Treatment Options for ADHD

Theresa R. Cerulli, MD: Andy, if you wouldn’t mind, provide us an overview of treatments of ADHD stimulants and nonstimulants?

Andrew Cutler, MD: We’ve already have gone through some of this. I usually start by asking, is this a patient I’m going to start with a stimulant? Or do I need to start with a nonstimulant for many reasons? These might include the parent says, “Whatever you do, don’t give my kid a stimulant.” Maybe the patient has substance abuse issues, and I’m not comfortable with that. Maybe the person has a cardiac issue, and I’m a little concerned about using a stimulant. Sometimes there’s a psychiatric comorbidity, depression or anxiety, that I might want to use a nonstimulant for. In any case, the majority of the time, we’re using a stimulant first. It’s methylphenidates vs amphetamines.

The important thing there is that there are delivery systems, formulations, the duration of action, and the PK [pharmacokinetic] curve. Can the patients swallow pills? Would they prefer not to? Do they want a preparation that they have a certain amount of control over? In other words, something that they can control the duration themselves, such as a patch or a liquid, so you can dial the dose up or down or the duration up or down based on your requirements and needs for the day.

There are also the various nonstimulants, such as atomoxetine, which has been around for 20 years. We can all agree that there’s a little disappointment with atomoxetine. We found that it’s a finicky thing— when it works, it works; when it doesn’t, it doesn’t. Meta-analyses have shown that it works in only 30% to 40% of our patients. In my experience with viloxazine extended release, that feels more like 50% to 60% of patients respond. Of course, with stimulants, 80% to 90% of patients respond.

Extended-release guanfacine and clonidine are also terrific medicines. The problem with monotherapy is that they tend to be pretty sedating and a little hard to tolerate. Most of my use of those medicines has been in combination, particularly with stimulants. That’s the overview. Maybe we can get into more details about these different formulations in a minute.

Transcript edited for clarity