Atomoxetine, a specific norepinephrine reuptake inhibitor, is an FDA-approved alternative to stimulants for ADHD treatment in children and adolescents. Based on 3 RCTs7 of 588 children between the ages of 7 and 18 years, atomoxetine showed dose-related improvement in ADHD rating scales. Side effects of atomoxetine are similar to stimulants and include mild but significant increases in blood pressure and pulse.7
A meta-analysis of 11 non-randomized trials using clonidine for ADHD showed a smaller effect size compared with stimulants.8 One RCT of 136 children with ADHD and tics showed improvement of both problems with the use of methylphenidate and clonidine, particularly in combination.9 Second-line medications such as clonidine, pemoline (Cylert), and tricyclic antidepressants have more potential serious side effects and are not well studied.10
Recommendations from others
The American Academy of Pediatrics recommends that clinicians: 1) manage ADHD as a chronic illness, 2) collaborate with parents, the child, and school personnel to define specific desired outcomes, 3) use stimulant or behavioral therapy to improve these outcomes; if one stimulant is not effective at the highest feasible dose, try another, 4) reevaluate the diagnosis, treatment options, adherence, and possible coexisting conditions if treatment is not achieving the desired outcomes, and 5) follow-up regularly with parents, child, and teachers to monitor for progress and adverse effects.11
TABLE
Commonly used medications for ADHD
| Medication | Starting dose | Maximum dose | Monthly cost (generic) |
|---|---|---|---|
| Methylphenidate | 5–10 mg 2–3 times daily | 45 mg/d | $20 |
| Dextroamphetamine | 5 mg 1–2 times daily | 40 mg/d | $18 |
| Amphetamine/Dextroamphetamine | 5 mg 1–2 times daily | 60 mg/d | $50 |
| Atomoxetine | 40 mg once daily | 100 mg/d | $86 |
| Common adverse drug reactions for all ADHD medications: Nervousness, insomnia, dry mouth, anorexia, abdominal pain, nausea, constipation, palpitations, tachycardia. | |||
CLINICAL COMMENTARY
When patients, parents, and teachers are educated, we achieve better outcomes
Jerry Friemoth, MD
University of Cincinnati
Stimulants and atomoxetine improve symptoms of ADHD quite effectively, making office treatment of ADHD a gratifying experience. Like many other diagnoses, there are numerous medications available to treat ADHD. Becoming familiar with a few and regularly prescribing them makes the treatment of ADHD more comfortable for the physician.
Sometimes patients and parents are hesitant to take medication for ADHD. Education about ADHD, along with trials of behavioral therapy, often improves patient satisfaction and compliance with medication. Likewise, children and adolescents may resist medication because of stigma or feeling unfairly labeled with a disease. Because of this, it is helpful to choose a medication with a long duration, so school dosing can be avoided. Artful negotiation with the patient and parent is beneficial.
In my experience, when patients, parents, and teachers are well-educated about ADHD and use behavioral therapy along with medication, we achieve better outcomes. Useful information for physicians and parents regarding medication use and behavioral therapy are described in the American Academy of Pediatrics ADHD Toolkit available at www.nichq.org/resources/toolkit.