Clonidine (Catapres) Dosing for ADHD
For ADHD treatment in children and adolescents aged 6-17 years, initiate clonidine at 0.1 mg orally at bedtime, then titrate upward by 0.1 mg increments to a typical maintenance dose range of 0.2-0.4 mg/day divided into 2-3 doses, with a maximum of 0.4 mg/day. 1
Starting Dose and Titration Protocol
- Begin with 0.1 mg orally at bedtime to minimize initial sedation, which is the most common adverse effect 1
- For extended-release clonidine (Kapvay), the starting dose remains 0.1 mg once daily 1
- Increase gradually by 0.1 mg increments to achieve optimal symptom control while monitoring tolerability 1
- The typical therapeutic range is 0.2-0.4 mg/day, with dosing divided BID to TID for immediate-release formulations 1
- The maximum dose of 0.4 mg/day should not be exceeded regardless of weight 1
Clinical Positioning
Clonidine is not a first-line treatment for ADHD—stimulant medications remain the gold standard initial treatment due to superior effect sizes (approximately 1.0 for stimulants versus 0.7 for clonidine) 2. However, clonidine represents an important option in specific scenarios:
- Comorbid sleep disturbances, where evening dosing can address both ADHD symptoms and insomnia 1
- Substance use disorder risk, as it is an uncontrolled substance, avoiding abuse potential concerns 1
- Adjunctive therapy with stimulants when ADHD symptoms remain inadequately controlled despite optimized stimulant monotherapy—clonidine extended-release is one of only two medications with FDA approval and sufficient evidence for combination use with stimulants 2, 3
- Comorbid tic disorders, as clonidine treats both conditions without worsening tics 4
Critical Safety Monitoring
Before initiating clonidine:
- Obtain baseline blood pressure and heart rate 1
- Screen for personal or family history of cardiac conditions including Wolf-Parkinson-White syndrome, sudden death, hypertrophic cardiomyopathy, and long QT syndrome 3
During treatment:
- Monitor blood pressure and heart rate at each dose adjustment 1
- Expect modest decreases in blood pressure (1-4 mmHg) and heart rate (1-2 bpm) 3
- Watch for somnolence, fatigue, headache, bradycardia, and hypotension 4, 5
Discontinuation Protocol
Never abruptly discontinue clonidine—it must be tapered to avoid rebound hypertension and potential hypertensive crisis 1. Taper by decreasing the dose gradually over several days (typically by 0.1 mg every 3-7 days) when discontinuation is necessary 1.
Comparison with Guanfacine
Guanfacine is generally preferred over clonidine due to higher alpha-2A receptor specificity, resulting in less sedation and better tolerability, plus the advantage of once-daily dosing versus clonidine's required twice-daily administration 3, 1. However, clonidine may have a faster onset of therapeutic effect 1.
Efficacy Timeline
Both clonidine and clonidine extended-release have been shown to be efficacious in treating ADHD symptoms as monotherapy or adjunctive therapy 4. Symptomatic improvement is typically apparent within 2 weeks of treatment initiation 5. In clinical trials, significantly greater reductions in ADHD-RS-IV total scores were evident at week 2 onwards for recipients of clonidine XR compared to placebo 5.
Common Pitfall to Avoid
Do not use clonidine in patients with baseline bradycardia (heart rate <60 bpm) or hypotension (systolic BP <90 mmHg), as clonidine causes further decreases in both parameters 3.