Pharmacological Management for ADHD with Comorbidities

Current Medication Issues

A 24-year-old female patient with severe ADHD, autism spectrum disorder, and history of anxiety/depression is experiencing inconsistent efficacy and side effects with Adderall, including medication "crash" periods and difficulty winding down at night, and has comorbid conditions that need to be considered 1

The American Academy of Child and Adolescent Psychiatry recommends switching from Adderall to atomoxetine (Strattera) for patients with ADHD and comorbid anxiety disorders, as it provides "around-the-clock" effects without the rebound/crash experienced with stimulants, and has demonstrated efficacy in patients with autism spectrum disorder 1, 2
Atomoxetine can be administered once daily, simplifying the medication regimen, and may require 4-6 weeks to achieve full therapeutic effect, with a maximum recommended dose of 100mg daily 2

If atomoxetine is ineffective, consider lisdexamfetamine (Vyvanse) as an alternative, which has a longer duration of action compared to immediate-release Adderall, and lower potential for rebound effects, with once-daily dosing 1, 3, 4, 5
Guanfacine extended-release can be used as an alternative or adjunct therapy, particularly beneficial for sleep disturbances, comorbid anxiety, and "around-the-clock" effects 2, 6

Assess efficacy of atomoxetine after 6-12 weeks, and monitor for common side effects including decreased appetite, headache, and stomach pain, as well as regular assessment of pulse and blood pressure 1, 2

Atomoxetine's non-stimulant mechanism may help address both ADHD symptoms and anxiety without the CNS side effects, and has shown efficacy for both ADHD and autism spectrum disorder 2
The patient's history of sexual side effects with sertraline is less likely to occur with atomoxetine, and the "crash" periods currently experienced with Adderall would likely be eliminated with atomoxetine's more consistent pharmacokinetic profile 1, 2