Guanfacine’s advantages over stimulants include no worsening of tic disorders, lack of misuse potential, and no insomnia. It can also be used as an add-on to stimulant medication. However, its delayed onset of effect (two to four weeks) and lower efficacy rates make it a second-line choice for ADHD generally. ER is now available in generic and easier to use than IR. Commonly used off label for anxiety and insomnia, but efficacy data are limited. From the Child Medication Fact Book for Psychiatric Practice, Second Edition (2023).

Focalin is just Ritalin but more potent. It’s available as a generic and may mean fewer tablets for patients. Focalin XR only recently went generic. Azstarys is a newly approved (and expensive) combination of Focalin and a prodrug version of Focalin—the Focalin is absorbed quickly while the prodrug is absorbed more slowly (it’s the Vyvanse of methylphenidate, with less potential misuse than Focalin). From the Child Medication Fact Book for Psychiatric Practice, Second Edition (2023).

Advantages: Unlike stimulants, atomoxetine has no abuse potential, causes less insomnia and anxiety, and is unlikely to worsen tics. Disadvantages: It is generally less effective than stimulants, and takes longer to work (two to four weeks).

Newer formulations of an old drug come with a high price tag. Stick to the usual amphetamine products like mixed amphetamine salts unless liquid or ODT dosing is absolutely necessary.