Guanfacine (Intuniv) Dosage and Treatment Guidelines for ADHD
For patients with ADHD, guanfacine extended release (Intuniv XR) should be initiated at 1 mg once daily and titrated by 1 mg weekly based on response and tolerability to a recommended target dose range of 0.05 to 0.12 mg/kg/day or 1 to 7 mg/day. 1
Dosing Recommendations
- Start with 1 mg once daily 1
- Titrate dose by 1 mg weekly based on clinical response and tolerability 1
- Target dose range: 0.05 to 0.12 mg/kg/day or 1 to 7 mg/day 1
- Maximum daily dose should not exceed 7 mg 1
Age-Specific Recommendations
- Approved for children and adolescents aged 6-17 years 1
- For elementary school-aged children (6-11 years), guanfacine extended release is FDA-approved, though evidence is stronger for stimulant medications 1
- For adolescents (12-18 years), guanfacine can be prescribed as part of ADHD treatment 1
- Limited data available on efficacy for adults with ADHD 1
Clinical Efficacy
- Significantly reduces ADHD symptoms compared to placebo with effect sizes ranging from 0.59-0.92 2, 3
- Effective for both core ADHD symptoms (inattention, hyperactivity, impulsivity) and oppositional symptoms 2, 4
- Response rates of approximately 58-64% compared to 29-40% for placebo 3
- Benefits can be sustained over long-term treatment (up to 24 months) 4
Monitoring and Safety Considerations
Most common treatment-emergent adverse events include:
Sedation-related side effects are most common during dose titration but typically resolve over time 2, 4
Monitor for modest changes in blood pressure and heart rate 5, 6
Not recommended for patients with significant cardiovascular history 5
Place in Therapy
- Guanfacine extended release is generally considered a second-line medication for ADHD after stimulants 3
- May be particularly useful when:
Important Considerations
- Guanfacine extended release (Intuniv XR) is not substitutable on a mg-for-mg basis with immediate-release guanfacine due to different pharmacokinetics 5
- Abrupt discontinuation should be avoided; taper gradually to minimize rebound effects 2
- Combination therapy with stimulants may be beneficial in some cases, though this should be approached with caution 1
- For children with intellectual disability and ADHD, guanfacine may be effective, though evidence is more limited than for methylphenidate 1
Clinical Pearls
- Sedation is the most common side effect but tends to improve with continued treatment 2, 4
- Once-daily dosing may improve adherence compared to multiple daily doses required with immediate-release formulations 4, 6
- Consider morning dosing to minimize daytime sedation, though individual response may vary 4
- Allow adequate time (4-8 weeks) at therapeutic doses to assess full clinical response 3