Helpful Info About ADHD Medications
There are a vast number of different medications available for the treatment of attention deficit hyperactivity disorder (ADHD or ADD). The process of choosing the most effective ADHD medication differs from one person to the other. Individuals with ADHD might be overwhelmed with the numerous medications available and how they differ from one another. That being said, it is best to categorize these medications in order to simplify the process. Individuals that are in need of medication should have a comprehensive understanding of the potential treatment options that they have as available options.
The medications for ADHD prescribed to both children and adults can be divided into two categories:
- Stimulants – these are considered the first-line ADHD medications. Stimulants include Amphetamines such as Adderall and Vyvanse. They also include methylphenidate and their derivatives such as Ritalin and Focalin.
- Nonstimulants – these are typically prescribed to patients who have tried stimulant medications and did not tolerate or respond well to them. Studies have shown that up to 30 percent of patients did not respond well to stimulants (1). There are three nonstimulants that are FDA approved for ADHD: atomoxetine (Straterra), guanfacine (Intuniv), and clonidine (Kapvay).
As mentioned earlier, choosing the most effective ADHD medication can be a long process that includes adjusting the dosage, timing, or switching medications entirely. Many factors can influence which medication and which dosage to use including a patient’s medical history, the side effects that are or are not tolerated, and an individual’s metabolism. It is vital for a physician and patient to have clear communication when determining history and what medication would be best suited for their particular needs.
How Do Stimulant Medications Work?
To understand how stimulant medications treat ADHD, it is important to discuss the biological mechanism. ADHD is a chronic neurological disorder characterized by functional impairments in the brain’s neurotransmitters. Neurotransmitters are chemicals that send messages in the nervous system. The neurotransmitters deficient in ADHD include dopamine and norepinephrine. Stimulant medications such as Adderall and Ritalin block the reuptake of dopamine and norepinephrine. As a result, the amounts of these neurotransmitters are increased and available by use in the nervous system. Both the amphetamine and methylphenidate class of stimulants work in this manner. Furthermore, all brand-name stimulants are variations of these two classes. For example, Adderall is a mixture of amphetamine and dextroamphetamine salts while Ritalin is the brand name of methylphenidate. Typically, stimulants in the methylphenidate class work best in children and amphetamines are more effective in adults. As stated earlier, there are still many factors to weigh in considering which form of treatment is right for each individual.
How Do Nonstimulants Work?
Atomoxetine (Strattera) is a nonstimulant medication used to treat ADHD. It does this by blocking the norepinephrine transporter (NET) and dopamine transporter (DAT) and thereby inhibiting the reuptake of these neurotransmitters. As a result, this increases the amount of norepinephrine and dopamine in certain brain regions such as the prefrontal cortex. In contrast to stimulants such as Adderall, Strattera has no abuse potential and causes less insomnia and anxiety. That being said, it is typically prescribed to individuals who do not respond well to stimulants. It may be a better option for people who have issues with going to sleep and who do not tolerate stimulants that may cause some heart issues for those with underlying cardiac conditions.
Clonidine (Kapvay) and Guanfacine (Intuniv) work via the same mechanism of action. They are both alpha-2 agonists meaning they bind to the alpha-2 receptor. Like atomoxetine, benefits of these two drugs include lack of potential for abuse and no insomnia. Furthermore, all 3 of these nonstimulants do not worsen tic disorders or Tourette’s syndrome.
Bupropion (Wellbutrin), is an atypical antidepressant that can also be prescribed off-label for ADHD. In some cases, depression is accompanied by ADHD. It can be prescribed as a non-stimulant medication for ADHD. With that being said, treating depression will also help treat symptoms of ADHD. Like other ADHD medications, bupropion blocks the reuptake of dopamine and norepinephrine and thus increase their levels.
What are Side Effects I Can Expect from ADHD Medication?
Typical side effects in stimulant medications include the following:
- Sleep disturbances/ insomnia
- Decreased appetite
- Gastrointestinal (GI) distress/ nausea
- Tachycardia (fast heart rate)
- Increased blood pressure
Typical side effects in nonstimulants medications include the following:
- Abdominal pain/nausea
- Decreased appetite
It is very common for individuals to experience side effects when initially using and adjusting ADHD medication. Your health care provider will typically start with a small dose and adjusting the dosage based on its benefits and how patients tolerate the side effects. There are many side effects, such as GI distress and nausea, that are temporary until the dosage is adjusted. Nonstimulant medications can be a great alternative to treat ADHD, in comparison to stimulant medications, for those with heart conditions that can be exacerbated by the side effects associated with amphetamines. As a result, good communication between the patient and provider is key in mitigating the side effects that may come with ADHD treatment.
How and when Should the Medication Administered?
Patients with ADHD may be asking themselves how the medication is administered. Most ADHD medications are administered orally via a capsule, tablet, or liquid. It is typically taken in the morning right after getting out of bed to avoid issues with sleep later in the day. It should also be noted that taking the medication with food or proton pump inhibitors (PPIs) like Nexium can delay the effects of medication, and should be avoided if the desired effects are intended to be more quickly to onset.
The one medication that is an exception to oral administration is Daytrana, a methylphenidate product. Daytrana is administered via a patch. This patch slowly releases the medication through the skin and into the bloodstream. This medication is primarily used for children who cannot take oral stimulants or others that have difficulty with the swallowing mechanism.
How Strong are the Dosages of the Common ADHD Medications? How Long Can I Expect Each Medication to Last?
Some of the most common medications include:
- Adderall (mixed amphetamine salts) is a tablet dosed from 5, 7.5, 10, 12.5, 15, 20, 30 mg. It lasts around 4 hours.
- Adderall XR is a capsule dosed from 5, 10, 15, 20, 25, 30 mg. It lasts around 10 – 12 hours.
- Mydayis (mixed amphetamine salts) is a long-acting capsule dosed from 12.5, 25, 37.5, and 50 mg. It lasts around 12-14 hours.
- Vyvanse (lisdexamfetamine) in a capsule form is dosed from 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, and 70 mg. It lasts around 10 – 12 hours.
- As a chewable tab, it is dosed from 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, and 60 mg
- Concerta (methylphenidate) is a tablet that is dosed from 18, 27, 36, 54 mg. It lasts around 12 hours.
- Ritalin SR (methylphenidate) is a tablet and is dosed at 20 mg. It lasts around 8 hours.
- Ritalin LA (methylphenidate) is a capsule and is dosed from 10, 20 30, 40, 60 mg. It lasts around 8 hours.
- Strattera (atomoxetine is a capsule dosed from 10, 18, 25, 40, 60, 80, 100 mg. It lasts around 24 hours.
- Kapvay (clonidine) is an extended-release tablet dosed from 0.1 and 0.2 mg. It lasts around 24 hours.
- Intuniv (guanfacine) is an extended-release tablet dosed from 1, 2, 3, 4 mg. It lasts around 24 hours.
- Wellbutrin (bupropion) is available as a tablet, SR tablet, ER tablet, and ER tablet with hydrobromide salt
- The tablet is dosed from 75 and 100 mg
- The SR tablet is dosed from 100, 150, and 200 mg
- The ER tablet is dosed from 150 and 300 mg
- Aplenzin (ER tablet with hydrobromide salt formulation) is dosed from 174, 348, and 522 mg
What is the Difference Between an Instant Release and Extended-Release Medication?
As you can see, some medications are immediately released while others are extended-released. Adderall IR (immediate release) and Adderall XR (extended release) is a prime example of this. As the name suggests, the difference is how the medications are released. Thus, the effects of Adderall IR can be felt quicker than the effects of Adderall XR. On the flip side, Adderall IR lasts around 4 – 6 hours while Adderall XR lasts from 10 – 12 hours. This difference is because Adderall XR is slowly released as time goes on. Adderall IR takes around 4 hours to reach peak ingredient levels in the blood while Adderall XR takes around 7 hours.
Understanding these differences will help patients and their clinicians provide the most effective medication. For instance, individuals would prefer a medication to last the whole day while others only need a few hours to stay alert. As a result, those who need longer lasting medication would respond much better to an extended-release drug such as Adderall XR or Vyvanse. Another example may be an ADHD patient struggling with sleep. This patient would respond much better to an instant release drug such as Adderall that does not last as long. As mentioned previously, nonstimulants causes no symptoms of sleep loss or insomnia. As a result, those struggling with sleep would respond better to nonstimulants such as Strattera. Nevertheless, there are many different medications that need to be catered towards an individual’s needs on a case by case basis.
Are Stimulant Medications or Nonstimulant Medications Best for Me?
As stated earlier, stimulant medications are first-line for the treatment of ADHD. However, there are many instances and circumstances when a clinician would prescribe a nonstimulant medication over a stimulant. For example, nonstimulants would be better for individuals with a history of substance abuse. This is due to the lack of abuse potential in nonstimulants. Another instance would be an individual with ADHD accompanied by depression and tobacco use. This individual would respond better to bupropion, a nonstimulant and antidepressant. Bupropion also has the added benefit of being FDA approved for tobacco cessation. The price of medication may also be a deciding factor in which medication is prescribed. Vyvanse for example is a relatively more expensive medication. As a result, individuals that are not insured and rely on self-pay may prefer a cheaper medication with similar benefits such as Adderall XR or Mydayis.
What Should I Discuss with My Doctor?
It’s not uncommon for patients to see all these different medication options and be overwhelmed in regards to which would work best for them. Thankfully, clinicians including psychiatrists and primary care providers are available to help determine which medication is best. That being said, clear and open communication between the patient and clinician is key in choosing the best medication. Patients should discuss with their doctors other pre-existing medical conditions, most notably hypertension. Since many stimulant medications increase blood pressure, it’s important to tell your doctor about any issues with blood pressure so that the correct ADHD medication and dosage can be prescribed. Furthermore, any cardiac conditions such as tachycardia or atrial fibrillation should be discussed with your doctor. Since many of these medications increase heart rate, any pre-existing heart conditions should definitely be known by the clinician prior to any prescription.
What Dosage of Medication can I Expect Initially?
As stated earlier, there are a myriad of different factors and considerations when your clinician prescribed medication to treat ADHD. Typically, your doctor or health care provider will recommend the lowest dosage of medication. This is to prevent or limit any unwanted side effects such as increased anxiety or insomnia. After a trial of typically a few weeks or a month, your clinician will adjust the dosage if needed. Additionally, your physician may recommend non pharmacologic treatments such as behavioral therapy or psycho-education. Ultimately, discussing options clearly with your physician will lead to the best treatment options and the highest quality of life to manage ADHD.