What medications do you recommend for a patient with ADHD and anxiety who becomes more anxious on a stimulant?

Consider non-stimulant ADHD medications such as atomoxetine and viloxazine. Although these are not as effective for nearly as many patients as the stimulants, they are a reasonable alternative and generally well tolerated.

Despite the potential for bupropion to also cause a patient to feel more anxious, I would also consider a trial of bupropion as an off-label treatment for ADHD. I warn patients that temporary jitteriness should not be mistaken for worsening anxiety. Often, the jitteriness will subside within a couple of weeks. I would start with low doses and titrate gradually as tolerated.

I often use beta-blockers such as low-dose propranolol (assuming blood pressure is not low) to block the anxiety from stimulants if needed. First options, though, would be to reevaluate the dose of the stimulant (is it too high?), the class of stimulant (switching from a short acting agent to an extended release agent, switching from an amphetamine to a methylphenidate or a non-stimulant, etc.), and the diagnosis itself (is the “ADHD” just a manifestation of poor concentration due to anxiety or other factors?).

I also sometimes add clonidine or guanfacine to the stimulant to both lower anxiety and improve focus.

Anxiety and ADHD go hand in hand. I have always considered ADHD to be a symptom of a larger disorder, e.g, PTSD.

The problem in treating ADHD with non-stimulants is if the patient has at any time prior taken Adderall or Methylphenidate. If that is the case, Atomoxetine does not seem to work since they have had the 'good stuff' which works faster and better. However, some might be willing to give Atomoxetine a try. Higher doses seem to work much better.

Secondly and more problematically, many of these patients are also using THC for 'sleep', 'focus', and 'anxiety,' etc. This is a really difficult group to work with. They usually end up with polypharmacy. Issues remain mostly the same. Over time, diagnosis may evolve into a Bipolar Diagnosis...

I use atomoxetine when ADHD is comorbid with an anxiety disorder after ascertaining that anxiety symptoms are not due to ADHD.

Atomoxetine ES for anxiety is 0.5, the same as SSRI/SNRI, and 0.6 for ADHD.

Viloxazine is better for ADHD with comorbid depression.

I'm 62 years old and have yet to see a patient respond to buproprion either on or off label. You can combine an SSRI with a stimulant. Non-stimulants, especially viloxidone (Qelbree), work great for ADHD. Viloxidone actually had indications for depression, anxiety, OCD, and ADD in Europe 40 years ago before being rebranded as an ADHD medication in the US. Try it. Works amazing.

Important to discern if ADHD is driving anxiety or if anxiety is a primary/co-morbid condition (by the way, anxiety disorders are one of the most common co-morbid issues with ADHD). Agree about starting non-stimulant ADHD options or guanfacine ER (Intuniv) for anxiety secondary to ADHD. If anxiety is significant, adding SSRIs, SNRI, or beta-blockers is helpful and can enable adding a stimulant later on. Consider underlying trauma. Also, psychotherapy or mindfulness-based interventions.