Adult ADHD Treatment with Medications

The treatment of attention deficit hyperactivity disorder (ADHD) in adults usually requires several actions in sequence. The primary treatment is often medication, which can significantly improve a person’s life and well-being when employed alongside behavioral therapies and lifestyle enhancements.

What Medications Are Used for Adult ADHD?

The two main categories of medications used to treat adult ADHD are stimulant and non-stimulant. Stimulants are the most commonly prescribed and include medications like methylphenidate and amphetamines. They increase dopamine and norepinephrine levels in the brain, boosting focus, attention, and impulse control.

Non-stimulants are prescribed when stimulants don’t work or have adverse effects, or when an individual doesn’t wish to be on habit-forming medication or can’t due to addiction. Non-stimulant drugs include medications like atomoxetine, which increases norepinephrine, and guanfacine or clonidine, which affects receptors in the brain to help regulate attention and impulse control. Stimulants and non-stimulants can both work, but it depends on individual needs, response, and tolerance.

Stimulant Medications

Stimulant medications are the best ADHD medication for adults. ^[1] They include methylphenidate and amphetamines.

1. Methylphenidate

Methylphenidate is one of the most commonly prescribed stimulants for adult ADHD. Examples include Ritalin and Concerta. It’s available in both short-acting and long-acting forms. Methylphenidate works primarily by blocking the reuptake of dopamine and norepinephrine. ^[2] Dopamine is associated with motivation, reward processing, and executive functions like planning and attention, while norepinephrine is involved in arousal, alertness, and regulating attention to stimuli.

Typically, after these neurotransmitters are released into the synaptic cleft (the gap between neurons), they are taken back into the presynaptic neuron via reuptake transporters. Methylphenidate blocks these transporters, preventing the reabsorption of dopamine and norepinephrine. This results in a higher concentration of these neurotransmitters in the synapse and, therefore, more stimulation of their respective receptors in the postsynaptic neuron. ^[1]

By increasing the activity of both of these neurotransmitters in the brain, methylphenidate helps focus, attention, and impulse control in individuals with ADHD.

1. Amphetamines

Amphetamines are adult ADHD medications that come in two main forms, immediate-release (IR) and extended-release (XR). Examples include Adderall and Vyvanse. These medications work in several ways to increase the availability of dopamine and norepinephrine in the brain.

Amphetamines release dopamine and norepinephrine from presynaptic neurons into the synapse, increasing their availability for receptor binding.

Like methylphenidate, amphetamines also block the reuptake of dopamine and norepinephrine by blocking the transporters that clear these neurotransmitters from the synapse. Amphetamines can also prevent the storage of dopamine and norepinephrine in vesicles within the presynaptic neuron. This means more of the neurotransmitters are available for release into the synapse.

Non-Stimulant Medications

While stimulant medications are considered the first-line treatment option for ADHD in adults, there are non-stimulant ADHD meds for adults who do not respond well to stimulants, experience adverse effects, or have personal reasons that don’t make stimulants the best option.

1. Atomoxetine (Strattera)

Atomoxetine is a selective norepinephrine reuptake inhibitor ^[3] (NRI) that is commonly prescribed for ADHD, especially when stimulants are not well-tolerated or are contraindicated.

Atomoxetine inhibits the norepinephrine transporter (NET), leading to increased norepinephrine (and, to a lesser extent, dopamine) levels in the brain, particularly in regions involved in attention and executive function.

Norepinephrine is crucial for regulating attention, focus, and alertness, and its increased availability can help manage symptoms of ADHD. Atomoxetine may be prescribed when an individual cannot tolerate stimulant medications due to side effects such as anxiety, insomnia, or elevated heart rate. It may also be an option for those with a history of substance abuse or those with co-occurring conditions like anxiety or tic disorders.

2. Guanfacine (Intuniv)

Guanfacine is an alpha-2 adrenergic agonist originally used for high blood pressure, but is now also employed for ADHD. It’s mainly used in combination with stimulants or when they aren’t working. The extended-release version of guanfacine is called Intuniv.

Guanfacine stimulates alpha-2 adrenergic receptors in the brain, especially in the prefrontal cortex, which is involved in attention, working memory, and executive function. This stimulation decreases sympathetic nervous system activity and has a calming effect that helps manage control, attention, and behavioral regulation.

Guanfacine is prescribed for adults with ADHD when stimulants aren’t appropriate (e.g., for patients with anxiety, sleep disturbances, or high blood pressure). It’s often used as an add-on for patients who still have significant symptoms despite stimulant use or for those who can’t tolerate stimulants.

Side Effects of ADHD Medication in Adults

Stimulant and non-stimulant medications used to treat ADHD can cause several side effects, some of which require medical attention. ^[1] Below are some of the potentially serious common side effects.

Common Side Effects

1. Insomnia: People using stimulants for ADHD may have difficulty falling or staying asleep. Stimulants increase norepinephrine and dopamine in the brain, disrupting sleep patterns, especially if taken later in the day.
2. Fatigue/Drowsiness: Non-stimulant medications like guanfacine have a calming effect on the brain, which can lead to drowsiness or fatigue, especially at higher doses.
3. Decreased Appetite: Stimulants can suppress appetite and may cause weight loss.
4. Anxiety/Nervousness: Stimulants activate the sympathetic nervous system and can cause anxiety, restlessness, or nervousness.
5. Headache: Mild to moderate headaches can be caused by the medication’s effect on blood vessels and overall nervous system stimulation.

Serious Side Effects

1. Cardiovascular Issues: Medications for adult ADHD can increase heart rate and blood pressure, which is dangerous for people with pre-existing heart conditions.
2. Liver Damage: Atomoxetine can, in rare cases, affect liver function.
3. Psychosis/Mania: High doses or overuse of stimulants can cause psychiatric disturbances, especially in individuals with a history of mood disorders or psychosis.
4. Severe Allergic Reactions: Some may be allergic to these meds, which can lead to adverse reactions like rashes, difficulty breathing, and swelling of the face or throat.

What Is the Best ADHD Medication for Adults?

When choosing medication for adults with ADHD, several factors determine the best treatment.

1. Individual Symptoms and Severity

Adults with ADHD often have symptoms of inattention, hyperactivity, and impulsive behaviors. The relative prominence of these symptoms can guide medication choice. For example, if the primary symptom is inattention, stimulants like methylphenidate (Ritalin) or amphetamines (Adderall) might be more effective as they tend to improve attention and concentration.

Atomoxetine (Strattera) or guanfacine (Intuniv) may be considered for hyperactivity. The more severe the symptoms, the more likely stimulants will be considered first. For mild ADHD, non-stimulants or lower doses of stimulants may be tried first.

2. Comorbid Conditions

Many adults with ADHD have comorbid mental health conditions such as anxiety, depression, substance use disorders, or sleep disorders. ^[4] Stimulants can sometimes worsen anxiety, so a non-stimulant like atomoxetine or an antidepressant may be considered. Patients with insomnia may consider non-stimulant medications like guanfacine or clonidine since stimulants can disrupt sleep.

Adults with a history of substance use disorders may be more likely to misuse stimulants. So, non-stimulants or meds with a lower risk of misuse may be better.

3. Response to Previous Treatments

Previous responses to ADHD medications are key. If a patient has tried stimulants and had good results with minimal side effects, they may be the best option. But, non-stimulant medications should be considered if they’ve had side effects or no results. ADHD medications often require trial and error to find the right medication and dose.

4. Lifestyle and Personal Preferences

Some medications, such as extended-release stimulants (e.g., Vyvanse or Concerta), last all day, making them suitable for busy people. However, shorter-acting or as-needed medications may be better for those requiring flexibility or who have trouble following a daily regimen.

Some adults may prefer non-stimulant medications because of concerns about stimulant use, side effects, or stigma. Others may prefer the faster and more potent effects of stimulant medications.

Monitoring and Adjusting Treatment

While ADHD meds (particularly stimulants) can provide significant relief, they do not work the same way for everyone. One person might experience significant improvements with minimal side effects, while another may struggle with side effects or not feel much of a benefit. Regular follow-ups allow healthcare providers to evaluate how well the medication controls symptoms like inattention, hyperactivity, and impulsivity.

Some people with ADHD may not respond well to the first medication prescribed, or they may experience side effects that interfere with daily functioning. In these cases, follow-ups are key to identifying issues early and switching to a different medication or formulation. Non-stimulant medications, like atomoxetine or guanfacine, may be considered when stimulants are ineffective or cause intolerable side effects. ^[5]

The response to ADHD treatment for adults is highly individualized, and dosage adjustments or medication changes may be necessary throughout the treatment journey. Because a person’s response to ADHD medication can change over time, healthcare providers may need to adjust dosages to achieve the right balance between effectiveness and minimizing side effects.

Many individuals with ADHD also have co-occurring conditions like anxiety, depression, or learning disabilities. Regular check-ins allow providers to assess how ADHD treatment is interacting with these other conditions and whether any adjustments need to be made to the overall treatment plan.