Do you ever feel overwhelmed by the sheer amount of medication options for ADHD? Is brand X really better than that generic you’ve been using forever? Listen, I get it. The ADHD medication landscape is constantly evolving, filled with products that have specific niches. However, I don’t view this as a negative; it allows us to tailor treatments to meet patient-specific needs like never before. But sometimes, we need to take things that appear complex on the surface and reduce them to the essentials. That’s what I want to do here: break down the medication essentials of ADHD.

It reminds me of a professor I had in pharmacy school who often referenced a “toolbox.” We might have a dozen different options for a tool, and many of them can solve the same problem, but at the end of the day, they’re all just variations of the same basic tools. In ADHD treatment, while we have a multitude of medications with different names and formulations, the core goal remains the same: to find the right fit for each patient’s needs.

Laying the Foundation: An Overview of ADHD Medication Classes

With so many ADHD medication options available, let’s dive into a few key classes, their effectiveness, and how they fit within the WVACC Guidelines found at wvadhd.org/guidelines/. Before starting any ADHD medication, however, the most important step is ensuring that the patient is an appropriate candidate for the treatment. Careful assessment of their medical history, comorbidities, and potential contraindications should guide the decision to initiate therapy. For more information, see our section in the WVACC Guidelines: Prior to Starting Medication, found at this link: https://wvadhd.org/guidelines/#priortostartingmedication%E2%80%8C.

• Stimulants: As a first-line pharmacological therapy for patients 6 years of age and older, in our guidelines and many others, stimulants are effective in 75-80% of children with ADHD (Briars & Todd, 2016).
  • Classes: Methylphenidates (e.g., Ritalin®, Concerta®) and Amphetamines (e.g., Adderall®, Vyvanse®).
  • Mechanism of Action: Stimulants block the reuptake of norepinephrine and dopamine in the synaptic cleft. By increasing the levels of these neurotransmitters, stimulants improve patients’ ability to focus and reduce hyperactivity.
    • Key Differences: Amphetamines also promote the release of norepinephrine and dopamine into the synaptic cleft, which can enhance their effectiveness but may also lead to more side effects. Due to this difference, methylphenidates are recommended by the American Academy of Pediatrics if used in children under 6 years of age for their comparatively better side effect profile.
  • Clinical Pearl: Approximately 40% of children will respond to either methylphenidate or amphetamines, while 40% may respond to one but not the other. Additionally, 20-35% may not respond to either class of medication (Childress & Sallee, 2014; Wolraich et al., 2019).
  • Most Common Adverse Effects: Appetite suppression and weight loss, insomnia, increased heart rate and blood pressure, anxiety, irritability, headaches, dry mouth
  • Black Box Warnings: Stimulants have a black box warning for risks of misuse, dependence, and serious heart events. These medications may increase the risks of sudden death, heart attack, or stroke, particularly in patients with heart conditions, so careful assessment and monitoring are essential.

• Non Stimulants:
  • Option 1: Selective Norepinephrine Re-uptake Inhibitors; these medications are also first-line in our guidelines for patients who are deemed not to be candidates for stimulants and adults as they have demonstrated effectiveness in reducing ADHD symptoms. The most commonly used products are atomoxetine (Strattera®) and viloxazine (Qelbree®)
  • Mechanism of Action: Selective inhibition of norepinephrine reuptake indirectly increases the concentration of norepinephrine in the synapse
  • Key differences: While atomoxetine, with an effect size of up to 0.7, is generally less effective than stimulants in treating core ADHD symptoms, it has been consistently shown to outperform placebo (Wolraich et al., 2019). A recent meta-analysis confirmed that chronic use of methylphenidate and atomoxetine improves executive functions, including attention, inhibition, and reaction time, with comparable effects, though only methylphenidate showed benefits for working memory (Isfandnia et al., 2024).
  • Clinical Pearl: It can take up to 4 to 8 weeks of consistent use to reach the full therapeutic effect. Atomoxetine is metabolized by CYP 2D6, so be cautious around some classes, such as SSRIs, TCAs, and SNRIs, which have some medications that, in combination with atomoxetine, can lead to an increase in adverse effects and the need to alter dosing for some patients. Viloxazine inhibits CYP1A2, which is the enzyme that metabolizes caffeine, so it is important to counsel patients on potentially reducing their caffeine intake if they are experiencing issues such as insomnia, gastrointestinal upset, and increased blood pressure.
  • Most Common Adverse Effects: Gastrointestinal issues such as nausea, vomiting, and stomach pain, decreased appetite and weight loss, fatigue and drowsiness, mood changes, dry mouth
  • Black box warning: Atomoxetine (Strattera®) and viloxazine (Qelbree®) carry black box warnings for an increased risk of suicidal thoughts in children and adolescents, particularly in the first few months or after dose changes.

• Option 2: Alpha-2-agonists are another study-tested class that shows improvements in ADHD symptom reduction. Clonidine extended-release (Kapvay™) and guanfacine extended-release (Intuniv®) are the FDA-approved treatment options for pediatric patients with ADHD that fall within this class.
• Mechanism of Action: This is not definitive, but the hypothesis is that they mimic the effects of norepinephrine on the alpha2-adrenoreceptor in the prefrontal cortex. In other words, the molecule acts as norepinephrine and stimulates the prefrontal cortex, a brain region affected by ADHD, resulting in improved symptoms.
• Clinical Pearl: These medications are FDA-approved for use in 6-17-year-old patients, and literature also supports use in adults. They are often useful as an adjunct therapy and can take 2 to 4 weeks to see the maximum benefit. Long-acting formulations are recommended due to a more favorable side effect profile, as they do not have the “peaks and troughs” we see in immediate-release products.
• Most Common Adverse Effects: drowsiness and fatigue, low blood pressure and dizziness, bradycardia, dry mouth, constipation

Equipping Your Team: The Importance of Education

Patient education is the cornerstone of a successful treatment plan, and setting realistic expectations for medication outcomes is essential. While ADHD medications can be highly effective in managing symptoms, it’s important to communicate that they do not ‘cure’ ADHD or eliminate all challenges associated with it. Even with stimulant treatment, some patients may continue to face difficulties in areas like organization, social skills, and emotional regulation.

A critical component of patient education is helping set a reasonable timeline for symptom improvement. While individual responses can vary, most stimulants produce noticeable effects within the first week of initiation. For non-stimulant medications such as atomoxetine or viloxazine, this period may take four to six weeks before robust symptom improvements become evident.

Upon initiating a new medication, Johns Hopkins’ Best Practice and Measure Tips recommends a follow-up visit within 14 to 21 days (Johns Hopkins Medicine, 2022). For maintenance visits, the WVACC guidelines recommend conducting follow-up visits every 3 months. These visits should include a thorough review of symptoms, a discussion on medication management (covering adverse effects, efficacy, control, and dose adjustments), and risk reduction strategies.

In addition, clinicians should consider non-pharmacological aspects of treatment, such as referrals to appropriate specialists or coordination of care. For younger patients, reviewing school accommodations (like IEPs or 504 Plans) can especially be important, and for adults, workplace accommodations can be valuable.

Each follow-up should also revisit the overall treatment plan, incorporating ADHD assessment scales to track symptom management, addressing any concerns from parents or family members, and scheduling future visits as necessary.

Measuring Twice: Using a Stimulant Conversion Chart

Sometimes, in clinical practice, transitioning a patient between stimulant medications can be stressful, although a necessary part of optimizing the treatment plan. To assist with this process, the WVACC Guidelines include a stimulant conversion chart that helps guide equivalent dosing across different stimulant classes. You can access the entire chart here with more details: https://wvadhd.org/wp-content/uploads/2024/07/Stimulant-Conversion-AID-1.pdf

Here is a brief explanation of how it works.

You take the currently prescribed mg/day dose of Drug A, such as the example here, multiply it by a conversion factor, and voila! You will have a new total daily dose of Drug B that you can then split if you are using immediate-release products or convert to the nearest available dose of an extended-release. Whether you round up or down is drug-dependent and patient-specific, but generally, it is usually recommended that meds are rounded down and started from the lower dose to minimize potential adverse effects.

Note: Some medications cannot, per package inserts, be directly converted to another product – that list is available at the bottom of the chart.

For a full explanation and details behind the conversion factors, check out Appendix 2.8 of the WVACC Guidelines or follow this link: https://wvadhd.org/wp-content/uploads/2023/08/Appendix-2.8-ADHD-Medication-Conversion-Aid-akh.pdf

Crafting Unique Solutions: Tailoring Treatment Plans

Creating an effective ADHD treatment plan is about finding the best fit for each patient’s lifestyle, preferences, and needs. Compliance is a key challenge in this population, so it’s essential to select formulations that are easy for patients to incorporate into their daily routines. If a patient dislikes capsules, alternatives like patches or sprinkle formulations can help improve adherence. Remember, all these fancy stimulant brand names fall into two primary classes: amphetamines and methylphenidates. Different isomers, salt forms, prodrugs, and delivery systems have been developed to enhance their effectiveness and adaptability. These innovations allow individualized treatment options that balance effective symptom management with a tolerable side effect profile. As clinicians, we are responsible for understanding the patient-specific details and identifying the best formulation for each individual. In cases involving youth patients, it’s also important to consider the household’s ability to support a consistent medication routine and monitoring, as parental involvement and oversight can be crucial.

Our WVACC guidelines, in particular, recommend long-acting stimulants for several reasons:

• Reduce the need for school-time administration, helping to prevent stigma for young patients
• Lower potential for misuse compared to shorter-acting options
• Support improved adherence by minimizing the frequency of doses
• Provide a gradual release, preventing the peaks and valleys associated with shorter-acting stimulants for steadier symptom management
• Increase the likelihood of effectiveness as monotherapy, simplifying the treatment plan

Final Touches

To hammer the nails home, ADHD treatment is about keeping things simple and focused on the essentials. Here are the big takeaways:

1. Assess Candidacy First – Before initiating any medication, ensure the patient is an appropriate candidate for stimulant treatment. This means collecting as much information as possible to guide your decision.
2. Consider Non-Stimulants – Non-stimulant medications can be effective alternatives, especially for patients who may not tolerate stimulants well or for whom stimulants are contraindicated.
3. There are Two Stimulant Classes with Many Formulations – Nearly all stimulant medications belong to one of two categories: methylphenidate-based or amphetamine-based products. Within these categories, a wide array of formulations exists to address each patient’s unique needs. Variations in isomers, salt forms, prodrugs, and delivery systems allow for tailoring treatment to achieve optimal symptom control while maintaining a manageable side effect profile. The WVACC guidelines have a detailed section devoted to breaking down all the types and formulations of these medications, which can be found here: https://wvadhd.org/wp-content/uploads/2023/08/Appendix-2.6-ADHD-Medications.akh.pdf.
4. Consider Formulary Options– Ensuring medication access is crucial for successful treatment.  Therefore, choosing a medication covered by a patient’s insurance or generically available for those without insurance is best to ensure they are regularly able to get their medication.  Further, prior authorizations or requests for medical necessity may be required for alternative options that better meet the patient’s needs.  
5. Prioritize Adherence – Select a formulation that best supports the patient’s lifestyle and adherence to ensure consistency in treatment.
6. Set Realistic Expectations – Help patients understand what to expect from their medication, emphasizing that these treatments don’t “cure” ADHD but can improve symptom management.  Counseling is vital for those nonstimulant options to let patients know that their medications may not have an immediate effect.
7. Follow-Up to Evaluate Effectiveness – Regular follow-up is essential to assess medication effectiveness and make necessary adjustments.
8. Ask for Help When Needed – ADHD treatment is a collaborative process, so involve other resources or specialists as needed. Our Academic Detailing Team is devoted to providing any assistance you need. Please find our contact information below.

With these principles, we keep our approach simple, focusing on selecting the right tools to build an effective, supportive treatment plan for each patient.

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We value your feedback and are here to support you. If you have any questions, comments, or concerns regarding ADHD or our blog content, please get in touch with us. Your insights are essential, and we aim to provide our readers with the most helpful and relevant information.

Follow this link to schedule a session with us: https://wvadhd.org/schedule-appointment/

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Resources

• American Academy of Pediatrics Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: https://publications.aap.org/pediatrics/article/144/4/e20192528/81590/Clinical-Practice-Guideline-for-the-Diagnosis?autologincheck=redirected
• American Psychiatric Association: https://www.psychiatry.org/patients-families/adhd/what-is-adhd
• American Psychological Association: https://effectivechildtherapy.org/concerns-symptoms-disorders/disorders/inattention-and-hyperactivity-adhd
• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD): CHADD.org
• Info About Kids: https://infoaboutkids.org/emotions/common-emotional-conditions/adhd-behavior-problems
• West Virginia Guide to Evidence-Informed Evaluation, Diagnosis, and Treatment of ADHD and Comorbid Concerns: WVADHD.org

References

• Briars, L., & Todd, T. (2016). A review of pharmacological management of attention-deficit/hyperactivity disorder. The Journal of Pediatric Pharmacology and Therapeutics, 21(3), 192–206. https://doi.org/10.5863/1551-6776-21.3.192
• Childress AC, Sallee FR. Attention-deficit/hyperactivity disorder with inadequate response to stimulants: approaches to management. CNS Drugs. 2014;28(2):121‐129. doi:1007/s40263-013-0130-6
• Isfandnia, F., El Masri, S., Radua, J., & Rubia, K. (2024). The effects of chronic administration of stimulant and non-stimulant medications on executive functions in ADHD: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 162, 105703. https://doi.org/10.1016/j.neubiorev.2024.105703
• Johns Hopkins Medicine. (2022). Follow-up care for children prescribed ADHD medication. Retrieved from link
• West Virginia University School of Pharmacy’s Rational Drug Therapy Program with Expert Panel. (2024). A West Virginia Guide to Evidence-Informed Evaluation, Diagnosis, and Treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) and Comborbid Concerns. https://wvadhd.org/
• Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & SUBCOMMITTEE ON CHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVE DISORDER. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528