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

There are many drugs other than psychostimulants that can be used to treat ADHD.

Nonstimulant Therapy

Strattera is the first nonstimulant approved for treatment of ADHD. Adderall XR, a psychostimulant medication, is also approved to treat adult ADHD.

Strattera and all the other nonstimulants are generally considered to be less effective than psychostimulants in the treatment of ADHD. The nonstimulants are considered second- and third-line medications.

Strattera works on the neurotransmitter (chemical in the brain that transmits nerve impulses) called norepinephrine. Like the stimulant drugs, Strattera is effective in treating and controlling ADHD symptoms, but it is not a controlled substance and people are less likely to abuse the drug or become dependent on it.

In addition, Strattera doesn't cause many of the potential side effects linked to psychostimulants, such as sleeplessness. However, Strattera can cause other side effects including abdominal pain, nausea, and drowsiness, especially when starting the medication. What Strattera does better than the stimulant medications is provide a longer and smoother action without the "roller coaster" effect of the stimulant starting to work and then wearing off.

How Does Strattera Work?

This medication works by increasing the amount of norepinephrine, an important brain chemical, in the brain. Doing this appears to help ADHD by increasing attention span and reducing impulsive behavior and hyperactivity.

What Are the Side Effects of Strattera?

The most common side effects seen with Strattera are:

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

These side effects can be significant and may require stopping the medication.

Generally, these side effects are not severe, and only a very small percentage of clinical trial participants stopped Strattera due to side effects.

There have been reports of slightly decreased growth in children and teens. It is recommended that children and adolescents be observed, measured, and weighed periodically while on Strattera.

Allergic reactions to Strattera are rare but do occur, usually as swelling or hives. The prescribing doctor or other health care professional should be advised immediately if anyone taking Strattera develops a skin rash, swelling, hives, or other allergic symptoms.

On Dec. 17, 2004, Eli Lilly, the makers of Strattera, added a warning to the drug noting that Strattera should be stopped in patients with signs of jaundice -- yellowing of the skin or whites of the eyes. Jaundice is a sign of liver damage. If blood tests show evidence of liver damage, the drug should also be stopped.

In September 2005, the manufacturer added a warning stating that the drug can increase suicidal thinking in teens who take the drug.

Who Shouldn't Take Strattera?

There are certain situations in which a person should not take Strattera. If you or your child has any of the following conditions, you should discuss them with your health care provider before taking Strattera:

• Narrow angle glaucoma (a condition that causes increased pressure in the eyes and can lead to blindness).
• Treatment with a type of antidepressant called monoamine oxidase inhibitors, such as Nardil or Parnate, within 14 days of starting Strattera.

Strattera: Tips and Precautions

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 high blood pressure, seizures, heart disease, glaucoma, or liver or kidney disease.
• 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 have had any jaundice in the past.
• If you become agitated or irritable or if you develop ideas of hurting yourself.

Strattera should always be taken exactly as prescribed. It is usually taken once or twice a day and may be taken with or without food. No specific laboratory testing is required while taking Strattera and it may be used for extended, or long-term, treatment as long as there are periodic evaluations with your health care provider.

Antidepressant Therapy

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 Strattera 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, headaches, 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.

How Do Antidepressants Work?

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.

Antidepressant treatment seems 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.

Who Should Not Take Antidepressants?

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.

Side Effects of Antidepressants

The most common side effects experienced with 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 EKGs 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.

Antidepressants Therapy: Tips and Precautions

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.

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 2-4 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.

Blood Pressure Drugs Used to Treat ADHD

Two drugs, clonidine and guanfacine, normally taken to treat high blood pressure, have been shown to be of some benefit for 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 Do Blood Pressure Drugs Treat ADHD?

How these 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.

Who Should Not Take Blood Pressure Drugs?

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

What Are the Side Effects of Blood Pressure Medications?

The most common side effects seen with these drugs include:

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

The drugs can rarely cause irregular heartbeats.

Blood Pressure Medication: Tips and Precautions

When taking one of these 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.