How to Select Adults With ADHD for Solriamfetol Treatment
How do clinicians identify which adults with ADHD are appropriate candidates for off-label solriamfetol treatment?
Some adults with attention-deficit/hyperactivity disorder have inadequate benefit, poor tolerability, or only partial response to approved ADHD medications. This guide applies the study's eligibility framework to help clinicians decide when solriamfetol can be considered and when it should be avoided.
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Confirm adult ADHD with current symptom burden
Use a systematic diagnostic evaluation to confirm DSM-5 ADHD in an adult patient. In the trial, participants had to meet DSM-5 criteria for ADHD and have an Adult ADHD Investigator Symptom Rating Scale total score of at least 20.
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Screen broadly for psychiatric comorbidity that could obscure diagnosis
Assess current and past mental health symptoms with a structured review of major DSM-5 conditions so that ADHD is not misattributed. In the study, the eligibility interview was supplemented by the Adult Self-Report to increase detection of exclusionary comorbid conditions.
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Rule out medical and reproductive exclusions
Do not proceed if the patient has renal insufficiency or impairment, major unstable medical illness, pregnancy, current nursing, recent cancer within the last 5 years, or cannot use reliable contraception during treatment if of childbearing potential. These were explicit exclusion criteria in the trial.
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Exclude conditions that sympathomimetic treatment may worsen
Avoid solriamfetol in patients with current or past psychotic disorder, bipolar disorder, current affective or anxiety disorder with more than mild symptoms, untreated hypertension above 140/90 mm Hg, narrow-angle glaucoma, drug abuse, or drug dependence other than nicotine. The study specifically excluded these conditions because a sympathomimetic agent could exacerbate them.
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Review current medications and stop excluded catecholaminergic agents before use
Do not combine study treatment with FDA-approved ADHD medications or catecholaminergic medications such as duloxetine, venlafaxine, and bupropion. In the trial, these agents had to be discontinued for 5 half-lives before participation, or longer if needed to assess eligibility; less than twice-a-week benzodiazepine or sedative-hypnotic use was allowed.
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Set expectations around likely benefits and limits
Discuss that in this 6-week pilot study, solriamfetol was associated with greater ADHD symptom improvement than placebo, with separation by week 3 and stronger effects on inattentive symptoms than impulsive-hyperactive symptoms. Also explain that this remains off-label use supported by a small pilot trial and needs replication.
Clinical Considerations
- This was a small 6-week pilot trial, so the eligibility framework supports cautious off-label selection rather than a definitive standard-of-care protocol.
- The study excluded many psychiatric and medical comorbidities, so applicability to more complex real-world ADHD populations is limited.
- Because concomitant medications were permitted in some participants, the study could not fully determine whether adverse effects were influenced by other agents.
Bottom Line
Consider solriamfetol only after confirming DSM-5 adult ADHD with clinically meaningful current symptoms and excluding psychiatric, cardiovascular, renal, reproductive, and medication-related factors that made patients ineligible for this sympathomimetic trial.
