Treatment of ADHD-like Symptoms in Autism with Guanfacine and Clonidine

Rationale for Combination Therapy

The American Academy of Child and Adolescent Psychiatry suggests that clonidine may be used to provide better control of ADHD symptoms after other medications have worn off, or to counteract insomnia, with extended coverage 1, 2
Clonidine requires divided dosing (up to 4 times daily) when controlling aggressive behavior, while guanfacine provides around-the-clock effects 3

The recommended dose of clonidine is within the range of 0.1-0.4mg/day maximum, typically started at 0.05mg at bedtime and increased slowly, according to the Journal of the American Academy of Child and Adolescent Psychiatry 1, 2
Guanfacine dosing is typically adjusted to body weight (0.1 mg/kg as a rule of thumb), with 1mg being a standard starting dose 3, 4

Cardiovascular assessment is necessary before and during treatment with this combination, including obtaining history of cardiac symptoms and family history of sudden death, repeated fainting, or arrhythmias, which would contraindicate use, as recommended by the Journal of the American Academy of Child and Adolescent Psychiatry 1, 2, 5
Baseline and ongoing vital signs must be monitored, as both medications cause hypotension and bradycardia, with additive effects when combined 4, 5

The American Academy of Child and Adolescent Psychiatry recommends that both medications must be tapered to avoid withdrawal effects and rebound hypertension, and never abruptly discontinued 3, 4, 5
Guanfacine has a more favorable side effect profile than clonidine, with less sedation due to higher specificity for alpha-2A receptors, according to Praxis Medical Insights 3