What Are the Main Types of Once-Daily ADHD Medications?
Once-daily ADHD medications are broadly classified into two categories: stimulants and non-stimulants. Stimulants are the most common and effective first-line treatment for ADHD, acting quickly to increase neurotransmitter levels like dopamine and norepinephrine. Non-stimulants offer an alternative for individuals who experience adverse effects from stimulants or have co-existing conditions like anxiety.
Once-Daily Stimulants
Stimulants are divided into two main chemical classes: amphetamine-based and methylphenidate-based. Extended-release formulations provide a steady, all-day effect, unlike their short-acting counterparts which require multiple doses.
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Amphetamine-based:
- Vyvanse (lisdexamfetamine dimesylate): This is a prodrug, meaning it is inactive until it is metabolized in the body into the active stimulant, dextroamphetamine. This unique mechanism provides a smooth, long-lasting effect, with some formulations lasting 10-12 hours. It is available in capsules and chewable tablets.
- Adderall XR (amphetamine/dextroamphetamine): As the extended-release version of Adderall, it uses a bead-based delivery system with two releases of medication over the day, lasting up to 12 hours.
- Mydayis (mixed amphetamine salts): A newer extended-release stimulant, Mydayis uses a triple-bead formulation to provide symptom control for up to 16 hours, suitable for adults and adolescents aged 13 and older.
- Azstarys (serdexmethylphenidate/dexmethylphenidate): This combines a prodrug (serdexmethylphenidate) with an immediate-release component (dexmethylphenidate) to offer a rapid onset and extended duration, approved for those aged 6 and up.
- Dyanavel XR (amphetamine): Available as a tablet or oral suspension, Dyanavel XR provides an extended-release effect for 8-12 hours.
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Methylphenidate-based:
- Concerta (methylphenidate): This uses an osmotic-release oral system (OROS) to provide a smooth, continuous dose throughout the day for up to 12 hours.
- Jornay PM (methylphenidate): Uniquely, Jornay PM is taken at night and uses a delayed-release mechanism to begin working in the morning, providing symptom relief for 12+ hours.
- Aptensio XR (methylphenidate): A bead-based capsule that lasts up to 12 hours.
- Cotempla XR-ODT (methylphenidate): An orally disintegrating tablet (ODT) that lasts 12-13 hours.
- Quillivant XR and QuilliChew ER (methylphenidate): Extended-release liquid and chewable tablet options.
Once-Daily Non-Stimulants
- Strattera (atomoxetine): As a selective norepinephrine reuptake inhibitor (SNRI), atomoxetine works by increasing norepinephrine in the brain. It is not a controlled substance, making it a suitable option for individuals with a history of substance abuse or who experience significant anxiety with stimulants. It takes several weeks to reach full effectiveness.
- Qelbree (viloxazine): Another SNRI non-stimulant, Qelbree is approved for children, adolescents, and adults. It provides 24-hour symptom coverage after building up in the system for a few weeks.
- Intuniv (guanfacine): An alpha-2 adrenergic agonist, Intuniv was originally developed for high blood pressure but helps manage ADHD symptoms like impulsivity, hyperactivity, and aggression. It provides a 24-hour effect and is not a controlled substance.
How Extended-Release Formulations Work
Long-acting, once-daily ADHD medications utilize advanced technology to deliver their active ingredients gradually over many hours. This extended release is achieved through different mechanisms:
- Bead-based systems: Many long-acting capsules (like Adderall XR and Aptensio XR) contain a mix of immediate-release and extended-release beads. This provides an initial dose followed by a second, delayed dose hours later.
- Osmotic-release systems (OROS): Concerta uses a unique tablet that releases the drug at a controlled rate via osmotic pressure, providing a smooth and steady dose.
- Prodrug technology: Vyvanse is a prime example of this, where the inactive drug is converted to its active form during metabolism. This process provides a gradual, predictable effect with low abuse potential.
- Delayed-release: Jornay PM is designed to be taken at bedtime, with a delayed-release coating that prevents the medication from being released until the morning.
Comparison of Key Once-Daily ADHD Medications
| Feature | Vyvanse (Lisdexamfetamine) | Concerta (Methylphenidate) | Strattera (Atomoxetine) |
|---|---|---|---|
| Drug Class | Stimulant (Amphetamine) | Stimulant (Methylphenidate) | Non-stimulant (SNRI) |
| Mechanism | Prodrug converted to dextroamphetamine | Osmotic pressure system for controlled release | Increases norepinephrine levels |
| Onset | Rapid (within 1-2 hours) | Rapid (within 1 hour) | Slow (several weeks) |
| Duration | 10-12 hours | 10-12 hours | 24 hours (with daily use) |
| Abuse Potential | High (Controlled substance) | High (Controlled substance) | Low (Not controlled) |
| Common Side Effects | Insomnia, decreased appetite, anxiety | Insomnia, decreased appetite, dry mouth | Sleepiness, nausea, decreased appetite |
| Anxiety Benefit | Can sometimes worsen anxiety | Can sometimes worsen anxiety | Can help manage co-existing anxiety |
| Formulations | Capsule, Chewable Tablet | Tablet | Capsule |
How to Choose a Once-Daily ADHD Medication
Selecting the right once-daily medication requires a thorough evaluation with a healthcare professional, considering various factors:
- Symptom Profile: Evaluate whether hyperactivity, inattention, or impulsivity is the primary concern. Different medications may target specific symptoms more effectively.
- Co-existing Conditions: If conditions like anxiety, depression, or a history of substance abuse are present, non-stimulants might be the preferred starting point due to their lower risk profile.
- Side Effect Tolerability: While common side effects like appetite suppression and insomnia can occur with stimulants, individuals' tolerance can vary. If side effects are intolerable, switching to a different stimulant formulation or a non-stimulant may be necessary.
- Lifestyle and Schedule: Consider daily routines, school schedules, and work demands. Some formulations, like Jornay PM, offer nighttime dosing for morning symptom control, while others require morning administration.
- Cost and Availability: Generic versions are often more affordable than brand names. However, some newer formulations may not have generic options yet. Patient assistance programs may also be available.
Common Side Effects of Once-Daily ADHD Medications
While once-daily formulations are designed to be well-tolerated, side effects can occur. Discussing these with your doctor is important to find the right balance between effectiveness and side effect management.
Stimulant Side Effects
- Loss of appetite and weight loss
- Insomnia or trouble sleeping
- Headaches and stomachaches
- Irritability and mood swings
- Increased heart rate and blood pressure
Non-Stimulant Side Effects
- Fatigue and sleepiness
- Nausea and upset stomach
- Decreased appetite
- Dry mouth
- Dizziness
Conclusion
Once-daily ADHD medication offers a significant advantage in managing ADHD symptoms by providing consistent, day-long relief with a single dose. The availability of diverse long-acting stimulants (like Vyvanse, Adderall XR, and Concerta) and non-stimulants (such as Strattera and Intuniv) means that treatment can be highly personalized. The choice of medication depends on an individual's specific symptom profile, side effect tolerance, co-existing conditions, and daily routine. Working closely with a healthcare provider is essential to navigating these options, selecting the most appropriate medication, and monitoring for effectiveness and tolerability over time. Medication is most effective when used as part of a comprehensive treatment plan that may also include behavioral therapy and lifestyle adjustments.
For more information on the efficacy of amphetamines for adults, you can review this NIHR-funded systematic review: Amphetamines probably the best first-choice treatment for adults with ADHD.
