Non-stimulant Approaches to ADHD

There are situations that come up in a primary care setting when a pediatric patient presents with symptoms that are concerning 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 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

are available through SmartCare — we can assist in diagnostic reappraisal and treatment plan reviews for specific cases.    Call us ad lib:   ( 858) 880-6405

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