A Non-Stimulant Medication
Used in the Treatment of ADHD

Given the potential unintended effects of stimulant medication, a non-stimulant medication would be welcome in the physician’s attempts to manage ADHD symptoms. Such drugs have been developed.  The non-stimulant medications have several advantages over the stimulant medications.  For example, the non-stimulant medications do not induce agitation or sleeplessness.  As they are not controlled substances, they do not present the same risk of abuse or addiction as do the stimulant drugs.  The non-stimulant drugs have a longer-lasting and gentler wear off effect.  Although there are positive effects associated with the non-stimulant medication in the treatment of ADHD, as the Table on the non-stimulant drugs makes clear, they can have extraordinarily serious consequences if not dosed properly or if combined with other CNS agents.

The first such drug developed and approved (cf. Food and Drug Administration, 2002) was Atomoxetine hydrochloride (commonly referred to as “Strattera”) which is a selective norepinephrine reuptake inhibitor.  It is administered to both children and adults.  Initial studies demonstrated its efficacy, but also a number of side effects, some of which can be lethal, such as suicidal ideation.  The drug is prescribed either once or twice daily and is efficacious either way.  Two additional non-stimulant medications approved by the FDA for use in the treatment of ADHD are “Intuniv” and “Kapvay”; both are approved for use with children ages 6-17 years.

Generic/Drug Name:

Atomoxetine hydrochloride

Guanfacine hydrochloride
Tenex

Clonidine hydrochloride

 

 

 

 

Mechanism of action:

• Selective norepinephrine reuptake inhibitor.
• The chemical signal between nerves that use norepinephrine is strengthened.

Central alpha-2 Adrenergic Agonist
Unclear how it works in treating ADHD

Central alpha-2 Adrenergic Agonist
Unclear how it works in treating ADHD

Prescribed for:

• ADHD
  • ADHD
  • Hypertension

 
  • ADHD
  • Hypertension

 

Tablet sizes and dose regimen:

• Available in 10, 18, 25, 40, 60, 80, and 100 mg.

Up to 70kg
• Begin with a total daily dose of approximately 0.5 mg/kg.
• Increase dose after a minimum of 3 days.
• Target total daily dose is 1.2 mg/kg.
• Single dose in the morning.
• Sedating effects may require evenly distributing the dose in the morning and late afternoon or early evening.
• Total daily dose should not exceed 1.4 mg/kg or 100 mg, whichever is less.

Above 70kg
• Begin with a total daily dose of approximately 40 mg.
• Increase dose after a minimum of 3 days to approximately 80mg.
• Single dose in the morning.
• Sedating effects may require evenly distributing the dose in the morning and late afternoon or early evening.
• Total daily dose should not exceed 100 mg.
  • 1, 2, 3, and 4mg extended release
  • Not weight based
  • Typical dose begins at 1mg
  • Adjusted for best response, if needed

 

0.1, 0.2, 0.3, and 0.4mg extended release

Typically begins with one 0.1 mg tablet at bedtime and one 0.1mg in the morning

Daily dosage may need to be adjusted in increments of 0.1 mg/day at weekly intervals to achieve the appropriate response

 

 

 

 

Effects:

The effects are subtle and their onset is gradual.
About three weeks before maximum effects are observed.

 

 

Drug interactions:

·    Potential increases in heart rate and blood pressure when interacting with oral or intravenous albuterol (or other beta2 agonists) or other pressor agents.
• Contraindicated with monoamine oxidase inhibitors (MAOI), or within 2 weeks after discontinuing their use, or initiated within 2 weeks after discontinuing Strattera.
  • Potential for increased sedation combined with other CNS depressants
  • May interact with other hypertensives that can reduce blood pressure
  • May increase CNS depressive effects when combined with alcohol or other suppressants
  • May interact with other hypertensives that can reduce blood pressure

Side effects:

The incidence is unknown for many side effects. Below are a few examples of side effects:

Mild

  • vomiting
  • tremor
  • diarrhea
  • rash
  • tinnitus

Moderate

  • constipation
  • depression
  • growth inhibition
  • urinary retention
  • hypertension

Severe

  • seizures
  • hepatic failure
  • hepatic necrosis
  • stroke
  • suicidal ideation

The incidence is unknown for many side effects. Below are a few examples of side effects:

Mild

  • vomiting
  • tremor
  • diarrhea
  • rash
  • tinnitus

Moderate

  • constipation
  • wheezing
  • constipation
  • blurred vision
  • edema

Severe

  • renal failure
  • heart failure
  • bronchospasm
  • stroke
  • AV block

The incidence is unknown for many side effects. Below are a few examples of side effects:

Mild

  • vomiting
  • nausea
  • fever
  • muscle cramps
  • rash

Moderate

  • confusion
  • chest pain
  • hallucinations
  • edema
  • hepatitis

Severe

  • GI obstruction
  • heart failure
  • angioedema
  • stroke
  • AV block

 

Physicians Desk Reference (2022)