The Waco Guide

Remote
Active
< 30% improvement after
adequate dose titration
Yes
Adequate response
(> 30% improvement)
No
< 30% improvement after
adequate dose titration
< 30% improvement after
adequate dose titration
Adequate response
(> 30% improvement)
Adequate response
(> 30% improvement)
Adult ADHD
Check prescription drug
monitoring database
Failed stimulant in past
or responded previously
to non-stimulant
Consider CBT in
combination with
pharmacotherapy at
any point during
treatment
SOR A
Medical
Comorbidities
Medical
If history of cardiac
arrhythmias or family
history of sudden
cardiac death, consult
cardiology
Substance use
Use non-stimulant or
long-acting stimulant
cautiously; consider
Vyvanse
Other
substances
Weigh risks
and benefits
of stimulants
Amphetamine
or Cocaine Avoid stimulants
Psychiatric
Comorbidities
Psychosis:
treat psychosis;
avoid stimulants
Depressive or
anxious
symptoms
Independent of ADHD &
its psychosocial
consequences
See corresponding decision
support tool and treat both
disorders concurrently
Consider bupropion for the
treatment of MDD (only
without comorbid anxiety)
SOR A
Secondary to
ADHD & its
psychosocial
consequences
Treat ADHD and
re-evaluate
depressive or
anxiety symptoms First choice: Stimulants (SOR A)
Amphetamines*
Methylphenidates
(Consider long-acting over
short/intermediate acting
based on diversion and misuse potential
of short acting agents)
Try another
first-line treatment
(Consider trying alternate stimulant class)
Second choice:
Atomoxetine
SOR A
Consider Bupropion
(third line; not FDA
approved)
*All things taken equally, consider amphetamine as first
choice in adults, based on meta-analysis data. Lancet
Psychiatry. 2018 Sep 5(9):727-738.
Maintain effective dose;
adjust as needed to
meet life needs

Does patient have comorbid psychiatric disorder(s)?