What is the standard practice for treating new adult Attention Deficit Hyperactivity Disorder (ADHD) diagnoses, especially when there are concerns about medication specificity?

Standard Practice for New Adult ADHD Diagnosis Treatment

For newly diagnosed adults with ADHD, non-stimulant medications such as atomoxetine, extended-release guanfacine, or extended-release clonidine are recommended as first-line treatment when there are concerns about medication specificity, substance abuse potential, or diversion risk. 1

Initial Medication Selection Algorithm

• Evaluate for substance abuse history before initiating any ADHD medication treatment 1
• Consider non-stimulant medications first when:
  • There is concern about medication diversion or misuse 1
  • Patient has history of substance abuse 1, 2
  • Medication specificity is a concern 2
  • There is comorbid anxiety that might be exacerbated by stimulants 1

Non-Stimulant Medication Options

• Atomoxetine (Strattera) is the most extensively studied non-stimulant for adult ADHD:

  • Starting dose: 40 mg daily, increased after minimum 3 days 3
  • Target dose: approximately 80 mg daily (single dose or divided) 3
  • Maximum dose: 100 mg daily 3
  • No abuse potential, making it suitable for patients with substance abuse concerns 1, 4

• Extended-release guanfacine (Intuniv) and extended-release clonidine (Kapvay):

  • Alpha-2 adrenergic agonists with no abuse potential 1
  • Particularly useful when there are concerns about stimulant misuse 1
  • Note: While recommended in guidelines, these medications are only FDA-approved for children and adolescents in the US 5

• Bupropion:

  • Has shown anecdotal benefits in adults with ADHD 1, 2
  • May be considered when atomoxetine is not tolerated or ineffective 2

Efficacy Considerations

• Non-stimulants have demonstrated efficacy but with smaller effect sizes compared to stimulants:
  • Stimulants: effect size approximately 1.0 1
  • Non-stimulants: effect size approximately 0.7 1, 6
  • Atomoxetine has shown significant efficacy in treating adult ADHD in multiple studies 4, 6

Special Considerations

• When comorbidities are present:

  • If depression is primary or severe, treat depression first 1, 2
  • If depression is secondary or mild, a trial of non-stimulant ADHD medication may be appropriate 2
  • For anxiety comorbidity, non-stimulants may be preferred initially 1, 2

• Monitoring requirements:

  • Screen for bipolar disorder before starting atomoxetine 3
  • Monitor for suicidal ideation, particularly during the first few months of atomoxetine treatment 3
  • Periodically reevaluate the need for continued medication 3

Treatment Progression

• If non-stimulants are ineffective after adequate trial (typically 4-6 weeks):

  • Consider stimulants with lower abuse potential such as lisdexamfetamine, OROS methylphenidate, or dermal methylphenidate 1
  • For patients with documented substance abuse history, maintain close monitoring if stimulants are prescribed 1, 2

• For patients who fail to respond to both non-stimulants and stimulants:

  • Consider combination therapy approaches 7
  • Reevaluate diagnosis and assess for comorbidities that might be complicating treatment 1, 7

Common Pitfalls to Avoid

• Underestimating diversion risk: Adults with ADHD and substance use disorders require careful monitoring for medication misuse 1, 2
• Inadequate dosing: Ensure atomoxetine reaches target dose of 80mg daily before determining lack of efficacy 3
• Premature discontinuation: Non-stimulants may take longer to show full therapeutic effect compared to stimulants 8
• Relying solely on self-report: Adults with ADHD may be unreliable reporters of their own behaviors; consider obtaining collateral information 1, 2