What can be used to augment Procentra (dextroamphetamine) in a 5-year-old child with Attention Deficit Hyperactivity Disorder (ADHD)?

Augmenting Procentra in a 5-Year-Old with ADHD

For a 5-year-old already on Procentra (dextroamphetamine), the only FDA-approved augmentation options are extended-release guanfacine or extended-release clonidine—these are the sole medications with sufficient evidence for adjunctive use with stimulants in children. 1, 2

FDA-Approved Adjunctive Medications

Only two medications have FDA approval for augmenting stimulant therapy in children:

• Extended-release guanfacine (Intuniv): Effect size approximately 0.7, particularly useful for residual hyperactivity, impulsivity, sleep problems, or oppositional symptoms 1, 2
• Extended-release clonidine (Kapvay): Similar effect size of 0.7, also addresses sleep disturbances and behavioral dysregulation 1, 2

All other medication combinations are off-label with only anecdotal evidence and cannot be recommended at this time. 1

Critical Age-Specific Considerations for 5-Year-Olds

This age group requires special attention because:

• Behavioral interventions should have been the first-line treatment before any medication was started 1, 3
• Methylphenidate has the strongest evidence base for preschool-aged children (4-5 years), not dextroamphetamine 1, 3
• Dextroamphetamine (Procentra) has FDA approval for ages 3+ based on outdated criteria without empirical evidence in this age group—methylphenidate would have been the preferred stimulant 1
• Preschoolers metabolize stimulants more slowly, requiring lower doses and smaller incremental adjustments 1

When to Consider Augmentation

Before adding a second medication, verify that:

• Evidence-based parent training in behavior management (PTBM) has been implemented and is ongoing 1, 3
• Behavioral classroom interventions are in place if the child attends preschool 1, 3
• The Procentra dose has been optimized: Starting dose 2.5 mg daily, increased by 2.5 mg weekly intervals, maximum 40 mg/day total 4
• Moderate-to-severe functional impairment persists across multiple settings (home, school, social) 1, 3

Practical Augmentation Strategy

If behavioral therapy is optimized and stimulant dose is maximized but symptoms persist:

1. Add extended-release guanfacine starting at 1 mg nightly, titrating by 1 mg weekly to target dose of 0.05-0.12 mg/kg/day 2

   • Addresses residual ADHD symptoms, sleep problems, and irritability
   • Monitor for somnolence, dry mouth, bradycardia, and hypotension 1, 2
   • Must taper gradually when discontinuing to prevent rebound hypertension 2

2. Alternative: Extended-release clonidine with similar dosing considerations and side effect profile 1, 2

Common Pitfalls to Avoid

• Do not use atomoxetine as augmentation—it has limited evidence for combination use and is off-label 2
• Do not add immediate-release stimulants—the child is already on a stimulant; optimize the current dose first 1
• Do not skip behavioral interventions—medication alone is insufficient; combined treatment provides superior outcomes 1, 5
• Do not forget cardiovascular screening—obtain personal and family cardiac history before starting alpha-2 agonists, perform ECG if risk factors present 2

Monitoring Requirements

• Baseline and ongoing: Blood pressure, pulse, height, weight 2
• Watch for: Somnolence (most common with alpha-2 agonists), irritability, dizziness, headache 1, 2
• Reassess monthly during titration, then every 3 months once stable 1

Evidence Quality Note

The recommendation for extended-release guanfacine and clonidine as the only appropriate augmentation options is based on FDA approval supported by controlled trials, while all other combinations lack sufficient safety and efficacy data in children. 1, 2