Could Intuniv (guanfacine) be helpful for a patient with Disruptive Mood Dysregulation Disorder (DMDD) and Attention Deficit Hyperactivity Disorder (ADHD)?

Guanfacine (Intuniv) for ADHD and DMDD

Guanfacine is an appropriate treatment option for patients with comorbid ADHD and Disruptive Mood Dysregulation Disorder (DMDD), particularly when stimulants are unsuitable or insufficient alone. 1

Treatment Algorithm for ADHD with DMDD

First-Line Approach

1. Stimulant medications remain first-line for ADHD due to superior efficacy (effect size 1.0) compared to non-stimulants 1
2. If stimulants are:
   • Not fully effective
   • Limited by side effects
   • Contraindicated
   • Complicated by comorbid conditions like DMDD

Role of Guanfacine

• Extended-release guanfacine (Intuniv) is indicated for ADHD in children and adolescents aged 6-17 years 2
• Particularly valuable as:
  • Adjunctive therapy with stimulants when stimulant monotherapy is insufficient 1
  • Alternative when stimulants are unsuitable
  • Option when mood dysregulation or irritability are prominent features

Evidence for Efficacy

ADHD Symptoms

• Guanfacine significantly improves core ADHD symptoms of inattention and hyperactivity-impulsivity compared to placebo 2
• As a non-stimulant α2A-adrenoceptor agonist, it offers a different mechanism of action than stimulants 3
• Improvements in ADHD symptoms typically begin within 3 weeks of treatment initiation 3

Mood Regulation

• Alpha-2 agonists like guanfacine can help manage irritability and impulsivity 4
• May be particularly helpful for DMDD symptoms given its effects on prefrontal cortical functioning and emotional regulation

Dosing Considerations

• Start with lower doses and titrate gradually
• Not substitutable on a mg-for-mg basis with immediate-release guanfacine due to different pharmacokinetics 2
• Doses of 1-4 mg/day have shown efficacy in clinical trials 2

Monitoring and Side Effects

Common Side Effects

• Sedation (most common) 5
• Fatigue 6
• Modest reductions in blood pressure and heart rate 2

Important Monitoring

• Regular vital sign monitoring required during treatment 2
• Must be tapered gradually when discontinuing to prevent rebound hypertension 1
• Not appropriate for children with clinically significant cardiovascular history 2

Special Considerations

• May be particularly useful when ADHD is complicated by:
  • Oppositional defiant symptoms 2
  • Tic disorders 1
  • Sleep disturbances 1
  • Impulsive aggression 2

Combination Therapy

• Combining guanfacine with behavioral interventions offers the best chance for symptom improvement 1
• Can be used in combination with SSRIs when OCD or anxiety symptoms are present 7
• May be used as adjunctive therapy with stimulants for enhanced ADHD symptom control 1

Caution

• Avoid in patients with significant cardiovascular disease 2
• Carefully monitor for sedation, especially during initial titration
• Regular follow-up within 2-4 weeks of medication initiation is recommended 1

For a patient with both ADHD and DMDD, guanfacine offers a valuable treatment option that can address both the attentional symptoms and mood dysregulation components of these disorders, either as monotherapy or as part of a combination approach.