Attention-Deficit/Hyperactivity Disorder Medications for Adults

What Is the Issue? Pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD) focuses on medications that elevate the levels of certain neurotransmitters in the brain such dopamine and norepinephrine to target ADHD symptoms of impulsivity, inattention, and hyperactivity. The medications are classified as stimulants and nonstimulants. Stimulants are drugs with a rapid effect, but they also have the potential for dependence, misuse, and diversion; nonstimulants may take longer to have an effect, but they do not have the same potential for drug misuse. Decision-makers are interested in understanding how medications are chosen to treat ADHD in the general adult population as well as in the correctional setting. What Did We Do? We identified and summarized the literature on the evidence of the clinical effectiveness, safety, and cost-effectiveness of stimulants and nonstimulants for the treatment of ADHD in adults. We also searched for evidence-based guidelines that provide recommendations on the use of stimulants and nonstimulants for the management of ADHD in adults. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened citations for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings. What Did We Find? We identified an Australian evidence-based guideline for ADHD. The aim of the guideline is to promote the timely identification, diagnosis, and treatment of ADHD across the lifespan of patients. With respect to medication choice for the treatment of ADHD in adults (aged 18 years and older), the guideline recommends that stimulants — such as methylphenidate, dexamfetamine, or lisdexamfetamine — be offered as first-line treatment for people living with ADHD whose symptoms cause significant impairment. The guideline recommends that nonstimulants, such as atomoxetine or guanfacine, be offered as second-line treatment if stimulants are contraindicated, not tolerated, or ineffective. Concurrent treatment with both stimulants and nonstimulants is also recommended to increase the benefit of treatment. Other drugs such as bupropion, clonidine, modafinil, reboxetine, and venlafaxine may be offered as third-line treatments. Regarding fourth-line treatments for adults with ADHD, based on expert opinion and clinical experience of the guideline development group members, a clinical practice point was made to include lamotrigine, aripiprazole, agomelatine, armodafinil, and desvenlafaxine. Although we found no evidence on the optimal medication choice for specific populations, such as people in the correctional system or people with co-occurring substance use disorder, the guideline recommends exercising caution when prescribing stimulants as first-line therapy to people who have a risk of misuse or diversion. We did not find any studies on the clinical effectiveness, safety, and cost-effectiveness of stimulants compared to nonstimulants for the management of adult ADHD. What Does This Mean? Recommendations from the identified guideline suggest that stimulants are commonly prescribed as first-line treatment for adult ADHD because of their rapid effect. However, for people living with ADHD who have a risk of misuse or diversion, prescribing nonstimulants as first-line therapy may be a better option.