What are the suggested alternatives for a patient with Attention Deficit Hyperactivity Disorder (ADHD) combined type who experiences tachycardia on both immediate and extended-release (XR) formulations of Adderall (amphetamine and dextroamphetamine)?

Alternative Medications for ADHD Combined Type with Tachycardia on Adderall

For a 25-year-old male with ADHD combined type experiencing tachycardia on both immediate and extended-release Adderall formulations, atomoxetine (Strattera) is the recommended first-line alternative medication. 1

Non-Stimulant Options

First-Line Alternative: Atomoxetine

• Atomoxetine is a selective norepinephrine reuptake inhibitor that provides "around-the-clock" symptom control 1
• Unlike stimulants, atomoxetine is not associated with significant increases in heart rate in most patients, making it suitable for those with tachycardia 2
• Typical dosing ranges from 40-100mg daily, with effects typically seen after 6-12 weeks of treatment 1
• Not a controlled substance, which may be beneficial for patients with substance use concerns 1

Second-Line Alternatives: Alpha-2 Adrenergic Agonists

• Extended-release guanfacine and extended-release clonidine are effective options for patients who cannot tolerate stimulants 1
• These medications may actually lower blood pressure and heart rate, potentially beneficial for a patient with tachycardia 1
• Common side effects include somnolence, fatigue, and hypotension 1
• Effects typically observed after 2-4 weeks of treatment 1
• Clonidine may require twice-daily dosing, while guanfacine is typically once-daily 1

Monitoring Recommendations

• Baseline and follow-up measurements of blood pressure and heart rate should be performed 2
• For atomoxetine, monitor for potential psychiatric side effects including suicidal ideation, particularly in the first few months of treatment 2
• For alpha-2 agonists, monitor for excessive sedation and hypotension 1
• All non-stimulant medications have a smaller effect size (approximately 0.7) compared to stimulants (approximately 1.0), so expectations should be managed accordingly 1

Special Considerations

• Amphetamines and other stimulants are known to potentially increase blood pressure and heart rate, which explains the patient's tachycardia 1
• The American College of Cardiology/American Heart Association guidelines recommend discontinuing or decreasing the dose of amphetamines when they cause elevated blood pressure 1
• Consider behavioral therapies as an adjunctive treatment regardless of medication choice 1
• If non-stimulant monotherapy is insufficient, some evidence supports combination therapy (e.g., atomoxetine plus behavioral therapy) 1

Clinical Pitfalls to Avoid

• Don't assume all stimulants will cause the same cardiovascular effects; however, given that the patient has already tried both immediate and extended-release Adderall formulations with similar results, other stimulants are likely to cause similar issues 3
• Avoid abrupt discontinuation of alpha-2 agonists (guanfacine, clonidine) as this can cause rebound hypertension 1
• Remember that non-stimulants typically take longer to show full therapeutic effects (6-12 weeks for atomoxetine, 2-4 weeks for alpha-2 agonists) compared to stimulants 1
• Don't overlook the potential for psychiatric side effects with atomoxetine, including rare cases of suicidal ideation 2