Research and clinical experience have shown that stimulant medications are the most effective first-line treatment for ADHD in both males and females.
Currently, there are many medication formulations, including stimulants (methylphenidate and amphetamine preparations) and nonstimulants for the treatment of attention-deficit/hyperactivity disorder. Although a few skeptics continue to voice concerns over the prescription of medication for children and adults with attention deficit hyperactivity disorder, studies suggest that stimulant medication is the most effective treatment option for ADHD and that, in some studies in children, medication alone has a positive treatment effect equal to medication in combination with behavior therapy.
Most patients respond equally well to either methylphenidate or amphetamine preparations. While early studies on the effectiveness of medications to treat ADHD were conducted solely on young boys, more recent studies have included women and girls with the disorder, who have responded as well as males to both stimulants and nonstimulants. Given the high variability in effective dose for each individual, however, when undertaking treatment of ADHD with stimulants or nonstimulants, a person should be started at the lowest dose possible and the dosage increased every 5 to 7 days until effective symptom reduction and normalization of functioning is achieved.
Methylphenidate products for the treatment of ADHD include the well-known brand, Ritalin, an immediate-release preparation that takes effect in a relatively short period of time and lasts about 4 hours. Ritalin is also available as long-acting formulation Ritalin LA. Other long-acting medications containing methylphenidate include Concerta, Focalin XR, Daytrana, Metadate CD, and Methylin.
Both Dexedrine, Adderall, and Vyvanse are trade names for products whose active component is a formulation of amphetamine or amphetamine salts. Dexedrine, which has been available for many years, is equally as effective as methylphenidate for a number of problems associated with attention deficit hyperactivity disorder, but is not prescribed as frequently. Adderall is the trade name for a generic compound of mixed amphetamine salts (three forms of d-amphetamine and one of l-amphetamine). Adderall, which has been studied in children, has been shown to be effective in reducing disruptive behaviors in a classroom setting, improving parent and teacher behavior ratings, and improving academic performance. It is recommended that the maximum daily dose not exceed 40 mg. The duration of effects of Adderall is generally dose-dependent, with higher doses resulting in longer duration of action (e.g., 5 mg is usually effective for 3.52 hours, and 20 mg usually produces effects for 6.4 hours). Adderall is also available as a once-daily formulation (called Adderall XR), which has a much longer duration of action (10 to 12 hours). Vyvanse is a newer long-acting drug formulation. Vyvanse is one of the longest-acting stimulant formulations on the market and has a low likelihood of abuse since the drug is not active until it is broken down in the body.
In addition to the first-line stimulants, nonstimulants have also been prescribed to treat attention deficit hyperactivity disorder, usually as an off-label use or second-line therapy. These nonstimulants include imipramine (Tofranil), desipramine (Norpramin), bupropion (Wellbutrin), venlafaxine (Effexor), clonidine (Catapres), guanfacine (Tenex), and modafinil (Provigil). In the past, however, these medications have never been quite as effective as stimulants and were used off-label, not having received Food and Drug Administration (FDA) approval for the treatment of attention-deficit/hyperactivity disorder.
Recently, a once-daily, extended-release formulation of Intuniv (guanfacine) has been approved for the treatment of ADHD in children and adolescents. In clinical trials, Intuniv demonstrated significant reduction in both ADHD and oppositional symptoms. Intuniv is not a controlled substance and has no known mechanism for abuse or dependence. The most common side effect of this drug is sedation, which is usually transient and mild to moderate in severity. Fainting occurred in approximately 1% of pediatric patients in the clinical trials. Small to modest changes in blood pressure, pulse rate, and electrocardiogram parameters were also observed.
In 2004, atomoxetine (Strattera), another nonstimulant, was approved for the treatment of attention-deficit/hyperactivity disorder. Full therapeutic effects of atomoxetine may take at least a week to be felt, but once adequate blood levels are obtained, effectiveness can last for 24 hours. Therefore. atomoxetine should be taken for 6 to 8 weeks before you decide whether it is working or not. Some people who do not respond to stimulants respond to atomoxetine. Atomoxetine has a low potential for abuse and is not a controlled substance.
Table lists medications (stimulants and nonstimulants) used to treat attention deficit hyperactivity disorder, their duration of action, and a brief description of each.
Duration 3-4 hours
|Ritalin||Methylphenidate||5 mg, 10 mg, and 20 mg|
|Focalin||Refined form of Ritalin, isolating the d-isomer||2.5 mg, 5 mg, and 10 mg|
|Methylin||Methylphenidate||5 mg, 10 mg, and 20 mg|
|Methylin chewables||Chewable methylphenidate||2.5 mg, 5 mg, and 10 mg|
|Methylin suspension||Liquid methylphenidate||5 mg/5 ml and 10 mg/5 ml|
Duration 8-12 hours
|Description IM/ER Ratio*||Dosages Available|
|Ritalin SR||Methylphenidate 50/50||20 mg|
|Ritalin LA||Methylphenidate 50/50, mimics twice a day dosing||10 mg, 20 mg, 30 mg, and 40 mg|
|Metadate CD||Methylphenidate 30/70||10 mg, 20 mg, 30 mg, 40 mg, 50 mg, and 60 mg|
|Concerta||Methylphenidate 22/78, mimics 3x a day dosing||18 mg, 27 mg, 36 mg, and 54 mg|
|Focalin XR||Dextromethylphenidate50/50||5 mg, 10 mg, 15 mg, and 20 mg|
|Methylin ER||Methylphenidate 50/50||10 mg and 20 mg|
|Daytrana||Methylphenidate Transdermal patch delivering 1.1/1.6/2.2/ 3.3 mg/hr over 9 hours||10 mg, 15 mg, 20 mg, and 30 mg|
Duration 4-5 hours
|Dexedrine||Dextroamphetamine||5 mg and 10 mg|
|Adderall||Mixed amphetamine salts||5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, and 30 mg|
Duration 8–14 hours
|Adderall XR||Mixed amphetamine salts, mimics twice a day dose||5 mg, 10 mg, 15 mg,20 mg, 25 mg, and 30 mg|
|Dexedrine Spansule||Dextroamphetamine||5 mg, 10 mg, and 15 mg|
|Vyvanse||Lisdexamfetamine (a prodrug activated in the body)||20 mg, 30 mg, 40 mg, 50 mg, 60 mg, and 70 mg|
Duration 24 hours
|Strattera||Atomoxetine||10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, and 100 mg|
|Intuniv||Guanfacine||1 mg, 2 mg, 3 mg, and 4 mg|
Medications Approved for Adults with ADHD
Although widely used in adults, only a few of these medications have been formally approved by the FDA for use in adults with attention-deficit/hyperactivity disorder. Since 2004, the following medications have been approved for the treatment of ADHD in adults: the nonstimulant Strattera (atomoxetine), Adderall XR (mixed amphetamine salts), Vyvanse (lisdexamfetamine), Focalin XR (dextromethylphenidate), and Concerta (methylphenidate). In addition to these medications, a few clinical trials have shown that Provigil (modafinil), a waking agent used for the treatment of excessive daytime sleepiness; Wellbutrin (buproprion); Tofranil (imipramine); and Norpramin (desipramine) can be somewhat effective, although none of these medications is specifically approved for the treatment of attention-deficit/hyperactivity disorder.
The ability of stimulants to treat ADHD is excellent.
Effectiveness of Medications to Treat ADHD
The ability of stimulants to treat ADHD is excellent; most are at least 70% effective when prescribed at appropriate dosages in adults. Studies that have looked at the effects of gender on the response to stimulants in women have not shown any difference in efficacy or safety. At higher doses, as many as 80% of adults respond to stimulants with a decrease in symptoms seen as early as the first week of treatment. Nonstimulants, (Strattera and Intuniv) are also quite effective but at slightly lower rates.
Selections from the book: “100 Questions & Answers About Attention-Deficit Hyperactivity Disorder (ADHD) in Women and Girls”, Patricia O. Quinn, MD, Director National Center for Girls and Women with AD/HD, Washington, DC, 2011