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Atomoxetine vs. Methylphenidate for ADHD
Both are more effective than placebo, but the stimulant remains the first-line choice.
Atomoxetine is the only norepinephrine reuptake inhibitor currently approved in the U.S. for treating ADHD. In a rigorously designed, two-part study, researchers compared atomoxetine with the standard drug methylphenidate (MPH).
First, 516 children aged 6 to 16 years with any ADHD subtype were randomly assigned in a 3:3:1 ratio to atomoxetine, osmotically released MPH, or placebo for 6 weeks. Maximum dose was 54 mg for MPH and 1.8 mg/kg for atomoxetine. Both atomoxetine and MPH were significantly more efficacious than placebo (response rates, 45%, 56%, and 24%, respectively), and MPH was statistically superior to atomoxetine.
Then, MPH recipients were switched in double-blind fashion to atomoxetine for 6 weeks (the original atomoxetine recipients entered a dose-adjustment trial; results not reported). Among the 178 patients switched to atomoxetine, 34% responded to either MPH or atomoxetine, but not both; 44% responded to both; and 22% responded to neither. Of the atomoxetine nonresponders, 42% had previously responded to MPH, and of the MPH nonresponders, 43% responded to atomoxetine.
Comment: After this study was begun, the U.S. Food and Drug Administration increased the maximum dose of osmotically released MPH to 72 mg/day and decreased the maximum atomoxetine dose to 1.4 mg/kg/day, but these changes are unlikely to have affected the outcome. The findings support MPH as a first-line medication due to its superior efficacy. In addition, because MPH products have been used for many decades, their long-term effects on growth and development are better known. If MPH is not effective for a patient, these findings strongly support trying an alternative medication. But before trying atomoxetine, clinicians should first turn to dexamphetamine products, which, like MPH, have been on the market for decades.
Published in Journal Watch Psychiatry April 14, 2008
Citation(s):
Newcorn JH et al. Atomoxetine and osmotically released methylphenidate for the treatment of attention deficit hyperactivity disorder: Acute comparison and differential response. Am J Psychiatry 2008 Feb 15; [e-pub ahead of print]. (http://dx.doi.org/10.1176/appi.ajp.2007.05091676)