHD treatment, with recommended dosing of 0.5 mg/kg/day initially, increased to a target dose of 1.2 mg/kg/day in children and adolescents, or starting at 40 mg/day and increasing to 80 mg/day in adults. 1

First-Line Non-Stimulant Medication: Atomoxetine

Dosing and Administration

• Children and adolescents ≤70 kg:

  • Initial dose: 0.5 mg/kg/day
  • Target dose: 1.2 mg/kg/day after minimum 3 days
  • Maximum dose: 1.4 mg/kg/day or 100 mg (whichever is less)
  • Can be given as single morning dose or divided doses 1

• Children/adolescents >70 kg and adults:

  • Initial dose: 40 mg/day
  • Target dose: 80 mg/day after minimum 3 days
  • Maximum dose: 100 mg/day
  • Can be given as single morning dose or divided doses 1

Efficacy and Advantages

• First FDA-approved non-stimulant for ADHD 2
• Selective norepinephrine reuptake inhibitor that acts on noradrenergic pathway 2
• Particularly useful for:
  • Patients at risk of substance abuse (no abuse potential) 3
  • Those with comorbid anxiety or tics 3
  • Patients who prefer non-controlled substances 3
  • Can be taken with or without food 1

Monitoring and Side Effects

• Most common side effects in children: dyspepsia, nausea, vomiting, decreased appetite, weight loss 2
• Most common side effects in adults: dry mouth, insomnia, nausea, decreased appetite, constipation, urinary difficulties, sexual dysfunction 2
• Monitor for:
  • Blood pressure and heart rate increases 3
  • Height and weight in pediatric patients 3
  • Suicidal ideation (black box warning) 3
  • Liver function (rare cases of liver injury) 3

Other Non-Stimulant Options

Alpha-2 Adrenergic Agonists

• Extended-release guanfacine (Intuniv):

  • Starting dose: 1 mg daily 4
  • Available in multiple Asian countries 5

• Extended-release clonidine (Kapvay):

  • Starting dose: 0.1 mg daily 4
  • Available in some Asian countries including India and Korea 5

Tricyclic Antidepressants

• Clonidine (0.1 mg) available in India with maximum dose of 0.2-0.4 mg 5
• Effective but limited by side effects 6

Non-Pharmacological Interventions

Behavioral Interventions

• Behavioral Parent Training (BPT) and Parent Training in Behavior Management (PTBM) 4
• Coordinate behavior plans between home and school 4
• Consider classroom adaptations and 504 Rehabilitation Act Plan or IEP 4

Psychological Approaches

• Cognitive Behavioral Therapy (CBT) principles for anxiety management 4
• Problem-solving treatment for depressive symptoms 4
• Relaxation training and physical activity 4

Treatment Algorithm for Non-Stimulant ADHD Management

1. First-line non-stimulant: Atomoxetine

   • Start at low dose and titrate gradually
   • Allow 4-6 weeks to assess full efficacy

2. If inadequate response or intolerable side effects:

   • Try alpha-2 adrenergic agonists (guanfacine ER or clonidine ER)

3. If still inadequate response:

   • Consider tricyclic antidepressants (with caution due to side effect profile)

4. Throughout treatment:

   • Implement appropriate behavioral and psychological interventions
   • Regularly monitor for side effects and treatment response
   • Periodically reevaluate the need for continued medication 1

Common Pitfalls to Avoid

• Expecting immediate results (non-stimulants typically take longer to show full effect than stimulants)
• Inadequate dose titration (follow recommended titration schedules)
• Discontinuing treatment prematurely (allow adequate trial period)
• Neglecting to monitor for side effects, particularly cardiovascular effects
• Failing to implement complementary non-pharmacological interventions
• Not screening for bipolar disorder before starting atomoxetine 1

Remember that atomoxetine and other non-stimulant medications should be part of a comprehensive treatment program that may include psychological, educational, and social interventions for optimal outcomes 1.