What are the next steps for an Attention Deficit Hyperactivity Disorder (ADHD) patient not responding adequately to Foquest (generic name not specified, possibly a brand name for a medication such as Atomoxetine) at 100mg?

Optimizing ADHD Treatment Beyond Foquest 100mg

For an ADHD patient with inadequate symptom control on Foquest 100mg (methylphenidate extended-release), switch to a different stimulant class—specifically lisdexamfetamine (Vyvanse) starting at 30mg daily—before considering non-stimulants, as 40% of patients respond to one stimulant class but not the other. 1, 2

Immediate Next Steps: Optimize Stimulant Therapy First

Before abandoning stimulants entirely, recognize that 20-35% of patients show inadequate response to their initial stimulant, but overall response rates reach 75-90% when both methylphenidate and amphetamine classes are tried 3, 1. Since Foquest is a methylphenidate formulation, switching to an amphetamine-based stimulant is the evidence-based next move 1, 2.

Switch to Amphetamine Class Stimulants

• Start lisdexamfetamine (Vyvanse) 30mg once daily in the morning, titrating by 10-20mg weekly up to 70mg daily maximum based on response 4
• Lisdexamfetamine offers once-daily dosing with 12-14 hour duration, improving adherence compared to multiple daily doses 4
• Approximately 40% of patients who don't respond adequately to methylphenidate will respond to amphetamines 1
• If lisdexamfetamine is unavailable or cost-prohibitive, try mixed amphetamine salts extended-release (Adderall XR) 10-20mg daily, titrating by 5-10mg weekly up to 40mg daily 4

Critical Assessment Before Switching

Before changing medications, verify these common causes of apparent treatment failure 2:

• Adherence issues: Confirm the patient is actually taking Foquest 100mg daily as prescribed 2
• Timing problems: Assess if symptoms occur outside the medication's duration of action (Foquest typically lasts 12-16 hours) 2
• Dose-limiting side effects: Determine if the patient couldn't tolerate higher doses that might have been more effective 2
• Comorbid conditions: Rule out untreated anxiety, depression, or sleep disorders masquerading as ADHD symptoms 5
• Psychosocial stressors: Distinguish between ADHD symptoms and behavioral reactions to environmental stressors 5

If Two Stimulant Classes Fail: Non-Stimulant Options

Only after adequate trials of both methylphenidate (already done with Foquest) and amphetamine-based stimulants should you consider non-stimulants 1, 2.

First-Line Non-Stimulant: Atomoxetine

• Start atomoxetine 40mg once daily, titrating every 7-14 days to 60mg, then 80mg daily 4
• Maximum dose is 1.4 mg/kg/day or 100mg daily, whichever is lower 5, 4
• Requires 6-12 weeks to achieve full therapeutic effect, unlike stimulants that work within days 5, 4
• Medium-range effect size (approximately 0.7) compared to stimulants 4
• Black box warning: Monitor closely for suicidal ideation, especially during the first few months or at dose changes 5
• Particularly useful if comorbid anxiety or substance use concerns exist 6

Second-Line Non-Stimulants: Alpha-2 Agonists

• Guanfacine extended-release: Start 1mg once daily in the evening, titrate by 1mg weekly up to 4mg daily maximum 4
• Clonidine extended-release: Alternative alpha-2 agonist with similar efficacy 5
• Both require 2-4 weeks for full effect 4
• Particularly useful when comorbid tics, sleep disturbances, or disruptive behavior disorders are present 4, 7
• Never abruptly discontinue—taper by 1mg every 3-7 days to avoid rebound hypertension 4

Augmentation Strategy: Combining Medications

If the patient achieves partial response to the new stimulant but symptoms remain problematic 2:

• Add guanfacine extended-release 1-4mg daily to the stimulant regimen for residual symptoms, particularly if oppositional behaviors or sleep issues persist 4
• This combination is FDA-approved and allows lower stimulant doses while maintaining efficacy 4
• Add atomoxetine to stimulants for patients with partial response—this combination has been specifically studied and shown to be safe 2

Common Pitfalls to Avoid

• Don't assume "more is better": If 100mg Foquest isn't working, switching classes is more effective than pushing to higher methylphenidate doses 5, 1
• Don't skip the amphetamine trial: Going directly from methylphenidate to non-stimulants means missing the 40% who respond to amphetamines but not methylphenidate 1
• Don't use bupropion as first-line alternative: It's explicitly a second-line agent with weaker evidence than approved ADHD medications 4, 3
• Don't forget reassessment: If medications aren't working, reassess the original diagnosis—comorbid disorders or psychosocial factors may be unaddressed 5
• Don't expect immediate results from non-stimulants: Atomoxetine takes 6-12 weeks and alpha-2 agonists take 2-4 weeks, unlike stimulants that work within days 5, 4

Monitoring During Transition

• Obtain weekly symptom ratings during dose adjustment using standardized scales 4
• Monitor blood pressure and pulse at baseline and regularly during treatment 5, 4
• Track height and weight at each visit, particularly in younger patients 4
• Assess for suicidality if using atomoxetine, especially during initial months 5
• Screen for substance use if switching to amphetamines in at-risk populations 5