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Column originally published May 31, 2016
Column last revised/updated on Jul 22, 2018

Strattera And Intuniv XR

Question: Our son is in grade four. He was diagnosed with ADHD more than a year ago. He couldn’t pay attention in school, and disrupted the class. Our paediatrician started him on Concerta. Within a short time, he became the model student, polite and helpful to the teacher. He went from struggling to excelling in reading and writing. However, in the last two months, his medicine is wearing off early. He started disrupting the class in the afternoon, and he is not allowed to come home on school bus. We are also struggling with his homework. We did try to increase the dose of Concerta, but he became emotional and has headaches. Is there anything else that we can try?


What you have described is not unexpected, a child can outgrow the dose of medicine after a few months or a year. Let me explain this to you.

Concerta is an excellent long-acting ADHD medicine that can work for about 8 to ten hours. It is usually taken at breakfast. By the time a student arrives at school, it has already started working. If he has the optimal dose, it can work throughout school hours and into the evening. Homework is a lot easier than before.

However, after months to sometimes years, a child will outgrow the dose of medicine. This is partly because children grow in weight and height. When that happens, parents and teachers usually find that the medicine is not as effective, and works for shorter period of time, usually better in the morning than the afternoon. As a result, afternoon classes can be a challenge, and he may refuse to do homework.

Adjusting the dose of medicine is usually the first step. A small increase in dosage can restore the full benefit. However, in your son’s situation, he had side effects after the dose was increased. Sometimes, it is not easy to get to the right balance. This is where we have to use a second medicine to help Concerta (or another ADHD medication) to work better and longer. There are two choices: Strattera and Intuniv XR.

Strattera has been available for about ten years. There is a generic formulation (atomoxetine) which works just as well and less expensive. It is available in capsules, and has to be swallowed. It has to be taken with food because it can cause stomach irritation. It is not a powerful medicine, but when combined with Concerta or other long-acting stimulants (like Adderall XR and Vyvanse), children can remain focused well into the evening. Some parents even find their morning less chaotic.

Intuniv XR is a newer medicine, available in Canada for about six years. It is closely related to clonidine, a blood pressure medicine. Intuniv XR has a calming effect on many children, and it works best when combined with long-acting ADHD medications that I have mentioned here. It has additional benefit of reducing oppositional tendency that happens in many children with ADHD. Some children may experience slight drowsiness initially, but it is not a serious problem.

The only downside of Intuniv XR is the cost. Most insurance companies have approved coverage of this medicine. Unfortunately, only a few provincial formulary will pay for it. This is something that you should discuss with your paediatrician.

You have seen how well your son can do when Concerta was working optimally. Hopefully, you and your paediatrician can find the right combination and dosage of medications so that your son can achieve his best in school and at home.