Clonidine
Clonidine was first released as an antihypertensive in 1966. Its approval for the treatment of ADHD came much later, in 2010. It is a centrally acting alpha 2A agonist and is one of the nonstimulants that can treat symptoms of ADHD. But it has many other uses in psychiatry.
Besides ADHD symptoms, what are the psychiatric symptoms clonidine helps with?
Insomnia
Explosive outbursts/anger
Anxiety
Affective instability and self-harm in Borderline Personality Disorder
Nightmares (including those from PTSD/trauma)
Tics
Autism— some studies support its use for impulse control, outbursts, and social skills.
Sweating
Manic symptoms: it is not strong enough to use as a mood stabilizer but there are studies showing benefit in bipolar mania.
Helps prevent relapse in patients with opiate addiction and also helps patients with various opiate withdrawal symptoms.
How does clonidine work in ADHD?
Clonidine assists in inhibiting impulsive and hyperactive behavior, and its cognitive benefits can be linked to its impact on the prefrontal cortex. The prefrontal cortex is like a mental sketch pad where we can store recent memories and draw from old ones to regulate our behavior, thoughts, and emotion. This is involved in decision making and helps with applying the appropriate behavioral response to a given situation.
Is clonidine approved for ADHD?
Yes, but in the extended release preparation, called Kapvay.
What are the side effects to watch for?
Clonidine is also used to treat high blood pressure, so it can lead to low blood pressure when taken. It also can be sedating so it’s best to start at a very low dose. It is often used as a sleep agent because it can be sedating.
How does clonidine compare to stimulants for treating ADHD?
It is important to note that this medication has a smaller effect size for ADHD than stimulant medications. It’s hard to beat the stimulants – methylphenidate and amphetamine’s effect sizes are among the largest in psychiatry. Clonidine ranks in the range of guanfacine and atomoxetine (Strattera) – their effect size is about 30-50% smaller than that of the stimulants.
How is clonidine dosed?
It depends on the age of the patient and what we are treating. But we generally start at 0.1mg and go up from there.
If it’s for ADHD during the day, it’s given up to 3x per day.
If it’s at night for sleep, the dose range is 0.1 to 0.4mg all at once, 30 mins prior to bedtime.
If it’s “as needed” for anxiety, it’s given at 0.1mg doses, but some start with 1/2 of a pill at first.
For children < 16 years old, always start with 1/2 pill for any daytime uses.
There is an extended release version called Kapvay which is given at night and lasts 24 hours. This is the version that is FDA approved for ADHD.
What are the most common side effects?
It often lowers blood pressure, so watch for dizziness, especially when standing up from a laying or seated position.
Dry mouth
Constipation
Sedation/lethargy