From the Guidelines
For a patient who has failed Strattera (Atomoxetine) and cannot use stimulants due to seizure development, I strongly recommend trying guanfacine (Intuniv) as the next treatment option for ADHD, given its "around-the-clock" effects and potential advantages in comorbid sleep disorder, substance use disorder, disruptive behavior disorders, and tic/Tourette's disorder. According to the evidence 1, guanfacine, an alpha-2 adrenergic agonist, is a viable option for ADHD treatment, especially when stimulants are contraindicated. Its mechanism of action, enhancing noradrenergic neurotransmission, differs from that of stimulants, which is beneficial in patients with seizure disorders.
Key Considerations
- Guanfacine is typically started at 1mg daily and can be titrated up to 4mg daily as needed 1.
- Regular monitoring of pulse, blood pressure, and potential adverse effects such as somnolence/sedation, fatigue, hypotension, and irritability is crucial 1.
- Non-pharmacological approaches, including cognitive behavioral therapy, organizational skills training, and environmental modifications, should be incorporated to complement medication therapy.
- Regular follow-up every 4-6 weeks during medication adjustment is important to monitor efficacy and side effects.
Alternative Options
- Clonidine (Kapvay) is another alpha-2 adrenergic agonist that could be considered, although it may require twice-daily dosing and has a higher risk of somnolence/sedation 1.
- Bupropion (Wellbutrin) is not recommended as a first-line alternative due to its potential risk of seizures at higher doses, despite its efficacy in ADHD treatment.
Prioritizing Patient Care
- Medication adherence should be regularly assessed, and potential issues openly discussed to ensure optimal treatment outcomes 1.
- Factors influencing adherence, such as patient attitudes, physician-patient relationship, family support, and knowledge about the disorder and medication, should be evaluated and addressed 1.
From the Research
Treatment Options for ADHD
Given the patient's failure to respond to Strattera (Atomoxetine) and the inability to use stimulants due to seizure development, alternative treatment options must be considered.
- The use of alpha2-adrenergic agonists, such as guanfacine and clonidine, has been studied as a potential treatment for ADHD, particularly in patients who cannot use stimulants 2, 3.
- A systematic review of randomized trials found that guanfacine and clonidine were significantly more efficacious than placebo in treating ADHD, although they may be less efficacious than stimulants like methylphenidate and amphetamine 4.
- In patients with comorbid ADHD and epilepsy, guanfacine and clonidine may be considered as alternative treatment options, as they have been shown to be effective in managing ADHD symptoms without exacerbating seizure activity 3, 5.
Considerations for Treatment
When selecting a treatment option, it is essential to consider the patient's individual needs and medical history.
- The patient's seizure disorder must be carefully managed, and any potential interactions between anti-epileptic medications and ADHD treatments must be considered 5.
- The use of non-stimulant medications, such as guanfacine and clonidine, may be preferred in patients with a history of seizure activity, as they may have a lower risk of exacerbating seizures compared to stimulants 3, 5.