Attention-Deficit/Hyperactivity Disorder: Nonstimulant Therapy (Strattera) and Other ADHD Drugs

While stimulants are usually the first choice for ADHD, they're not for everyone. In some people, they cause intolerable side effects; in others, they just don't work very well. The good news is that other effective options for ADHD treatment are available.

Two nonstimulant ADHD treatments have been approved by the FDA:

• Strattera was the first nonstimulant drug approved for ADHD. It's now used in both children and adults.
• Intuniv is approved for ADHD in children ages 6 to 17.
• Kapvay is approved for ADHD in children ages 6 to 17.

Strattera seems to increase the amount of norepinephrine, an important brain chemical. This appears to help ADHD by increasing attention span and reducing impulsive behavior and hyperactivity.

Intuniv and Kapvay have an effect on certain receptors in the brain. Studies show that they reduce distractibility and improve attention, working memory, and impulse control. Intuniv is an extended release medicine that contains the same active ingredient as Tenex, a blood pressure drug that's been used as an off-label ADHD treatment for years. Kapvay contains the same active ingredients seen in some types of blood pressure medications known as clonidine. These medications work on the brain to help control heart rate and blood pressure.

Nonstimulants have some advantages over many stimulants used for ADHD. For instance, nonstimulants:

• Don't cause agitation or sleeplessness
• Are not controlled substances and don't pose the same risk of abuse or addiction
• Have a longer-lasting and smoother effect than many stimulants, which can take effect and wear off abruptly

Of course, nonstimulants do have some potential side effects of their own.

Strattera Side Effects. The most common side effects of Strattera are:

• Upset stomach
• Decreased appetite, which may cause weight loss
• Nausea
• Dizziness
• Fatigue
• Mood swings

Other, less common risks from Strattera include:

• Jaundice and liver problems. If you develop yellowing of the skin or whites of the eyes, contact your doctor right away.
• Suicidal thinking. There's a possibility that Strattera -- like many antidepressantdrugs -- may slightly increase the risk of suicidal thinking in teenagers.
• Slowed growth in children. Your doctor will probably keep a close eye on your child's height and weight.
• Priapism, or erections that last more than four hours.
• Serious allergic reactions. While rare, some people develop rashes, hives, or swelling.

Intuniv Side Effects include:

• Headache
• Fatigue
• Abdominal pain
• Sleepiness and sedation

Since Intuniv can cause drowsiness, make sure you know how it affects you before you try driving or operating heavy machinery.

Rarer and more serious side effects include:

• Low blood pressure
• Heart rhythm changes

Kapvay contains the same active ingredients seen in some types of blood pressure medications known as clonidine. These medications work on the brain to help control heart rate and blood pressure.

Kapvay's common side effects include sleepiness and tiredness. Side effects may also include symptoms of upper respiratory infection, such as:

• cough
• runny nose
• sneezing
• irritability
• sore throat
• trouble sleeping (insomnia)

Nonstimulants are not the right medication for everybody with ADHD. You should probably not take Strattera if you:

• Have been diagnosed with narrow angle glaucoma (a condition that causes increased pressure in the eyes and can lead to blindness)
• Use a monoamine oxidase inhibitor (MAOI) for depression, like Nardil or Parnate
• Have an allergy to any of the ingredients in Strattera
• Have jaundice or liver problems

You should probably not take Intuniv if you:

• Have an allergy to any of the ingredients in Intuniv
• Take other products containing guanfacine, like the blood pressure medicine Tenex

Do not take Kapvay if you are allergic to clonidine in Kapvay.

Before starting treatment with a nonstimulant medication, talk to your doctor about your medical history and go over all the risks.

If you've been prescribed a nonstimulant for ADHD, be sure to tell your doctor:

• If you are nursing, pregnant, or plan to become pregnant.
• If you take any prescription medications for other conditions, like blood pressure drugs, antidepressants, sedatives, or antipsychotics.
• If you take any dietary supplements, herbal medicines, or over-the-counter medications.
• If you have any medical problems, including high or low blood pressure, seizures, heart disease, glaucoma, mental health issues, liver disease or jaundice, or kidney problems.
• If you have had an allergic reaction to any medications in the past.
• If you have a history of drug or alcohol abuse or dependency.
• If you become agitated or irritable, or develop suicidal thoughts.

Like any medication, Strattera Intuniv, and Kapvay should always be taken exactly as prescribed. Strattera is usually taken once or twice a day and Kapvay is taken twice a day. Intuniv is a once-a-day drug. Your doctor will probably want you to check in periodically. He or she may order some lab tests to make sure that the drug is working and not causing any problems.

Several types of antidepressant drugs can be used to treat ADHD. Antidepressant therapy for ADHD is sometimes used as the treatment of choice for children or adults who have ADHD and depression.

Antidepressants, however, are generally not as effective as stimulants or nonstimulants at improving attention span and concentration.

Antidepressants used for treating ADHD include the following:

• Tricyclic antidepressants, such as Pamelor, Aventyl, Tofranil and Norpramin, have been shown to be helpful in children and adults with ADHD, but they can cause some unpleasant side effects, such as dry mouth, constipation, or urinary problems. They are also relatively inexpensive.
• Wellbutrin is a different type of antidepressant that is very effective in treating ADHD in adults and children. It is generally well-tolerated, but it also has some side effects that may be a problem for some people who have anxiety or seizures.
• Effexor and Effexor XR are newer antidepressants that increase the levels of norepinephrine and serotonin in the brain. The drugs are effective at improving mood and concentration in adults as well as children and teens. Effexor can be used to treat ADHD, but not commonly.
• Monoamine oxidase (MAO) inhibitors are a group of antidepressants that can treat ADHD with some benefit, but are rarely used because they have significant and sometimes dangerous side effects and can dangerously interact with foods and other medications. They may be of benefit in people where other medications have failed. Examples include Nardil or Parnate.

Note: In October 2004, The FDA determined that antidepressant medications increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders. If you have questions or concerns, discuss them with your health care provider.

Since most antidepressants work by increasing the levels of brain messenger chemicals (neurotransmitters), such as norepinephrine, serotonin, and dopamine, it makes sense that they might have effects similar to other ADHD stimulant and nonstimulant treatments that appear to work by similar mechanisms.

Antidepressants seem to improve attention span as well as impulse control, hyperactivity, and aggressiveness. Children and adolescents treated with antidepressants are often more willing to take direction and are less disruptive.

Antidepressants have the advantage of a low potential for abuse, and there is no evidence that they suppress growth or contribute to significant weight loss.

Antidepressants should not be used in the following situations:

• If you have a history or tendency toward manic behavior or manic depression (bipolar disorder).
• Wellbutrin can't be taken if you have any history of seizures or epilepsy.
• Treatment with antidepressants should not be initiated if you have taken a MAO inhibitor antidepressant, such as Nardil or Parnate, within the last 14 days.

Each type of antidepressant has its own contraindications and usage warnings, and you should discuss these with your doctor.

The most common side effects of tricyclic antidepressants include:

• Stomach upset
• Constipation
• Dry mouth
• Blurred vision
• Drowsiness
• Low blood pressure
• Weight gain
• Tremor
• Sweating
• Difficulty urinating

In addition, tricyclics are potentially lethal in the event of an overdose of medication.

Tricyclics also have the potential to cause serious heart conduction defects and may require periodic ECGs to look for these heart problems.

Wellbutrin sometimes causes stomach upset, anxiety, headaches, and rashes.

Effexor can cause nausea, anxiety, sleep problems, tremor, dry mouth, and sexual problems in adults.

MAO inhibitors can cause a wide variety of side effects, including dangerously increased blood pressure when combined with certain foods or medications.

When taking antidepressants for ADHD, be sure to tell your health care provider:

• If you are nursing, pregnant, or plan to become pregnant.
• If you are taking or plan to take any dietary supplements, herbal medicines, or nonprescription medications.
• If you have any past or present medical problems, including high blood pressure, seizures, heart disease and urinary problems.
• If you have a history of drug or alcohol abuse or dependency or if you have had mental health problems, including depression, manic depression, or psychosis.
• If you develop any depressive symptoms or feelings that you might harm yourself.
• If you develop irregular heartbeats (heart palpitations) or fainting spells.

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The following are useful guidelines to keep in mind when taking antidepressants or giving them to your child for ADHD:

• Always give the medication exactly as prescribed. If there are any problems or questions, call your doctor.
• Antidepressants usually take at least 2 to 4 weeks before the full effects are apparent. Be patient and don't give up before giving them a chance to work.
• Your doctor will probably want to start your medication at a low dose and increase gradually until symptoms are controlled.
• It is better not to miss doses of antidepressants. Most are given once or twice a day. If you miss a day or two of Effexor, it can cause an unpleasant withdrawal syndrome.
• Tell your doctor if you notice any new or unusual side effects.

Some drugs normally taken for high blood pressure, like Catapres and Tenex, may help control ADHD when used alone or in combination with stimulant drugs. The drugs can improve mental functioning as well as behavior in people with ADHD.

How high blood pressure drugs work in treating ADHD is not yet known, but it is clear that they have a calming effect on certain areas of the brain.

Clonidine can be applied in a weekly patch form for gradual medication release. This delivery method helps decrease some side effects, such as dry mouth and fatigue. After a few weeks, side effects usually diminish considerably.

Clonidine and guanfacine can help reduce some of the side effects of stimulant therapy, especially sleeplessness and aggressive behavior. However, combining stimulants with one of these drugs is controversial, because there have been some deaths in children taking both stimulants and Catapres.

It is not known whether these deaths were due to the combination of drugs, but caution should be exercised whenever such combinations are used. Careful screening for heart rhythm irregularities and regular monitoring of blood pressure and electrocardiograms help reduce these risks. If your doctor thinks that combining these two treatments offers more benefits than risks, it may be a good option.

Clonidine and guanfacine may be ruled out if there is a history of low blood pressure or other personal or family history of a significant heart problem.

The most common side effects seen with high blood pressure drugs include:

• Drowsiness
• Lowered blood pressure
• Headache
• Sinus congestion
• Dizziness
• Stomach upset

The drugs can rarely cause irregular heartbeats.

When taking one of these high blood pressure drugs for ADHD, be sure to tell your doctor:

• If you are nursing, pregnant, or plan to become pregnant.
• If you are taking or plan to take any dietary supplements, herbal medicines, or nonprescription medications.
• If you have any past or present medical problems, including low blood pressure, seizures, heart rhythm disturbances, and urinary problems.
• If you develop irregular heartbeats (heart palpitations) or fainting spells.

The following are useful guidelines to keep in mind when taking clonidine or guanfacine or giving them to your child for ADHD:

• Always take or give the medication exactly as prescribed. If there are any problems or questions, call your doctor. It is best not to miss doses or patches as this may cause the blood pressure to rise quickly, which may cause headaches and other symptoms.
• Your health care provider will probably want to start the medication at a low dose and increase gradually until symptoms are controlled.
• Clonidine patches come in various sizes. Rotate the placement of the patch to avoid skin irritation.
• For very young children, clonidine tablets can be formulated into a liquid by a compounding pharmacy to make it easier to give the medication. Tablets can be crushed and mixed with food if necessary.
• Do not stop clonidine or guanfacine suddenly since this can cause rebound increase in blood pressure. These medications must be tapered off gradually.