Clonidine Dosing for ADHD
For ADHD treatment, clonidine should be initiated at 0.05-0.1 mg at bedtime with titration by increasing the dose by 0.1 mg BID-TID to a maximum of 0.4 mg per day. 1
Dosage Guidelines
Initial Dosing
- Start with 0.05-0.1 mg at bedtime
- Gradually titrate by increasing dose by 0.1 mg BID-TID
- Target effective dose range: 0.2-0.4 mg/day
- Maximum daily dose: 0.4 mg/day
- Typically administered in 2-4 divided doses daily 1
Age-Specific Considerations
- Not recommended for children under 6 years of age 1
- Same dosing parameters apply for both children (6-12 years) and adolescents (13-17 years)
- Extended-release formulation is FDA-approved for ADHD in children and adolescents aged 6-17 years 2
Formulations
- Immediate-release tablets (0.1 mg)
- Extended-release tablets (available in various strengths)
The extended-release formulation may offer advantages of more consistent blood levels and potentially fewer side effects compared to immediate-release formulation 2.
Monitoring and Precautions
Baseline Assessment
- Personal and family cardiac history should be obtained
- ECG should be considered if cardiac risk factors are present 1
- Assess for depression (contraindication) 1
- Screen for substance abuse in adolescents 1
Side Effect Monitoring
- Most common side effects: sedation/somnolence (especially during first 2 weeks), dry mouth, dizziness, irritability, headache 1
- Cardiovascular effects: monitor for bradycardia and hypotension 1
- 31% of patients may experience mild adverse effects 3
Drug Interactions
- Use caution with concomitant CNS depressants which may potentiate sedative effects 1
- Avoid abrupt discontinuation due to risk of rebound hypertension
Clinical Efficacy
- Clonidine is more effective for hyperactivity and impulsivity than for inattention 1
- In children with comorbid ADHD and tic disorders, clonidine has shown particular efficacy (96% positive response) compared to those without tic disorders (53% response) 4
- Clonidine has also shown efficacy for ADHD-associated sleep disturbances, with 85% of patients showing improvement 3
Comparative Considerations
Clonidine vs. Guanfacine
- Clonidine is approximately 10× more potent than guanfacine
- Clonidine affects all alpha-2 subtypes (A, B, C) while guanfacine is alpha-2A selective
- Clonidine has more pronounced sedative effects
- Guanfacine has a more favorable side effect profile with less sedation 1
Treatment Algorithm
- First-line: Stimulant medications (methylphenidate or amphetamine derivatives)
- Second-line: Non-stimulant medications including alpha-2 agonists (clonidine, guanfacine) or norepinephrine reuptake inhibitors (atomoxetine, viloxazine) 5
- Combination therapy: Clonidine can be used as monotherapy or added to stimulants for augmentation 5, 6
Clonidine is particularly useful for patients who:
- Cannot tolerate stimulants
- Have incomplete response to stimulants
- Are at risk for stimulant diversion
- Have comorbid tic disorders
- Experience ADHD-related sleep disturbances
- Have families who prefer to avoid stimulants 5
Remember that treatment response should be assessed after approximately 2 weeks, as symptomatic improvement has been observed following this timeframe 2.