Non-Stimulant ADHD Medications Available in Chewable or Liquid Form
Pemoline (PEM) is available as a chewable, strawberry-flavored 37.5 mg tablet for patients who cannot tolerate other ADHD medications. 1
Available Non-Stimulant Formulations
Chewable Options
- Pemoline is available as a chewable, strawberry-flavored tablet in 37.5 mg strength, which may be preferred by some children who have difficulty swallowing pills 1
- This medication should only be considered after failing trials of stimulants and other non-stimulant medications due to risk of severe hepatic failure 1
Liquid Options
- Currently, the major FDA-approved non-stimulant medications (atomoxetine, guanfacine XR, clonidine XR, and viloxazine) are not widely available in liquid formulations 2
- The last two decades have seen an increase in novel delivery systems for ADHD medications, but these have primarily focused on stimulant medications rather than non-stimulants 2
Clinical Considerations for Non-Stimulant Medications
FDA-Approved Non-Stimulants
- Atomoxetine (Strattera): Available in capsule form only; works by inhibiting presynaptic norepinephrine transporter 2
- Guanfacine extended-release: Available in tablet form (1,2,3, and 4 mg); alpha-2 adrenergic agonist 2
- Clonidine extended-release: Available in tablet form (0.1 and 0.2 mg); alpha-2 adrenergic agonist 2
- Viloxazine: Newer norepinephrine reuptake inhibitor; not available in liquid or chewable form 3
Important Prescribing Considerations
- Non-stimulants generally have medium effect sizes compared to the larger effect sizes seen with stimulants 2, 4
- Non-stimulants require several weeks to reach full effectiveness (atomoxetine: 6-12 weeks; clonidine/guanfacine: 2-4 weeks) 2
- These medications provide "around-the-clock" effects rather than time-limited coverage 2
Safety Considerations with Pemoline
- Pemoline carries significant risk of severe hepatic failure requiring liver function monitoring 1
- Parents must sign written informed consent acknowledging risk of liver failure and death 1
- Baseline liver function tests and biweekly monitoring of ALT are required 1
- Maximum dose is 112.5 mg/day, with titration in 18.75 or 37.5 mg increments every 3 days 1
Alternative Approaches
- For patients who cannot swallow pills and require non-stimulant options, consider:
- Consulting with a compounding pharmacy about the possibility of creating liquid formulations of atomoxetine or other non-stimulants (though this would be off-label) 3
- Exploring behavioral therapy as a primary treatment, especially for younger children (4-5 years) 4
- Considering transdermal clonidine patch (available in 0.1,0.2, and 0.3 mg dosages) as an alternative non-oral administration route 2
Common Side Effects of Non-Stimulants
- Atomoxetine: Initial somnolence, gastrointestinal symptoms, decreased appetite, rare risk of suicidal thoughts 5, 4
- Guanfacine/Clonidine: Somnolence, fatigue, dry mouth, dizziness, irritability, hypotension, bradycardia 2, 5
- Evening administration of clonidine and guanfacine is generally preferred due to sedation effects 2
The limited availability of non-stimulant ADHD medications in chewable or liquid formulations represents a significant gap in treatment options for patients who have difficulty swallowing pills or require non-stimulant therapy.