From the Guidelines
For a 6-year-old male weighing 15.3 kg who is too small for clonidine and is currently on Concerta for ADHD but experiencing dysregulation, I recommend considering guanfacine (Intuniv) as a first-line alternative, as it has been shown to be efficacious in treating ADHD with a relatively better safety profile for younger children with lower weight 1. Start with 0.5 mg once daily at bedtime and gradually increase to 1-2 mg daily as needed and tolerated. Guanfacine can help with emotional regulation while complementing the ADHD treatment effects of Concerta. Some key points to consider when prescribing guanfacine include:
- Its effect size is around 0.7, which is less robust than that of stimulant medications but still effective in reducing core symptoms of ADHD 1
- Common adverse effects include somnolence, dry mouth, dizziness, irritability, headache, bradycardia, hypotension, and abdominal pain 1
- Guanfacine should be tapered off rather than suddenly discontinued to avoid rebound hypertension 1 Another option would be low-dose risperidone starting at 0.25 mg daily, but this should be considered second-line due to metabolic side effects. Non-pharmacological approaches should be implemented concurrently, including:
- Consistent behavioral management strategies
- Establishing predictable routines
- Considering parent management training Regular monitoring of vital signs, growth parameters, and side effects is essential with any medication adjustment. If dysregulation persists despite these interventions, referral to a child psychiatrist for specialized assessment would be appropriate. It's also important to note that the treatment effects of guanfacine may not be observed until 2-4 weeks after initiation of treatment 1. Overall, guanfacine is a viable option for treating ADHD in children who are too small for clonidine, and its safety profile and efficacy make it a suitable first-line alternative.
From the Research
Treatment Options for ADHD
The patient is currently on Concerta for ADHD, but is too small for clonidine. The following options can be considered:
- Methylphenidate: Studies have shown that methylphenidate can be effective in reducing ADHD symptoms in children with tics 2, 3.
- Guanfacine: Guanfacine has been shown to improve tic symptoms and ADHD symptoms in children 2, 3.
- Atomoxetine: Atomoxetine is a non-stimulant medication that can be used as an alternative to stimulants, and has been shown to be effective in reducing ADHD symptoms in children with tics 2, 3.
- Desipramine: Desipramine has been shown to improve tic symptoms and ADHD symptoms in children, but its use is limited due to safety concerns 2, 3.
Considerations for Treatment
When considering treatment options, it is essential to take into account the potential side effects and interactions with other medications. For example:
- Stimulants such as methylphenidate can increase heart rate and blood pressure, and may not be suitable for children with certain medical conditions 4.
- Alpha agonists such as guanfacine can cause sedation and may interact with other medications 2, 3.
- Non-stimulant medications such as atomoxetine can cause appetite suppression and weight loss, and may interact with other medications 3.
Monitoring and Follow-up
Regular follow-up is crucial in the management of ADHD, and should include assessments of symptoms, overall function, presence of comorbidities, adverse effects of treatment, and medication use 5.