What medication should be tried next for a patient with Attention Deficit Hyperactivity Disorder (ADHD) who has previously taken Focalin (dexmethylphenidate)?

Medication Options After Focalin for ADHD

For a patient with ADHD who has previously taken Focalin (dexmethylphenidate), atomoxetine (Strattera) should be tried next as it offers a different mechanism of action with proven efficacy and is particularly beneficial when stimulants have been ineffective or poorly tolerated. 1, 2

Rationale for Atomoxetine as Next Option

Atomoxetine is a selective norepinephrine reuptake inhibitor that works differently from stimulants like Focalin:

• It increases both noradrenaline and dopamine in the prefrontal cortex 1
• It provides 24-hour symptom control, unlike the time-limited effects of stimulants 2
• It has demonstrated efficacy in reducing ADHD core symptoms with large effect sizes 1
• It improves overall quality of life and reduces functional impairment 1

Dosing and Administration

• Starting dose: 0.5 mg/kg/day 2
• Target dose: 1.2 mg/kg/day or maximum of 100 mg/day (whichever is lower) 1, 2
• Can be administered as a single daily dose or split into two evenly divided doses 3
• Evening-only dosing is possible to reduce adverse effects 2
• Titration should occur gradually, with dose adjustments every 7-14 days 2

Important Monitoring Considerations

• Warning: Monitor closely for suicidal ideation, especially in children and adolescents during the first few months of treatment 4
• Allow 6-12 weeks for full therapeutic effect before concluding treatment failure 2
• Regular monitoring of vital signs is recommended as atomoxetine can affect blood pressure and heart rate 1
• Watch for common side effects: dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness 5

Alternative Options if Atomoxetine Fails

If atomoxetine proves ineffective or poorly tolerated, consider these alternatives in sequence:

1. Guanfacine extended-release (GXR):

   • Recommended as next-line treatment after atomoxetine failure 2
   • Can be administered in the evening due to common side effect of somnolence 2
   • May help with sleep disturbances common in ADHD 2

2. Amphetamine-based stimulants:

   • Patients may respond to either amphetamine or methylphenidate with high overall response rate when both are tried 1
   • Consider lisdexamfetamine (Vyvanse) which is a prodrug converted to dextroamphetamine 1

3. Other non-stimulant options:

   • Tricyclic antidepressants (TCAs) such as desipramine or imipramine 2
   • Viloxazine, a newer non-stimulant with noradrenergic activity 2
   • Bupropion, particularly if comorbid depression exists 2

Special Considerations

• Atomoxetine is metabolized through CYP2D6 pathway - be aware of potential drug interactions with SSRIs 1
• Atomoxetine carries negligible risk of abuse or diversion and is not a controlled substance, making it advantageous for patients with substance use concerns 3, 5
• Atomoxetine has shown efficacy in patients with comorbid anxiety, tics, or oppositional defiant disorder 6

Common Pitfalls to Avoid

• Underdosing atomoxetine is a common reason for apparent treatment failure 2
• Expecting immediate results from atomoxetine (unlike stimulants, it takes 6-12 weeks for full effect) 2
• Failing to address comorbid conditions like anxiety and depression that can mimic or exacerbate ADHD symptoms 2
• Not allowing adequate trial duration before concluding treatment failure 2

By following this approach, you can provide effective medication management for patients with ADHD who have previously taken Focalin and require an alternative treatment option.