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

Non-Stimulant Medications for Adult ADHD

Atomoxetine is the most established non-stimulant medication for treating ADHD in adults, with other effective options including bupropion and viloxazine. 1

First-Line Non-Stimulant Options

Atomoxetine (Strattera)

• FDA-approved specifically for adult ADHD 2
• Mechanism: Selective norepinephrine reuptake inhibitor 3
• Dosing:
  • Starting dose: 0.5 mg/kg/day 1
  • Target dose: 1.2 mg/kg/day (maximum 1.5 mg/kg/day) 1, 4
  • Can be administered once daily in the morning or as divided doses 4
• Efficacy:
  • Clinical trials show 28-30% reduction in ADHD symptoms compared to 18-20% with placebo 2
  • Maintains effectiveness in long-term treatment 4
• Advantages:
  • Not a controlled substance (no abuse potential) 2
  • Can be particularly useful for patients with substance use disorders 1

Bupropion

• Mechanism: Norepinephrine and dopamine reuptake inhibitor 5
• Dosing:
  • Starting dose: 100-150 mg daily (sustained-release) or 37.5 mg every morning 1
  • Target dose: 150 mg twice daily 1
• More effective than placebo in adults with ADHD 5
• Particularly useful when ADHD co-occurs with depression 6

Viloxazine

• Recently shown to be significantly more efficacious than placebo in treating ADHD in adults 5
• Newer option with demonstrated effectiveness 6

Second-Line Non-Stimulant Options

Guanfacine (Intuniv)

• Alpha-2 adrenergic agonist 1
• Starting dose: 0.1 mg/kg once daily 1
• Particularly useful when ADHD co-occurs with tics 1
• Can be combined with stimulants for enhanced effectiveness 1

Considerations for Medication Selection

1. Comorbid Conditions:

   • For ADHD with anxiety/depression: Consider atomoxetine or bupropion 1
   • For ADHD with substance use disorders: Non-stimulants preferred due to lower abuse potential 1
   • For ADHD with tics: Consider guanfacine 1

2. Side Effect Profiles:

   • Atomoxetine: Most common side effects include dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sexual problems 2
   • Bupropion: Side effects may include insomnia, headache, dry mouth
   • Guanfacine: May cause sedation, fatigue, hypotension

3. Monitoring Requirements:

   • Regular assessment of ADHD symptoms using standardized scales
   • Monitor blood pressure and heart rate, especially with atomoxetine 1
   • Watch for suicidal ideation, particularly when initiating treatment 1

Optimizing Treatment Outcomes

• Combine medication with Cognitive Behavioral Therapy (CBT) for best results 1
• Allow adequate trial period (4-8 weeks) to assess full effectiveness
• Consider once-daily dosing of atomoxetine for improved adherence 4

Important Precautions

• Avoid combining atomoxetine with monoamine oxidase inhibitors due to risk of serotonin syndrome 1
• Use caution with medications that can reduce blood pressure 1
• Monitor for cardiovascular effects, especially in patients with pre-existing conditions 3

Non-stimulant medications provide valuable alternatives for adults with ADHD who cannot tolerate stimulants, have contraindications to stimulant use, or have comorbid conditions where stimulants may be problematic.