There are situations that come up in a primary care setting when a pediatric (and some adult patients) presents with symptoms that are compatible with a diagnosis for Attention Deficit Hyperactivity Disorder (ADHD) but where there are concerns about prescribing a stimulant medication. These are some of the situations when this can occur:
1. The patient’s presentation meets the symptom checklist for ADHD but the underlying cause is an anxiety disorder or developmental disorder or in utero drug exposure.
2. The patient did not have a therapeutic response to a previous stimulant trial or had problematic side effects
3. There are concerns about misuse or diversion of a controlled medication
4. The caregiver and/or patient has concerns about stimulant medications
5. The patient has a medical condition (ex: structural heart defect, arrhythmia) that might be a contraindication for stimulant medication
These are some of the clinical situations when a primary care provider might consider a non-stimulant alternative. These include the alpha 2 agonists (guanfacine/guanfacine ER and clonidine/clonidine ER); atomoxetine; and bupropion.
Guanfacine (Tenex) is typically dosed BID with a max dose of 4mg/day. Guanfacine ER (Intuniv) is dosed daily and cannot be chewed or opened. Clonidine (Catapres) is typically dosed BID-TID with a max dose of 0.4 mg/day. Clonidine ER (Kapvay) is typically dosed BID. The primary side effects to be aware of with alpha 2 agonists include sleepiness, hypotension and dry mouth. Generally speaking guanfacine causes less sleepiness than clonidine and is better tolerated in the daytime. Clinically the alpha 2 agonists are often used when symptoms of impulsivity are prominent.
Atomoxetine is dosed initially at 0.5mg/kg and increased to a target dose of 1.2mg/kg/day and can be given AM or as split dose BID. For adults the dose range is from 40 – 100mg daily, with gradual up-titration recommended for all patients. The primary side effects related to atomoxetine include: decreased appetite, elevation in blood pressure or heart rate, and rarely hepatoxicity. Atomoxetine also carries the FDA Black Box warning about the increased risk of spontaneous reporting of suicidal thoughts in young people, similar antidepressants and mood stabilizers.
Bupropion (Wellbutrin) can be helpful for co-morbid depression and ADHD and is typically dosed between 100-300mg/day with immediate release, sustained release and extended release formulations available. The main side effects to monitor for with bupropion include: headache, insomnia, dry mouth and tremor. There is a mild seizure risk with bupropion, but this is less concerning with the SR and XL formulations.
SmartCare provider consultations are an available option for specific cases to help determine if a non-stimulant should be considered for treatment for a patient’s ADHD symptoms and identify a stepwise treatment plan to implement the treatment recommendation.