What are the common medications and doses used to treat Attention Deficit Hyperactivity Disorder (ADHD)?

Medications and Dosages for ADHD Treatment

Stimulant medications are recommended as first-line pharmacological treatment for ADHD due to their large effect sizes and rapid onset of action, with non-stimulants recommended as second-line therapy. 1

First-Line Medications: Stimulants

Methylphenidate (MPH)

• Available in immediate-release (IR), extended-release (ER), and osmotic-controlled release oral delivery system (OROS) formulations 1
• Mechanism: Reuptake inhibition of dopamine and norepinephrine 1
• Dosing:
  • Children and adolescents: Starting dose typically lower with titration based on response
  • Maximum doses vary by formulation and region:
    • MPH-IR: 60 mg/day 1
    • OROS-MPH: 54-72 mg/day 1
• Common side effects: Decreased appetite, sleep disturbances, increased blood pressure/pulse, headaches 1
• Monitoring required: Height, weight, pulse, blood pressure 1

Amphetamines

• Includes lisdexamfetamine (LDX) and mixed amphetamine salts 1
• Mechanism: Reuptake inhibition plus release of dopamine and norepinephrine 1
• Dosing:
  • LDX: Maximum dose 70 mg/day 1
  • Amphetamine formulations: Dosing varies by preparation
• Side effects: Similar to methylphenidate 1
• Monitoring: Same as methylphenidate 1

Second-Line Medications: Non-Stimulants

Atomoxetine

• Mechanism: Selective norepinephrine reuptake inhibitor 1, 2
• Dosing:
  • Starting dose: Approximately 0.5 mg/kg/day 2
  • Target dose: 1.2-1.8 mg/kg/day 2
  • Maximum dose: 100 mg/day or 1.4-1.8 mg/kg/day (whichever is less) 1
• Onset of action: 6-12 weeks until full effects observed 1
• Side effects: Decreased appetite, headache, stomach pain, potential suicidal ideation (carries FDA black box warning) 1, 2
• Monitoring: Suicidality, clinical worsening, pulse 1, 2

Alpha-2 Adrenergic Agonists

• Includes guanfacine extended-release (GXR) and clonidine 1
• Mechanism: Agonism at alpha-2 adrenergic receptors 1
• Dosing:
  • Guanfacine ER: Maximum 6 mg/day 1
  • Clonidine: Maximum 0.4 mg/day 1
• Onset of action: 2-4 weeks until effects observed 1
• Side effects: Somnolence/sedation, fatigue, hypotension, irritability 1
• Monitoring: Pulse, blood pressure 1

Treatment Selection Algorithm

1. Initial Assessment:

   • For children 6 years and older and adults: Consider stimulants as first-line 1
   • For preschool-aged children (4-5 years): Consider behavioral therapy first; methylphenidate if needed for moderate-to-severe symptoms 1

2. First-Line Treatment:

   • Start with methylphenidate or amphetamine-based stimulant 1
   • Select formulation based on:
     • Duration of symptom control needed 1
     • Need for in-school dosing (extended-release formulations reduce this need) 3
     • Patient/family preference 1

3. If First-Line Treatment Fails:

   • If methylphenidate ineffective, switch to lisdexamfetamine 1
   • If stimulants ineffective or contraindicated, switch to non-stimulants 1

4. Special Considerations:

   • For comorbid substance use disorders, tics/Tourette's, or sleep disorders: Consider non-stimulants as first-line 1
   • For patients requiring 24-hour symptom control: Consider non-stimulants for "around-the-clock" effects 1

Important Clinical Considerations

• Medication Adjustments: Changes to medication regimens are common and should be expected due to changes in symptomatology, psychosocial situation, or normal development (e.g., weight gain) 1

• Regional Variations: Treatment approaches vary globally; Japanese guidelines recommend psychosocial interventions as first-line with medications as second-line, while Western guidelines typically recommend medications as first-line 1

• Safety Concerns:

  • Stimulants are controlled substances due to potential for misuse 1
  • Atomoxetine carries a black box warning for increased risk of suicidal ideation in children and adolescents 2
  • Alpha-2 agonists should be tapered rather than abruptly discontinued to avoid rebound hypertension 1

• Medication Combinations: Extended-release guanfacine and clonidine are FDA-approved for use as adjunctive therapy with stimulants when stimulant monotherapy is not fully effective 1