What are the common drugs for adult ADHD, How long is the course and much they cost, What are the side effects in long term
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"Attention Deficit Disorder with Hyperactivity"[MeSH Terms] AND "adult"[MeSH Terms] AND "Central Nervous System Stimulants"[MeSH Terms]
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adult ADHD medication cost per month methylphenidate lisdexamfetamine atomoxetine NHS NICE guideline duration treatment
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long-term adverse effects ADHD medication adults cardiovascular risk stimulants systematic review
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ADHD medication cost per month without insurance Adderall Vyvanse Concerta generic atomoxetine price GoodRx
Common drugs for adult ADHD
Stimulants (first-line, controlled drugs)
- Methylphenidate (Ritalin, Concerta, Medikinet XL and others)
- Lisdexamfetamine (Vyvanse/Elvanse)
- Dexamfetamine and mixed amphetamine salts (Adderall)
Non-stimulants (second-line)
- Atomoxetine (Strattera)
- Guanfacine. A 2023 meta-analysis found a response rate of about 60%, against about 30% for placebo.
- Viloxazine and bupropion are also used, but with less supporting data.
NICE recommends methylphenidate or lisdexamfetamine first. Atomoxetine is offered if those aren't tolerated, or if there was no response to a separate 6-week trial of each. Extended-release stimulants are preferred over immediate-release because they carry less risk of tolerance, misuse and diversion (The Maudsley Prescribing Guidelines in Psychiatry, 15th ed., p. 823-824). Atomoxetine is also a reasonable choice if misuse is a concern.
How long is the course?
There is no fixed course length. For most adults ADHD is a long-term condition, and drug treatment continues for as long as it works.
- Start-up: Doses are titrated over several weeks. Atomoxetine takes a few weeks to work, whereas stimulants act quickly (Kaplan & Sadock's Comprehensive Textbook of Psychiatry).
- Trial length: NICE advises switching between methylphenidate and lisdexamfetamine after a 6-week trial at an adequate dose with a poor response.
- Review: A trained clinician should review the medication at least once a year and discuss whether to continue (Maudsley, p. 822).
- Response over time: Stimulant response may lessen over longer treatment in a significant minority of patients (Maudsley, p. 823).
- Breaks: Some people take planned breaks, but that is an individual decision to make with your prescriber.
Cost
Costs depend heavily on the country and on whether you have insurance. These are web-sourced estimates, not figures from the textbooks, so check your local pharmacy.
US, cash price, approximate monthly (per CoveredUSA and NeuroLaunch):
| Drug | Brand | Generic with coupon |
|---|---|---|
| Adderall | about $200-415 | $15-60 |
| Vyvanse / lisdexamfetamine | $300-558 | $60-120 |
| Concerta / methylphenidate ER | $200-545 | $30-90 |
| Strattera / atomoxetine | $200-400 | $60-100 |
UK: On the NHS, prescriptions are either free or a fixed charge. The larger cost is the assessment. A private assessment is reported at £400-£1,200 or more. NHS waits for assessment and titration are reported at 6-18 months. Many NHS services accept a private diagnosis and then take over prescribing under a shared-care agreement.
Shortages of ADHD medication have forced some patients onto pricier alternatives or off treatment entirely (Maudsley).
Long-term side effects
Long-term data are more limited than short-term data. Stimulants are generally well tolerated and safe in the short term (Maudsley, Table 9.1).
Common effects, which can persist with continued use
- Insomnia, appetite suppression and weight loss (Kaplan & Sadock)
- Raised heart rate and blood pressure. Guidelines advise monitoring weight, blood pressure and pulse regularly, about every 6 months.
- Headache, nausea and fatigue with atomoxetine
Cardiovascular risk
- A 2022 meta-analysis of 19 observational studies (3.9 million people, median follow-up 1.5 years) found no statistically significant increase in cardiovascular disease. That held for young and middle-aged adults (RR 1.04, 95% CI 0.43-2.48) and for older adults.
- The authors could not rule out a modest increase in cardiac arrest or tachyarrhythmia. Long-term risk and risk in people with existing heart disease still need study.
- NICE says no ECG is needed before starting if the cardiovascular history and examination are normal.
Other risks
- Misuse and dependence: Stimulants have abuse potential, so care is needed with a history of addiction.
- Psychiatric: Medication can worsen bipolar disorder or psychosis, including treatment-emergent mania.
- Atomoxetine: Watch for liver problems and suicidal thoughts.
- Priapism: Prolonged erection has been reported rarely with methylphenidate and atomoxetine (Campbell-Walsh Urology, FDA warning 2013).
- Tolerance: Response may fade over time.
My PubMed check for recent meta-analyses and systematic reviews turned up nothing that contradicts the above. The results were about brain stimulation and neuroimaging, not drug safety.
This is general information. The right drug, dose and monitoring depend on your heart health, mental health, substance use history and other medicines, so decide with a prescriber.
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