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 does not appear to fit with a straightforward ADHD presentation, but rather appears to be the result of an underlying anxiety disorder, developmental disorder or in utero drug exposure.
2. The patient did not have a favorable therapeutic response to a previous stimulant trial or had significant problematic side effects.
3. There are concerns about misuse or diversion of a controlled medication.
4. The caregiver has concerns about stimulant medications.
5. The patient has a medical condition (ex: structural heart defect, arrhythmia) that might be contraindications 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 (Tenex) /guanfacine ER (Intuniv) or clonidine (Catapres)/clonidine ER (Kapvay)); atomoxetine (Strattera); and/or  bupropion (Wellbutrin).

Guanfacine is typically dosed BID with a max dose of 4mg/day. Guanfacine ER is dosed daily, typically at night and cannot be chewed or opened.

Clonidine is typically dosed BID-TID with a max dose of 0.4 mg/day. Clonidine ER 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.

Atomoxetine is dosed initially at 0.5mg/kg and increased to a target dose of 1.2mg/kg/day and can be given qday or BID. The primary side effects 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 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.

On Demand Child Psychiatry telephone consultations

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It is a somewhat complicated question and answer because there are multiple factors to look at: is this ADHD alone or co-morbid with something else; stimulant and non-stimulant choices; short-acting and long-acting formulations; dose and side effect considerations; an assortment of preparations available; and insurance considerations. If we start with the position of using a stimulant medication first, unless there is a reason not to (previously failed stimulant trial, significant co-morbid anxiety, substance abuse concerns, weight concerns), the first decision really is whether to start with a short-acting or long-acting formulation. Unless the child is very young, in most circumstances it would be appropriate to start with a long-acting formulation. If a child is unable to swallow a pill, there are long-acting versions that can still be used: Adderall XR capsules can be opened, Quillivant XR is a long-acting liquid methylphenidate preparation, and the Daytrana patch to name a few.

In terms of making the decision whether to start with a methylphenidate-based preparation or an amphetamine-based preparation, it mostly depends on provider preference. For children under the age of 6, it is slightly easier to get insurance approval for an amphetamine-based preparation because there is better research on the use of that class of stimulants in young children. If planning to prescribe a stimulant medication to a young child under the age of 6, it is best to start with an immediate release preparation, typically Ritalin or Adderall, and then to consider changing to a long-acting preparation over time if needed.

At this point there are so many preparations of long-acting stimulants, which can be confusing for providers. They are available in capsules, tablets, sprinkles, liquid, and patch forms. They mostly don’t vary much in terms of length of effect and side effect profile. Some vary in terms of how the active medication is released throughout the day. In general, if a patient does not do well on a long acting preparation from one class of stimulant, for example if s/he was started on Concerta, it probably does not make sense to try another long acting methylphenidate medication, but it makes more sense to try one from the amphetamine class instead.

Unfortunately many medication decisions are made based on what is covered by a patient’s health insurance. In the case of prescribing stimulant medications, this limitation can be seen as helpful to narrow down the choices available to the provider.

Given the seemingly never-ending list of stimulant options, providers might find it helpful to develop a list of stimulant medications they are comfortable prescribing, making sure to cover the basic insurances and the basic preparations and both short-acting and long-acting preparations. It might also be a good idea to develop a comfort level with some of the non-stimulant medication options, like Strattera, Tenex, and Clonidine. These have been discussed in previous e-Weekly newsletters and will be reviewed again soon in a future e-Weekly newsletter.