What are the recommended treatments for Attention Deficit Hyperactivity Disorder (ADHD) in adults?

Treatment of ADHD in Adults

Stimulant medications (methylphenidate or amphetamines) are the recommended first-line treatment for adults with ADHD, with methylphenidate showing 78% response rates versus 4% with placebo. 1

First-Line Pharmacological Treatment: Stimulants

Methylphenidate

• Start with 5-20 mg three times daily, titrating to a total daily dose of approximately 1 mg/kg 1
• Extended-release formulations should be preferred to improve adherence, reduce rebound effects, and minimize diversion risk 2
• The maximum recommended daily dose is 60 mg 3
• Administer preferably 30-45 minutes before meals 3
• For patients with sleep difficulties, give the last dose before 6 PM 3

Dexamphetamine (Dextroamphetamine)

• Dose range: 5 mg three times daily up to 20 mg twice daily 1, 2
• Extended-release formulations offer similar advantages as methylphenidate ER 2

Key Advantages of Extended-Release Formulations

• Once-daily morning dosing improves compliance 2
• Reduced risk of manipulation and abuse (particularly important in adults) 1
• Minimizes afternoon/evening rebound symptoms 2
• Maintains privacy and reduces stigma 1

Second-Line Treatment: Atomoxetine

When to Use Atomoxetine First-Line

• Comorbid substance abuse disorder (stimulants are contraindicated or high-risk) 1, 2
• Severe anxiety disorders 4
• Pre-existing sleep disorders 4
• Patient preference for non-stimulant medication 5

Dosing

• Maximum dose: 1.4 mg/kg/day or 100 mg/day, whichever is lower 2, 5
• Titrate gradually based on clinical response 5
• Provides "around-the-clock" effects without rebound 4

Critical Safety Monitoring

• Monitor for suicidal ideation, especially during the first few months (FDA black box warning) 2, 5
• Monitor appetite and weight 4

Alternative Second-Line Options

• Bupropion has shown anecdotal benefits in adults with ADHD 1, 2
• Consider when stimulants are contraindicated or ineffective 6

Treatment Algorithm for Adults with ADHD

Step 1: Pre-Treatment Assessment

• Confirm ADHD diagnosis with documented onset in childhood 2
• Perform cardiac history and family history of sudden death or ventricular arrhythmia 3
• Screen for substance abuse with toxicology testing if indicated 2
• Evaluate all psychiatric comorbidities (depression, anxiety, tic disorders) 1
• Assess for motor/verbal tics or Tourette's syndrome 3

Step 2: Initial Treatment Selection

For patients WITHOUT substance abuse:

• Start methylphenidate ER or dexamphetamine ER 2
• Titrate to optimal dose based on response and tolerability 1

For patients WITH substance abuse history:

• Use atomoxetine as first-line 2, 4
• Consider close monitoring with extended-release stimulant formulations resistant to manipulation only if atomoxetine fails 2

Step 3: Managing Comorbid Depression

If depression is primary or severe (with psychosis, suicidality, or severe neurovegetative signs):

• Treat depression first 1, 2
• Re-evaluate ADHD symptoms after depression stabilizes 1

If depression is secondary or mild:

• Start with stimulant trial first 1, 2
• Rapid onset allows quick assessment of ADHD symptom response 1
• Reduction in ADHD-related morbidity often improves depressive symptoms 1
• If ADHD improves but depression persists, add cognitive behavioral therapy or SSRI 1, 2

Step 4: Managing Comorbid Anxiety

• Initiate stimulant trial even with comorbid anxiety, as stimulants improve both ADHD and anxiety symptoms in most cases 4
• If anxiety remains problematic after stimulant optimization, add psychosocial intervention or SSRI 2, 4
• Consider atomoxetine as first-line only if anxiety is severe with major avoidance or significant distress 4

Monitoring and Side Effects

Common Side Effects

• Loss of appetite, insomnia, and anxiety are the most common with stimulants 1, 2
• Transient increase in heart rate may occur (typically 5 bpm increase at week 4) 7

Ongoing Monitoring

• Evaluate cardiovascular parameters (blood pressure, pulse) regularly 4
• Assess continued need for treatment, including consideration of medication-free intervals 2
• Obtain collateral information from family members, as adults with ADHD are unreliable self-reporters 1, 2

Critical Warnings and Pitfalls

Substance Abuse Comorbidity

• This represents the highest risk scenario for stimulant prescription 1, 2
• Use atomoxetine preferentially 2
• If stimulants are necessary, use only extended-release formulations resistant to manipulation 2
• Implement close monitoring protocols 2

Abuse and Diversion Risk

• Methylphenidate has high potential for abuse, misuse, and addiction 3
• Assess each patient's risk before prescribing 3
• Educate patients about proper storage (preferably locked) and disposal 3
• Extended-release formulations reduce but do not eliminate diversion risk 3

Contraindications

• Do not prescribe stimulants with concurrent MAOI use or within 14 days of MAOI discontinuation (risk of hypertensive crisis) 3
• Known hypersensitivity to methylphenidate (risk of angioedema/anaphylaxis) 3

Dosing Errors to Avoid

• Inadequate dose titration leads to suboptimal outcomes 6, 7
• Titrate systematically to maximum tolerated dose rather than using strict mg/kg calculations 4
• Most adults require 0.55-1.0 mg/kg/day of methylphenidate for optimal response 1, 7