Clonidine as adjunct therapy for ADD/ADHD

[cbrons]

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Anyone prescibe this along w stimulant therapy? For adults? Do you ADD adult pts w hypertension who use this in addition to methylphenidate or another stimulant? Basically trying to figure out how common this is. Indications for anxiety/panic disorder?

Also any better alternative to achieve similar effects?

 

[TexasPhysician]

Who hasn't prescribed clonidine with stimulants?

 

[billypilgrim37]

Also any better alternative to achieve similar effects?

Incredibly common.

Wouldn't say better, but guanfacine is a similar option with some properties preferable to clonidine in many contexts.

 

[DebDynamite]

Agree with both posts above. I have also treated patients who have come to me already on clonidine for panic d/o (social phobic), but have not initiated it myself for this indication. I have used propranolol more often than clonidine in that respect.

I have had good results with guanfacine in kids. So much so, that I have located compounding pharmacies in my area that will score the pills to 0.25 mg for extremely sensitive (hypotensive prone) patients.

 

[cbrons]

Dr gave a patient with diagnosed panic disorder and ADHD Adderall XR 20mg QAM, Catapres 0.1mg BID.

I asked him if stimulants were contraindicated in patients with panic disorder and he said the clonidine should calm the pt down. Btw the patient was on Provigil 200mg, complained it did not do much for his distractibility issues. Pt had BP taken in office and was normotensive (110/70).

I just thought it was an interesting combination, I have heard of beta blockers being used as anxiolytics but it seems that catapres o is used in part to off-set the undesirable side effects of the adderall.

Is this a good tx plan for someone with panic attacks AND focus problems?

 

[whopper]

I've tried Clonidine and guanfacine. From experience with patients, it seemed to only work well as an augmentation agent though I'm sure there's cases here or there where it could've yielded some benefit as a primary treatment. Oddly, I've had patients who had a great reaction to only one of them and not the other.

I had one case where Clonidine stabilized someone who without it was screaming, yelling, threatening, and would disrobe and expose his unit.

He was IMHO misdiagnosed with bipolar disorder. Indeed, what he had seemed like bipolar disorder when observing his behavior. The two things that got me thinking this was not bipolar disorder was that when interviewed, his thought process was linear though highly irritable, and he has fetal alcohol syndrome.

After reviewing the literature on FAS, I wondered if this was merely ADHD to the worst degree I ever saw it. FAS could cause it, and his mother drank extremely large amounts of alcohol daily. I didn't want to try him on a stimulant because he was on a forensic facility and tried Clonidine first under this idea (I tried Zyprexa, Depakote, Lithium, Haldol, Risperdal, Abilify, Geodon, Thorazine....no success. Thorazine wouldn't even knock him out even when given in mega-doses such as a few hundred mg at a time, and he told me it only made him feel even more agitated).

In hindsight, was this ADHD to the worst extreme? I don't think so now even though the Clonidine worked. From my other ADHD patients, I've noticed Clonidine or guanfacine only seemed to augment to stimulants or Wellbutrin, but in and of itself it hardly did anything.

 

[BobA]

Dr gave a patient with diagnosed panic disorder and ADHD Adderall XR 20mg QAM, Catapres 0.1mg BID.

I asked him if stimulants were contraindicated in patients with panic disorder and he said the clonidine should calm the pt down. Btw the patient was on Provigil 200mg, complained it did not do much for his distractibility issues. Pt had BP taken in office and was normotensive (110/70).

I just thought it was an interesting combination, I have heard of beta blockers being used as anxiolytics but it seems that catapres o is used in part to off-set the undesirable side effects of the adderall.

Is this a good tx plan for someone with panic attacks AND focus problems?

Does the patient have a diagnosis of narcolepsy?

If the provigil was intended to be used for ADHD then I think this combo is a little strange since the dose of adderall is low. It's better to use one medication than two.

But yes - I use intuniv frequently as an adjunct in patients with ADHD, especially if there is co-morbid anxiety.

Strattera monotherapy would be another option for ADHD (esp mild) with co-morbid anxiety.

 

[firedoor]

Is this a good tx plan for someone with panic attacks AND focus problems?

SSRI/SNRI + stimulant would generally be my first choice for panic w/ comorbid ADHD.

 

[cbrons]

SSRI/SNRI + stimulant would generally be my first choice for panic w/ comorbid ADHD.

Isn't that a little too sympathomimetic when doing snri with stimulants?

 

[firedoor]

Isn't that a little too sympathomimetic when doing snri with stimulants?

Generally not, in my experience. I tend to prescribe more Cymbalta than Effexor, but theoretically I'm sure Epocrates would warn of an additive hypertensive risk in combining Effexor with a stimulant, which is plausable, but again a relative contraindication. It is not uncommon for psychiatrists to combine Wellbutrin or Strattera with a stimulant. But of course each patient is unique.

Mechanistically, others here may be able to correct me or provide a better explanation, but I believe that a time-dependent (days to weeks) down-regulation of CNS beta-adrenergic receptors occurs with norepinephrine-reuptake inhibition which correlates with an overall attenuation of autonomic arousal. In fact, looking at it this way, an SNRI may theoretically attenuate the sympathetic activation produced by a psychostimulant, perhaps especially in patients whom have a baseline or propensity for psychosomatically-related hyperarousal (e.g. panic disorder).

I haven't done the digging, but selegiline would be an interesting consideration for comorbid ADHD and panic disorder.

This is a pretty interesting article too: Transdermal Nicotine in Adult ADHD With Depression and Anxiety: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2446482/

 

[whopper]

There is data showing that SNRIs do benefit ADHD and that is not surprising given that Strattera benefits ADHD and it's an NRI.

I've had several ADHD patients that met the criteria of panic disorder (other than that any DSM disorder's criteria could not be caused by another disorder) and once given a stimulant their panic attacks went away. My only theory as to why that happened was that their ADHD was causing secondary anxiety and the stimulant got the ADHD under control, then the secondary anxiety.

 

[firedoor]

I've had several ADHD patients that met the criteria of panic disorder (other than that any DSM disorder's criteria could not be caused by another disorder) and once given a stimulant their panic attacks went away. My only theory as to why that happened was that their ADHD was causing secondary anxiety and the stimulant got the ADHD under control, then the secondary anxiety.

I'll buy that. Kind of like how antipsychotics can treat anxiety secondary to unfamiliarity/confusion in dementia or delirium.

 

[Fastball32]

Clonidine is an alpha-2 agonist, same as Guanfacine. Long-acting Guanfacine, or Intuniv, is FDA approved for the treatment of ADHD, both for mono therapy and as an adjunctive therapy with stimulants. Guanfacine is less sedating than Clonidine, so it could be a better choice...Intuniv has a half-life of 18 hours and can be dosed morning or night. Alpha-2 agonists when used with stimulants, can improve ADHD sxs by 20%. So to answer the original question, yes, you can use clonidine or guanfacine with stimulants.