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# Attention-Deficit/Hyperactivity Disorder (ADHD) Medications
## Overview
ADHD medications are primarily classified into stimulants (methylphenidate and amphetamine derivatives) and non-stimulants (atomoxetine, alpha-2 agonists, viloxazine). Stimulants act by increasing synaptic dopamine and norepinephrine; non-stimulants utilize varying mechanisms to modulate catecholamine pathways.
## Primary Indications
ADHD and Narcolepsy (stimulants only).
## Adult Dosing
* **Methylphenidate (e.g., IR):** 5–20 mg BID–TID; Max: 60 mg/day.
* **Lisdexamfetamine:** Start 30 mg daily; Max: 70 mg/day.
* **Mixed Amphetamine Salts (IR):** 5–20 mg BID–TID; Max: 60 mg/day.
* **Atomoxetine:** 40 mg daily; increase to 80 mg after 3 days; Max: 100 mg/day.
* **Guanfacine ER:** 1 mg daily; Max: 4 mg daily (adjunctive/monotherapy).
## Pediatric Dosing (Age 6+)
* **Methylphenidate:** Start 0.3–0.5 mg/kg/day divided BID–TID; Max: 60 mg/day.
* **Lisdexamfetamine:** Start 30 mg daily; Max: 70 mg/day.
* **Mixed Amphetamine Salts (ER):** 5–10 mg daily; Max: 30 mg/day.
* **Atomoxetine:** 0.5 mg/kg/day; increase to target 1.2 mg/kg/day; Max: 100 mg/day or 1.4 mg/kg (whichever is lower).
* **Guanfacine ER:** 1 mg daily; Max: 4 mg/day (age 6–17).
## Dose Adjustments
* **Renal/Hepatic:** Atomoxetine requires 50% dose reduction in moderate hepatic impairment; avoid in severe. Stimulants generally require no formal adjustment, but caution is advised in severe impairment.
* **Note:** Exact titration protocols vary by institution; always consult local electronic health records or practice guidelines.
## Contraindications
* **Stimulants:** Symptomatic cardiovascular disease, moderate-to-severe hypertension, hyperthyroidism, glaucoma, MAOI use within 14 days, history of drug abuse.
* **Atomoxetine:** Glaucoma, pheochromocytoma, severe cardiovascular disorders, MAOI use within 14 days.
## Adverse Effects
* **Stimulants:** Insomnia, decreased appetite/weight loss, tachycardia, elevated blood pressure, irritability, tic exacerbation.
* **Non-stimulants:** Atomoxetine (nausea, fatigue, hepatotoxicity—rare); Guanfacine/Clonidine (hypotension, bradycardia, sedation).
## Key Drug Interactions
* **MAOIs:** Absolute contraindication (hypertensive crisis).
* **CYP2D6 Inhibitors (e.g., fluoxetine, paroxetine):** Increases levels of atomoxetine and some amphetamines.
* **Antihypertensives:** Potential for additive hypotension with alpha-2 agonists.
## Monitoring
* Baseline and periodic blood pressure and heart rate.
* Weight and height (pediatric growth charts).
* Assessment of psychiatric status (emergence of anxiety, tics, or suicidal ideation).
## Clinical Pearls
* **Stimulant Selection:** Choice is often dictated by insurance formulary, pill burden, and duration of action preferences.
* **Abuse Potential:** Stimulants are Schedule II controlled substances; monitor for diversion or misuse.
* **"Drug Holidays":** May be considered in pediatrics to manage growth suppression, though efficacy in symptom management may decline.
* **Non-stimulants:** Have delayed onset of action (2–4 weeks for full effect) and are beneficial for patients who do not tolerate stimulants or have a history of substance abuse.
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**Educational Disclaimer:** This information is for educational purposes only. Drug dosing, contraindications, and interaction profiles can change. Always verify current prescribing information using official clinical resources (e.g., Lexicomp, UpToDate, or the FDA label) and consult professional medical guidance before making prescribing decisions.
