What are non-stimulant medication options for adults with Attention Deficit Hyperactivity Disorder (ADHD)?

Non-Stimulant Medication Options for Adults with ADHD

Atomoxetine is the first-line non-stimulant medication for adults with ADHD due to its proven efficacy, once-daily dosing, and lack of abuse potential. 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/day (whichever is lower)
  • Dose adjustments typically every 7-14 days 1, 2
  • Can be administered once daily in the morning or divided into morning and late afternoon doses 2

• Key advantages:

  • FDA-approved specifically for adult ADHD
  • No abuse potential, making it ideal for patients with substance use disorders 1, 3
  • Once-daily dosing improves medication adherence 1
  • Effective for both ADHD and comorbid anxiety or depression 1
  • Preferred for patients with tic disorders/Tourette's syndrome 1

• Common side effects:

  • Dry mouth, insomnia, nausea, decreased appetite, constipation
  • Dizziness, sweating, urinary issues, sexual problems, palpitations 4, 5
  • Modest increases in heart rate and blood pressure (typically resolve upon discontinuation) 5

Second-Line Non-Stimulant Options

Bupropion

• Key advantages:

  • Beneficial for patients with comorbid depression and ADHD 1
  • Lower abuse potential compared to stimulants 1
  • May be considered for pregnant or breastfeeding individuals 1

• Important precautions:

  • Use extreme caution when combining with medications that lower seizure threshold 6
  • Avoid concomitant use with MAO inhibitors (allow at least 14 days between discontinuing one and starting the other) 6
  • Monitor for potential drug interactions, especially with CYP2D6 substrates 6

Other Non-Stimulant Options

• Tricyclic antidepressants:

  • Shown efficacy in ADHD treatment
  • Limited by side effect profile 7

• Alpha-2-adrenergic agonists (e.g., guanfacine):

  • Some evidence for efficacy in adult ADHD 8
  • Less extensively studied than atomoxetine

• Viloxazine:

  • Newer non-stimulant option with noradrenergic activity 8

Treatment Selection Algorithm

1. For patients with substance use concerns:

   • Atomoxetine is the first choice due to no abuse potential 1, 3
   • Bupropion as an alternative 1

2. For patients with comorbid conditions:

   • Anxiety disorders: Atomoxetine (though may increase anxiety in some patients with GAD) 1
   • Depression: Atomoxetine or bupropion 1
   • Tic disorders: Atomoxetine 1

3. For patients with cardiovascular concerns:

   • Use atomoxetine with caution and monitor blood pressure and heart rate 3

4. For patients requiring once-daily dosing:

   • Atomoxetine can be administered once daily in the morning 2

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks after initiating treatment
• Monitor vital signs, side effects, and treatment effectiveness
• Assess for emerging comorbidities and evaluate functional improvement across settings 1

Combination with Non-Pharmacological Approaches

• Cognitive Behavioral Therapy (CBT) is the most extensively studied psychotherapy for adult ADHD and increases effectiveness when combined with medication 1
• Mindfulness-Based Interventions (MBIs) help with inattention symptoms, emotion regulation, and executive function 1
• Psychoeducation decreases disorganization and inattention while increasing self-confidence 1