| | Advantages | Disadvantages | Comments |
| Short-acting stimulants | - Extensive data efficacy and safety.
- Generic formulations available.
- Flavored oral suspension and chewable tablet available for methylphenidate.
- Flavored oral suspension and oral disintegrating tablet available for amphetamine.
| - Must be taken 2 to 3 times per day if full-day coverage is desired.
| - Methylphenidate preferred for preschool-age children.
|
| Long-acting stimulants | - Can be dosed once per day (can avoid administration at school).
| - Side effects may extend later in the day.
- Increased cost.
- Fewer generic options.
| - Short-acting stimulant can be added in PM for afternoon boost when needed.
|
| Single-pulse sustained release (eg, Metadate ER) | - Generic formulations available.
| | - Must be swallowed whole.
- Preferably taken 30 to 45 minutes before meal.
|
| Extended release oral suspension (Dyanavel XR, Adzenys ER, Quillivant XR), extended-release chewable tablet (eg, Quillichew ER, Dyanavel XR), or oral disintegrating tablet (Adzenys XR-ODT, Cotempla XR-ODT) | - May be used for children who have difficulty swallowing pills.
- These preparations are flavored and may be more palatable.
| - No generic options.
- Increased cost.
| - May be taken with or without food.*
- Do not mix oral suspensions with food or other liquids before taking.
|
| Sustained release bead preparations (eg, Ritalin LA, Focalin XR, Adderall XR, Metadate CD, Aptensio XR, Adhansia XR, Mydayis¶) | - Approximates a twice-per-day or 3-times-per-day dosing schedule.
- Can be sprinkled into soft foods for children who have difficulty swallowing pills.
- Generic formulations are available for some products.
| | - The beads should not be chewed.
- Some products should not be taken with antacids or other drugs that decrease gastric acidity.
- Ingestion with a high-fat meal may delay time of onset and increase peak concentration.
|
| Methylphenidate HCl extended-release capsules (Jornay PM) | - Designed to deliver drug in the early morning. Lasts throughout the day, using delayed-release and extended-release technology.
| - No generic options.
- Increased cost.
| - Initiate dosing at 8:00 PM. Adjust the timing of administration between 6:30 PM and 9:30 PM to optimize efficacy and tolerability the next morning and throughout the day.
- May be taken with or without food. May be taken whole, or the capsule may be opened, and the entire contents sprinkled onto applesauce (to be consumed immediately and entirely without chewing).
|
| Prodrug coformulated with immediate release (serdexmethylphenidate-dexmethylphenidate [Azstarys]) | - Fast onset (from immediate-release dexmethylphenidate) and duration that lasts throughout the day (from serdexmethylphenidate [dexmethylphenidate prodrug]).
- Can be sprinkled over applesauce or into water for children who have difficulty swallowing pills.
| | - May be taken with or without food. May be taken whole or the capsule may be opened and the entire contents sprinkled onto applesauce or into water (to be consumed within 10 minutes).
|
| Osmotic release (eg, Concerta, Relexxii) | - Approximates a 3-times-per-day dosing schedule.
- Osmotic release approved generics for Concerta with limited availability.
| - Children with decreased GI absorption or intestinal resection may not receive the full benefit.
| - Capsule should not be opened or chewed.
- Capsule is passed through the GI tract and into the stool intact.
|
| Patch (Daytrana, Xelstrym) | - Can be used for patients who cannot take oral medications.
| - Patch must be applied 2 hours before needed effect.
- Associated with application site reactions (including permanent loss of pigmentation with Daytrana).
- No generic options.
- Increased cost.
| - Early removal of the patch permits controlled duration (effects last approximately 2 to 3 hours after patch is removed).
|
| Prodrug (Lisdexamfetamine [Vyvanse]) | - May have lower risk for abuse.
- Capsules can be opened and mixed with water for children who have difficulty swallowing capsules.
- Chewable tablet available.
| - No generic options.
- Increased cost.
| |
| Selective norepinephrine reuptake inhibitors | - Can be dosed once per day.
- Lower potential for abuse than stimulants.
- Not a controlled substance.
| - May be less efficacious than stimulants.
- Potential increased risk of suicidal ideation.
- "Drug holidays" are not an option.
| - Concomitant use or use within 14 days after discontinuing monoamine oxidase inhibitor is contraindicated.
|
| Atomoxetine | - Generic formulation available.
| - More time to steady state (up to 2 weeks for initial response; up to 8 weeks for maximal effect).
| - Weight-based dosing.
- Taking with food may prevent nausea.
- Requires dosing adjustment if administered with agents that strongly inhibit the cytochrome P450 2D6 (CYP2D6) enzyme.
|
| Viloxazine ER capsules | - Earlier onset than atomoxetine (initial response may occur within 1 week; up to 5 weeks for maximal effect).
- Capsule may be opened and contents sprinkled over a teaspoonful of applesauce for children who have difficulty swallowing capsules.
| | - May be taken with or without food.
- Strong CYP1A2 inhibitor; concomitant administration of sensitive substrates is contraindicated; other CYP1A2 substrates may require dosing adjustments.
|
| Extended release alpha-2-adrenergic agonists | - Not a controlled substance.
- May also treat coexisting conditions (eg, sleep disorders, tic disorders).
- Generic formulations available.
- FDA approved for monotherapy and as an adjunct to stimulants.
| - May be less efficacious than stimulants.
- More time to steady state (up to two weeks for initial response).
- "Drug holidays" are not an option.
| - Must be swallowed whole, not crushed or chewed.
- May lead to hypotension and orthostasis.
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