Nonstimulants
Atomoxetine
StratteraR is a selective norepinephrine reuptake inhibitor (SNRI) recently approved for the treatment of ADHD. This medication may be useful for treating ADHD in children who do not tolerate stimulants due to side-effects such as tics or weight loss.
A suggested guide to prescribing atomoxetine is as follows:
Initial dose: 0.5 mg/kg q AM. Increase q 3-7 days to 1.2 mg/kg/day or 0.6mg/kg BID.
Maximum dose: 1.8 mg/kg/day or 100mg/day. (Usual adult dose: 80 mg q AM)
Monitor: ht, wt, BP, HR
Common side effects: Anorexia, somnolence, headache, dizziness, pruritus, rhinitis. Somnolence is especially pronounced in children switched from stimulants to atomoxetine.
Available doses: 10mg, 18mg, 25mg, 40mg, 60mg tablets
Drug interactions : If used with strong CYP 450 2D6 inhibitor (fluoxetine, paroxetine) maintain at initial dose for 4 wk, then increase to lesser of 1.2 mg/kg/24 hr or 80 mg max.
Alpha-adrenergic agonists
Clonidine and guanfacine (TenexR, IntunivR) are (-adrenergic agonists. Clonidine has been used off-label to reduce impulsivity and is effective as a sleep aide for children. Guanfacine has been used off-label for ADHD and has the benefit of once-daily dosing; it was recently approved by the FDA for treatment of ADHD under the brand name IntunivR.
Guanfacine is available as 1,2,3 or 4 mg tablets. Patients must be monitored for hypotension and bradycardia, and treatment should not be withdrawn abruptly. Clonidine is usually given as a sleep aide, 0.1 mg at bedtime. A child should not receive both of these medications concurrently.
These agents can be used when stimulants are contraindicated (e.g., for patients who develop tics with stimulants). They may be useful in "lengthening the fuse"-i.e., reducing impulsively angry responses to frustrating situations for children with severe ADHD or ODD, or for evening hyperactivity.
