Choose Nonstimulants with Care in ADHD

By Walsh, Nancy | Clinical Psychiatry News, September 2005 | Go to article overview

Choose Nonstimulants with Care in ADHD


Walsh, Nancy, Clinical Psychiatry News


NEW YORK -- Options are available for children with attention-deficit hyperactivity disorder who do not respond to treatment with stimulants or are troubled by side effects, but they must be chosen and used carefully, Laurence L. Greenhill, M.D., said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

First the diagnosis should be reviewed, as many conditions that will not respond to stimulants can overlap or mimic ADHD. These include oppositional defiance disorder, anxiety problems, depression, occasionally bipolar disorder, and psychotic conditions.

"And don't forget substance abuse disorder, which is a pretty good neutralizer of some stimulant treatments," said Dr. Greenhill, who is professor of clinical psychiatry at Columbia University, New York, and director of research for the pediatric psychopharmacology unit at the New York State Psychiatric Institute.

The preferred second-line drug is atomoxetine (Strattera), a nonstimulant, highly specific norepinephrine reuptake inhibitor. This is not a controlled substance, so it also is useful for parents who are uncomfortable giving their child a schedule II drug, he said.

As a 24-hour drug, atomoxetine significantly improves behavior and activities in both evening and early morning.

"The most important thing you can do for your patients is to start this drug slowly and give it twice a day when you are titrating it," Dr. Greenhill said. Patients are much less likely to experience severe somnolence if the drug is titrated over a week, despite the fact that the labeling says upward titration to a full dose of 1.2 mg/kg per day can begin after 3 days on the initial dose of 0.5 mg/kg per day.

If the full dose is given rapidly, there is a good chance that a formerly disruptive ADHD child will fall asleep in class. …

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