What are non-stimulant treatment options for adults with Attention Deficit Hyperactivity Disorder (ADHD), including doses?

Non-Stimulant Treatment Options for Adults with ADHD

For adults with ADHD requiring non-stimulant treatment, atomoxetine is the first-line non-stimulant option, starting at 0.5 mg/kg/day and titrating to a target dose of 1.2 mg/kg/day (maximum 1.4 mg/kg/day or 100 mg/day, whichever is lower). 1

First-Line Non-Stimulant Option

Atomoxetine (Strattera)

• Dosing regimen:

  • Starting dose: 0.5 mg/kg/day
  • Target dose: 1.2 mg/kg/day
  • Maximum dose: 1.4 mg/kg/day or 100 mg daily (whichever is lower)
  • Dose adjustment: Every 7-14 days
  • Administration: Can be given once daily or divided into two doses 1, 2

• Key advantages:

  • First non-stimulant approved by FDA specifically for adult ADHD 2
  • Negligible risk of abuse or diversion (not a controlled substance) 2, 3
  • Demonstrated efficacy in well-controlled adult trials with 28-30% reduction in ADHD symptoms 2, 3

• Best for patients with:

  • Comorbid anxiety disorders 1
  • Tic disorders/Tourette's syndrome 1
  • Substance use disorders 1, 3
  • Patients who do not wish to take controlled substances 3

• Common side effects:

  • Dry mouth, insomnia, nausea, decreased appetite, constipation
  • Dizziness, sweating, urinary difficulties, sexual problems
  • Modest increases in heart rate and blood pressure 2, 3

Alternative Non-Stimulant Options

Bupropion

• Indications:

  • Particularly beneficial for patients with comorbid depression and ADHD 1
  • Preferred for patients with substance use disorders due to lower abuse potential 1
  • May be considered during pregnancy or breastfeeding as an alternative to stimulants 1

• Caution:

  • Not as efficacious as stimulants for ADHD treatment 1
  • Specific dosing for ADHD not provided in guidelines, but typically follows depression dosing protocols

Guanfacine

• Monitoring requirements:
  • Regular blood pressure and heart rate monitoring due to potential hypotension
  • Watch for excessive sedation, especially during initial titration 1

Viloxazine

• Recently studied non-stimulant with demonstrable efficacy 4
• Shares noradrenergic mechanism similar to atomoxetine

Treatment Algorithm for Non-Stimulant Selection

1. First attempt: Atomoxetine at recommended dosing

   • Start at 0.5 mg/kg/day
   • Titrate to 1.2 mg/kg/day over 2-4 weeks
   • Allow 4-6 weeks at target dose to assess full efficacy

2. If inadequate response or intolerable side effects:

   • Consider bupropion, especially with comorbid depression
   • Consider guanfacine, particularly if hyperactivity/impulsivity are prominent

3. For specific comorbidities:

   • Anxiety disorders → Atomoxetine preferred 1, 5
   • Tic disorders → Atomoxetine preferred 1
   • Substance use disorders → Atomoxetine or bupropion 1, 3
   • Depression → Bupropion preferred 1

Important Monitoring Considerations

• Schedule follow-up within 2-4 weeks after initiating treatment
• Monitor vital signs at each visit
• Assess for side effects including:
  • Insomnia, appetite changes, mood effects
  • Sexual dysfunction (occurs in approximately 2% of patients on atomoxetine) 5
• Use caution in patients with hypertension or significant cardiovascular disorders 5

Adjunctive Non-Pharmacological Interventions

• Cognitive Behavioral Therapy (CBT) - most extensively studied psychotherapy for adult ADHD
• Mindfulness-Based Interventions (MBIs) - help with inattention symptoms and emotion regulation
• Psychoeducation - decreases disorganization and inattention, increases self-confidence 1

Common Pitfalls to Avoid

• Expecting immediate results - non-stimulants typically take longer to show full efficacy compared to stimulants
• Inadequate dosing - ensure proper weight-based dosing for atomoxetine
• Insufficient trial duration - allow 4-6 weeks at target dose before determining efficacy
• Combining multiple serotonergic drugs without appropriate monitoring for serotonin syndrome 1
• Discontinuing treatment prematurely due to initial side effects, which often diminish over time