Non-Stimulant ADHD Treatment — MRCPsych Paper B MCQ

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ModerateChild & Adolescent PsychiatryNon-Stimulant ADHD TreatmentMRCPsych Paper B

A 6-year-old boy with ADHD continues to have clinically significant symptoms and impairment despite separate 6-week trials of methylphenidate and lisdexamfetamine at adequate, optimised doses, including consideration of alternative preparations. Neither stimulant produced sufficient benefit. According to NICE NG87, which listed non-stimulant medication should now be offered?

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Correct answer: D — Guanfacine

The correct answer is D, guanfacine. NICE recommends offering atomoxetine or guanfacine to a child aged 5 years or over after inadequate responses to separate 6-week trials of methylphenidate and lisdexamfetamine at adequate doses, with alternative preparations considered. Atomoxetine is not listed, so guanfacine is the single best answer. At age 6, guanfacine is also within its UK licensed age range. Clonidine is an off-label specialist option, principally considered with sleep disturbance, rages or tics and only following tertiary ADHD-service advice. Risperidone is not routine ADHD monotherapy and requires tertiary advice when considered alongside stimulants for pervasive aggression or irritability. Modafinil and bupropion are not recommended NICE treatment options in this situation. Guanfacine requires monitoring for sedation, hypotension, bradycardia and syncope.

Reference: National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management (NG87), recommendation 1.7.10, 2018, amended 2019. https://www.nice.org.uk/guidance/ng87/chapter/recommendations