Adult ADHD Medication: Types, Side Effects & Risks

What Is Adult ADHD

Adult ADHD is diagnosed in patients that likely had ADHD as a child but were never diagnosed due to inadequate access to healthcare, or to parents, teachers or doctors missing the signs and symptoms in childhood.¹ Adults present with signs different than that of children, more likely with restlessness or difficulty carrying out tasks, while children may display hyperactivity and inattentiveness.¹

Adults with ADHD may have trouble in work related activities due to problems carrying out tasks, or may more frequently switch jobs because of it. In a relationship, they may have issues with forgetting chores or keeping organized; their partner may be impacted by this over time, which may result in distress.¹

Adult ADHD Treatment

Treatment for adult ADHD involves decision making by both the physician and patient. Together, they may elect to try a short acting stimulant, long acting stimulant or non-stimulant medication. A long acting stimulant medication may be chosen over a short acting if patients are only able to take medications once a day. A non-stimulant medication may be chosen over a stimulant medication if patients have pre-existing medical conditions or can not tolerate the side effect profile of stimulant medications. You should always discuss the risks and side effects of taking ADHD medication with your doctor prior to doing so.

In addition to medication, CBT with a neurodiverse affirming therapist may be beneficial. A neurodiverse therapist will work with patients to learn both the challenges and strengths that come with a patient’s diagnosis.

ADHD Medications for Adults vs Children

While children tend to have more hyperactivity, adults tend to have more restlessness. Similarly, adults with inattentiveness may have difficulty carrying out tasks or balancing their schedule and responsibilities. The main goal for adults with ADHD is improvement in daily function, such as keeping up with tasks throughout the day and staying organized.

“Psychostimulant medications are typically the first choice when treating ADHD in both adults and children. Adults are more likely to have conditions that might make the use of stimulants less desirable, such as hypertension or substance abuse problems, but overall the treatment for children and adults is very similar. Regarding differences in child versus adult ADHD, we don’t have much evidence that the physiology of the disorder or the treatment changes as we age, however the symptoms may present differently and cause different problems at different ages. For example, adults have more control over how they spend their time, and a person who is always late may have the option to try to get a job with flexible hours. Interpersonal issues related to inattention and impulsivity, on the other hand, can be problematic and difficult to control at any age.” – Dr. Rachel E. Dew⁷

The best ADHD medications for adults are stimulants .They have been proven to be the most effective in managing symptoms such as concentration and forgetfulness, seen in patients with ADHD. Stimulant medications come in two forms, short and long acting. While they have similar mechanisms of action, long acting stimulants usually require once daily dosing while short acting stimulants require multiple doses throughout the day.

With stimulant medication, there is no evidence to show that long acting is better than short acting or vice versa. They consist of the same active medication, just delivered in different ways depending on the duration of action desired. However, long acting stimulants significantly decrease the amount of pills a patient needs to take per day, which makes it easier for patients.

Most Effective ADHD Medication for Adults

The most common and effective medication for adult ADHD are stimulant medications. While short acting stimulants were more frequently used in the past, long acting stimulants are more commonly used now due to decreased amount of dosing requirements.

Patients that do not respond or have contraindications to stimulant medications have the option of non stimulant medications to manage their symptoms. The only FDA approved non-stimulant medication for the treatment of adult ADHD is atomoxetine. Other non-FDA approved options include bupropion, venlafaxine, and guanfacine.

Stimulants

Stimulants are the first line agents for treating adult ADHD. Stimulant medications work by increasing the level of the neurotransmitters norepinephrine and dopamine in the central nervous symptom.² They do this by increasing the release of the neurotransmitters in the brain and by stopping them from being recollected, making them more active.²

The goal for stimulant medication is for patients to improve daily function in their relationships and work life. Stimulant medications are a good first option for many patients, however they should be used with caution for patients with hypertension, tics, psychosis, or heart conditions as they increase both heart rate and blood pressure.

Some of the most commonly prescribed stimulants include:¹

• Ritalin (methylphenidate)
• Adderall (mixed amphetamine salts)
• Focalin (dexmethylphenidate)
• Vyvanse

Note that stimulant medications for ADHD carry a black box warning for drug abuse and dependence, and the risk of sudden death and serious heart events due to misuse. A black box warning is the most serious warning from the FDA.

Short-Acting Stimulant Medications

Short-acting stimulants act immediately, but have a half-life of about 3-4 hours which requires redosing every 3-4 hours.¹ Effects, such as increasing concentration and decreasing forgetfulness, are commonly seen in less than one hour.

Long Acting Stimulant Medications

Long-acting stimulants allow for sustained release throughout the day and therefore only need to be taken once a day. They also act immediately with effects commonly seen within 1 hour. Examples include Concerta (which is long acting methylphenidate), Focalin XR, Adderall XR and Vyvanse. In adults, current research seems to suggest that Adderall and Vyvanse are more effective than methylphenidate.

Non-Stimulants

Non-stimulant medications are considered second line for ADHD and are less commonly used to treat ADHD. This is likely due to less efficacy and longer treatment time to see improvement in symptoms (4-6 weeks). This may be a good option for treating ADHD in patients with substance abuse, tics, and psychosis. However, patients with hypertension should be followed closely in the outpatient setting.

The only non-stimulant medication approved by the FDA for adult ADHD is atomoxetine. Atomexetine works by blocking norepinephrine reuptake in the synapse.³

Some of the most commonly prescribed non-stimulants include:

• Atomoxetine (FDA approved)
• Guanfacine
• Clonidine
• Bupropion (wellbutrin)

Note that non-stimulant medications for ADHD carry a black box warning for suicidal thoughts and behavoris in children, adolescents, and young adults. A black box warning is the most serious warning from the FDA. Intuniv (guanfacine) does not carry this black box warning.

Off-Label ADHD Meds for Adults

The off-label medications that may be used for ADHD include wellbutrin, guanfacine, and clonidine. Off-label medications do not have FDA approval for treatment of ADHD but have shown improvement in some patients in small studies with a small follow up period.

Bupropion (Wellbutrin)

Wellbutrin works by decreasing norepinephrine and dopamine reuptake and allows dopamine to stay in the brain for longer.⁵ It can be prescribed for adult ADHD if other FDA approved options, such as stimulants, do not show benefit. However, it is contraindicated in patients with any history or risk factors of seizures including eating disorders. It works to treat both the restlessness and inattentiveness seen in ADHD.

Guanfacine & Clonidine

Guanfacine and clonidine were originally designed to treat adults with hypertension. However, they are very rarely used for hypertension anymore. There has been some benefit for patients with ADHD who either had an inadequate response to stimulant medication or decided to stop stimulant medication due to the side effects. They aim to reduce similar symptoms to stimulant medications, but do so with less efficacy. They tend to work better for restlessness and impulsivity than for inattention.⁶

ADHD Medication Side Effects

Side effects of stimulants can either be seen immediately or after months to years of use. Side effects can be reduced by taking only the amount of medication prescribed and monitoring blood pressure and pulse with monthly primary care appointments. Generally all stimulant medications have a similar side effect profile.^1,2

Side effects resolve after treatment, however, it is important that patients follow up regularly with their primary care physician for monitoring and a cardiologist if underlying heart conditions are present.

General side effects from stimulants include:^1,2

• Dry mouth
• Appetite suppression
• Abdominal Pain
• Insomnia
• Weight loss
• Nausea/vomiting

General side effects from non-stimulants include:^4,5,6

• Nausea/vomiting
• Diarrhea
• Anxiety
• Dizziness
• Insomnia
• Somnolence

If you experience chest pain/palpitation or shortness of breath you should contact your doctor or call 911 immediately. Other signs to monitor for include tremors, sweating, anxiety, and fever.

Risks & Warnings of Using ADHD Medication

All medications come with side effects and it’s important for you to know what to look out for. All side effect profiles of medications should be discussed during a clinical visit with your doctor. While stimulant medications have been shown to be the most effective medication for ADHD, patients with heart disease or other medical problems (blood pressure) may not tolerate them well.

Atomoxetine can be used for adult ADHD as well, but may cause palpitations in some patients. Wellbutrin is used as an off-label medication for the treatment of adult ADHD but may increase the risk for seizures in some patients.

Risks for stimulant medications include:

• Increased risk of heart disease especially in patients with a previous history of heart disease.
• Increased risk with longer duration of treatment
• Appetite suppression
• Increased blood pressure, palpitations
• Abuse potential resulting in amphetamine toxicity

Risks for Atomoxetine include:

• Increased risk of suicidal ideation in children and teenagers
• Headache, nausea, vomiting, drowsiness
• Increased blood pressure, palpitation

Risks for Wellbutrin include:

• Increasing risk for seizures (especially in underweight patients)
• palpitations and tachycardia
• Insomnia, agitation, anxiety

Risks for Guanfacine include:

• Hypotension causing dizziness, somnolence, or falls
• Irritability

ADHD Medication Interactions

Stimulant medications can have side effects in patients with previous heart disease such as heart failure, arrhythmias, or angina. Stimulant medications should be taken with caution in patients with medications that raise heart rate. Patients should be followed up with regularly in the outpatient setting to monitor blood pressure/heart rate. Caution should be taken when used with other non-prescription stimulants found in cold medicines and with caffeine.

Patients should be monitored closely if they take both a stimulant medication and SSRI/SNRI for the increased risk of serotonin syndrome. While children have routine follow up to monitor for appetite and proper growth, this is not done for adults.^1,2

Patients taking antidepressants (SSRIs and SNRIs) should not take Atomoxetine or wellbutrin for the management of their ADHD due to increased risk of serotonin syndrome. Similarly patients should avoid other medications that are known to increase serotonin (some nausea medications, antibiotics, etc). It is crucial that patients and doctors review all medications before adding medications used for adult ADHD.^4,5

Questions to Ask Your Health Team About ADHD Meds for Adults

You should feel comfortable with the treatment plan before starting medication. Discussing how these medications may affect you on an individual basis is an important part of your treatment plan. Patients should be clear on their dosing, how many times a day they should be taking the medication, and one or two important side effects to watch out for. You can always request additional reading materials to better understand your treatment plan.

Questions to ask your care team about before taking medication for adult ADHD include:

1. How does the medication work?
2. How can I tell if the medication is effective at treating my ADHD symptoms?
3. What are common side effects I should be aware of?
4. What are the high risk side effects that require immediate attention?
5. What should I do if these side effects are present?
6. What is the correct dose I should be taking and when should I take it?

Final Thoughts

If adult ADHD is interfering with your daily life and you’re interested in medication, you should discuss your treatment plan with a doctor. Medication, therapy, or behavioral changes might be part of the treatment plan for you.