What medication can help a 15-year-old boy with Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depression, and a history of dyslexia, who has not tolerated Vyvanse (lisdexamfetamine) and Adderall (amphetamine and dextroamphetamine) due to increased weight loss and failed a trial of Zoloft (sertraline)?

Medication Recommendation for a 15-Year-Old with ADHD, Anxiety, Depression, and Dyslexia

Atomoxetine (Strattera) is the most appropriate medication choice for this 15-year-old boy with ADHD, anxiety, depression, and dyslexia who experienced weight loss with stimulants and failed a trial of Zoloft. 1, 2

Rationale for Atomoxetine Selection

• Atomoxetine is recommended as a second-line therapy for ADHD after stimulant failure, making it appropriate for this patient who couldn't tolerate Vyvanse and Adderall due to weight loss 1
• Atomoxetine provides "around-the-clock" effects for ADHD symptoms, which is beneficial for a teenager with multiple comorbidities 1
• This medication is particularly suitable for patients with comorbid anxiety and depression, which are present in this case 1, 3
• Atomoxetine has a lower risk of appetite suppression and weight loss compared to stimulants, addressing a key concern with this patient's previous medication trials 2, 3

Dosing Recommendations

• For adolescents up to 70 kg: Start at 0.5 mg/kg/day and increase after a minimum of 3 days to a target dose of approximately 1.2 mg/kg/day 2
• For adolescents over 70 kg: Start at 40 mg/day and increase after a minimum of 3 days to a target dose of approximately 80 mg/day 2
• Atomoxetine can be administered either as a single daily dose in the morning or as evenly divided doses in the morning and late afternoon/evening 2
• It may take 6-12 weeks to observe the full therapeutic effects, unlike the rapid onset seen with stimulants 1, 3

Alternative Options if Atomoxetine Fails

If atomoxetine is not effective or not tolerated, consider these alternatives:

1. Extended-release guanfacine or clonidine:

   • Alpha-2 adrenergic agonists that provide "around-the-clock" effects 1
   • Particularly helpful for patients with comorbid sleep disorders, which may be relevant given the patient's anxiety and depression 1, 4
   • Start with low doses and titrate slowly, with effects typically observed within 2-4 weeks 1
   • Note: These medications should be tapered rather than abruptly discontinued to avoid rebound hypertension 5

2. Bupropion:

   • May be considered for ADHD with comorbid depression, though it has less robust evidence than atomoxetine 6, 7
   • Could address both ADHD symptoms and depression simultaneously 6

Important Monitoring Considerations

• Regular monitoring of height, weight, and vital signs is essential, particularly given the patient's history of weight loss with stimulants 2
• Monitor for potential side effects of atomoxetine, including:
  • Gastrointestinal symptoms (most common and typically transient) 3
  • Decreased appetite (though less severe than with stimulants) 2, 3
  • Headache and somnolence 1, 2
  • Suicidality (particularly important given comorbid depression) 1, 2

Potential Pitfalls and Caveats

• Atomoxetine requires daily compliance for effectiveness, unlike stimulants that work only when taken 5, 3
• Patient and family should be informed about the delayed onset of action (6-12 weeks for full effect) to manage expectations 1, 3
• Screen for bipolar disorder before initiating atomoxetine to avoid potential mood destabilization 2
• Consider that non-pharmacological interventions, particularly behavioral therapy, should complement medication treatment 1, 6

This treatment approach addresses both the ADHD symptoms and comorbid conditions while avoiding the weight loss experienced with stimulants and the ineffectiveness of Zoloft in this patient.