What medications are used to treat Attention Deficit Hyperactivity Disorder (ADHD)?

Medications for ADHD Treatment

Stimulant medications (methylphenidate and amphetamine-based) are the first-line pharmacological treatment for ADHD due to their superior efficacy (effect size ~1.0), while non-stimulants like atomoxetine, extended-release guanfacine, and extended-release clonidine are effective alternatives (effect size ~0.7). 1

First-Line Medications

Stimulants

1. Methylphenidate (MPH)

   • Formulations:
     • Immediate-release (MPH-IR): Effects last ~4 hours 2
     • Extended-release (MPH-ER): Effects last 8-12 hours 2
     • OROS-MPH (osmotic pump system): Effects last up to 12 hours 2
   • Mechanism: Blocks dopamine reuptake, enhancing prefrontal cortex functioning 1
   • Dosing:
     • Start low (10-15 mg/day)
     • Increase by 10-15 mg weekly
     • Maximum: 60-72 mg/day depending on formulation 3

2. Amphetamine-based medications

   • Formulations:
     • Lisdexamfetamine (LDX)
     • Various extended-release formulations
   • Maximum dose: Up to 70 mg/day for LDX 3

Key considerations for stimulants:

• Rapid onset of action (30 minutes)
• Maximum behavioral effects occur during increasing plasma concentrations
• Regular monitoring of vital signs required due to cardiovascular effects
• Common side effects: insomnia, appetite suppression, rebound irritability 1

Second-Line Medications (Non-stimulants)

1. Atomoxetine (Strattera)

   • Mechanism: Selectively inhibits norepinephrine transporters 1
   • Indications: FDA-approved for ADHD treatment 4
   • Dosing:
     • Starting dose: 0.5 mg/kg/day
     • Target dose: 1.2 mg/kg/day
     • Maximum: 1.4 mg/kg/day or 100 mg/day (whichever is lower) 1
   • Advantages: Lower abuse potential, preferred for patients with substance use concerns 1

2. Alpha-2 Adrenergic Agonists

   • Guanfacine extended-release (GXR)
     • Maximum dose: 6 mg/day 3
   • Clonidine extended-release
     • Maximum dose: 0.4 mg/day 3

Treatment Algorithm

1. Initial Assessment:

   • Confirm ADHD diagnosis using DSM criteria
   • Assess for comorbidities (anxiety, depression, substance use)
   • Consider contraindications to stimulant use

2. Medication Selection:

   • First choice: Methylphenidate (for most patients without contraindications)
   • Alternative first choice: Amphetamine-based medications
   • For patients with substance use concerns or stimulant contraindications: Atomoxetine

3. Titration Process:

   • Start with low dose
   • Increase gradually every 1-2 weeks
   • Adjust based on symptom control and side effects
   • Continue until optimal response or maximum tolerated dose

4. Monitoring:

   • Follow-up within 2-4 weeks after medication changes
   • Regular monitoring of vital signs, especially with stimulants
   • Assess for side effects: insomnia, appetite changes, mood effects
   • Monitor growth in children and adolescents

Special Considerations

• Adults with ADHD: May benefit from combined pharmacotherapy and psychotherapy 5
• Long-term safety: 2-year data shows methylphenidate is generally safe with minimal impact on growth when properly monitored 6
• Drug interactions: Use caution when combining atomoxetine with serotonergic medications (SSRIs, St. John's wort, triptans) due to risk of serotonin syndrome 1

Regional Availability

Medication availability varies by country, with most Asian countries having access to methylphenidate and atomoxetine, while fewer have access to guanfacine and lisdexamfetamine 3.

Remember that medication is most effective when used as part of a comprehensive treatment program that may include behavioral interventions, parent training, and educational support 4.