Understanding Nonstimulant Medications for ADHD
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental condition estimated to affect around 9.4% of children in the United States. The hallmark symptoms include difficulty paying attention, excessive activity, and impulsive actions.
For decades, stimulant medications like Ritalin and Adderall have been the first-line pharmacological treatments for ADHD. However, more recently nonstimulant options have emerged providing additional choices.
Nonstimulants may be preferable for certain families given concerns about stimulant side effects, abuse potential, or just wanting a different mechanism of action. Two of the newest nonstimulant ADHD drugs approved are Qelbree and Strattera.
How Nonstimulants Work
Instead of increasing dopamine and norepinephrine like stimulants, nonstimulants modulate neurotransmitters through different pathways. For example:
- Strattera - Norepinephrine reuptake inhibitor
- Intuniv - Alpha-2A agonist
- Kapvay - Alpha-2A agonist
- Qelbree - Norepinephrine reuptake inhibitor and sigma-1 receptor modulator
In general, nonstimulants may have a slower onset of action taking several weeks to reach full effect. However, they provide sustained symptom relief throughout the day without wearing off.
Benefits of Nonstimulant ADHD Drugs
Potential advantages of nonstimulant medications include:
- Lower abuse potential
- Fewer impacts on sleep and appetite
- Alternative mechanism of action
- Option for stimulant non-responders
- Less rebound when discontinued
- May be combined with a stimulant if needed
Ultimately the choice between stimulant and nonstimulant ADHD medication depends on weighing pros and cons for the individual child and family.
Comparing Strattera vs Qelbree
Strattera was the first nonstimulant ADHD medication approved by the FDA in 2002. Qelbree was more recently approved in 2021, providing a newer alternative. How do Strattera and Qelbree stack up?
Mechanism of Action
Both Strattera and Qelbree influence norepinephrine, a key neurotransmitter involved in attention regulation. Specifically:
- Strattera - selective norepinephrine reuptake inhibitor (SNRI)
- Qelbree - SNRI + sigma-1 receptor modulator
Strattera works by blocking reabsorption of norepinephrine at the synapse, increasing its activity. Qelbree does this as well, plus acts on sigma-1 receptors involved in cellular signaling.
Effectiveness for ADHD Symptoms
Studies show both Strattera and Qelbree effectively reduce core ADHD symptoms of inattention, hyperactivity, and impulsivity in children. Published trials found:
- Strattera - Improved ADHD Rating Scale scores by 11-15 points
- Qelbree - Reduced ADHD-RS-5 scores 14.2 points (200 mg dose)
However, Qelbree appears faster acting with benefits seen in 2 weeks versus 4-6 weeks for Strattera. Maximum effects occur at 6 weeks for Qelbree and up to 8 weeks for Strattera.
Approved Ages
Both medications are FDA approved for ADHD treatment in children, but age ranges differ slightly:
- Strattera - Approved for ages 6 and up
- Qelbree - Approved for ages 6-17
Qelbree was specifically studied in children ages 6-11 in clinical trials, while Strattera has a more expanded approved age range. However, doctors may still prescribe either medication off-label if deemed appropriate.
Dosage Forms
Strattera and Qelbree come in different dosage forms:
- Strattera - Capsule taken daily
- Qelbree - Once daily capsule sprinkled onto applesauce or swallowed whole
Qelbree capsules cannot be opened, broken, or chewed due to a bitter taste. Strattera may be opened and mixed into liquids if needed.
Dosage Schedule
Both medications are taken once daily, but timing differs slightly:
- Strattera - Morning or evening daily
- Qelbree - Morning daily
Taking Qelbree in the morning helps maintain sleep quality as it can cause insomnia if taken later in the day. Strattera is more flexible with AM or PM dosing.
Side Effects and Safety
When comparing the safety profiles of Strattera vs Qelbree, they are relatively similar with a few key differences.
Most Common Side Effects
The most frequent side effects of Strattera and Qelbree include:
- Strattera - Upset stomach, decreased appetite, nausea, fatigue, mood swings
- Qelbree - Sleep issues (insomnia), decreased appetite, headache, fatigue, upper respiratory infection
Strattera is more associated with gastrointestinal effects like nausea and vomiting, while Qelbree is more likely to cause sleep disturbance and insomnia.
Growth and Weight
Nonstimulants have less impact on growth and weight compared to stimulants. However, Strattera may result in more appetite suppression and weight loss than Qelbree.
In studies, Strattera caused an average weight loss of 2.7 lbs over 9 weeks compared to no weight change with Qelbree. Both drugs led to slight reductions in expected height growth.
Heart Rate and Blood Pressure
Stimulants commonly increase heart rate and blood pressure, while Strattera and Qelbree do not significantly affect cardiovascular parameters at therapeutic doses.
In overdose, Qelbree may cause slowed heart rate and low blood pressure based on its pharmacology. Strattera overdose is less likely to impact heart rate or blood pressure.
Suicidal Thoughts
All ADHD medications come with an FDA warning about potential increased risk of suicidal thoughts and behavior. Careful monitoring for changes in mood and behavior is warranted when starting any ADHD drug.
No completed suicides occurred in clinical trials of either Strattera or Qelbree. The long-term real world risk remains unclear for the newer drug Qelbree.
Final Key Considerations
When deciding between trying Strattera or Qelbree for your child's ADHD, keep the following key factors in mind:
Onset of Action
Qelbree works more rapidly than Strattera, with benefits seen in just 2 weeks. Strattera can take 4-6 weeks to have full effect. This quicker response may make Qelbree preferable.
Cost and Insurance Coverage
As a newer drug, Qelbree is more expensive than the generic version of Strattera. It may also take time for insurance policies to include Qelbree in their drug formularies. Check on coverage specifics.
Impact on Sleep
The sedating effect of stimulants can be beneficial for some children at night. Qelbree's activation and insomnia side effect may be concerning for families of kids who already struggle to fall asleep.
Type of ADHD Symptoms
Some data suggests Qelbree may have greater efficacy for reducing hyperactivity and impulsivity symptoms specifically. It may be preferable for ADHD presentations with prominent hyperactivity.
Age of Child
Qelbree is only approved for ages 6-17 years old, while Strattera can be used starting at age 6 and continuing into adulthood. If your child is older than 17 or you want a medication that can follow them into adulthood, Strattera may be the better option.
Discuss all benefits and risks thoroughly with your child's doctor to decide if Strattera or Qelbree is more appropriate as a nonstimulant medication choice for their ADHD treatment.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.
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