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Column originally published Aug 27, 2019

Clonidine And Guanfacine Are Blood Pressure Medications That Can Help ADHD

Question: Our eight years old daughter has ADHD. She is hyperactive and strong-willed; very excitable, and hard to calm down. She is very smart, and did well in grade 2. Our paediatrician started her on Biphentin several months ago. For the first time, she didn’t disrupt the class. She is more happy with herself, and she has more friends now. Lately, however, the medicine is not working as well in the afternoon; she is more defiant, and gets upset easily. Our doctor suggested that we add a medicine called Intuniv. Unfortunately, our insurance doesn’t cover this; it will cost a lot of money. I searched the internet, and found that a similar medicine called clonidine can be useful. What do you think?


It is wonderful to hear that your daughter has improved after starting Biphentin. For some children, the main concern is difficulty paying attention. For others, it is hyperactivity and impulsive talking. This can interrupt the classroom, and make it difficult for others to learn. She would not make too many friends; she can get ostracized and lose her self esteem.

Biphentin is an excellent Ritalin-based medicine for ADHD. It comes as capsules with small beads inside; the capsules can be opened, and the beads mixed with soft food. It is ideal for children who cannot swallow pills. However, 40% of fast- acting Ritalin is released right away, leaving only 60% as long-acting medicine. As a result, it may work for only 6 hours in some children. It can wear off before school is over, making it difficult to finish homework and participate in after-school activities.

Intuniv XR is a long-acting formulation of guanfacine. Clonidine and guanfacine can lower blood pressure by acting on adrenaline-receptors in the brain. Recent research has shown that they can also reduce impulsivity and hyperactivity, improve frustration tolerance and compliance in children with ADHD, but their effectiveness is very short, and they can cause drowsiness.

Intuniv XR has been approved in Canada for several years. This long-acting guanfacine is helpful for many children (and some adults) with ADHD. Most of the time, it is added to one of the stimulants, Ritalin- or Dexedrine-based medications. It can enhance the effectiveness of these stimulants, and make them last longer. Drowsiness can still happen, but tends to disappear over time. The biggest drawback of Intuniv XR is the cost; some insurance does not cover this medicine.

Although clonidine is also effective for ADHD, we don’t have any long-acting formulation available in Canada. In United States, a long-acting clonidine called Kapvay was approved several years ago. Research has shown that it can be beneficial for some children with ADHD.

Without long-acting clonidine, specialists have used the short-acting medicine, mostly for those who have difficulty settling and falling asleep. It is quite effective and safe. Rarely, I have used small doses of clonidine several times a day for children with severe ADHD.

You can also consider changing your daughter’s medicine to Concerta. This is a long-acting pill; 22% of fast-acting Ritalin on outside, and 78% of remaining medicine is released over 8-12 hours. Most parents find Concerta works longer than Biphentin. If your daughter hasn’t learned how to swallow pills, you can find instruction videos online.

One word of caution here. Your pharmacy may tell you that your insurance only covers the generic version. I don’t recommend this “generic Concerta,” although it is also Ritalin-based. This generic Concerta is a pill made with compressed powder, and works no longer than 4-5 hours. This duration can be shorter than Biphentin. It doesn’t have the special OROS absorption system in brand-name Concerta.

Most pharmacies and physician offices have co-pay cards that will pay for the difference in price between “generic” and brand-name Concerta. You and your doctor have to insist on getting the brand-name version. Health Canada made a mistake years ago by approving this “generic Concerta,” even though it doesn’t work well.

I hope you can find the optimal treatment for your daughter, although it may take some time.