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Guanfacine (brand name Estulic, Tenex and the extended release Intuniv) is a sympatholytic drug used in the treatment of attention deficit hyperactivity disorder (ADHD) and hypertension. It is a selective α2A receptor agonist. These receptors are concentrated heavily in the prefrontal cortex and the locus coeruleus, with the potential to improve attention resulting from interaction with receptors in the former. Guanfacine lowers both systolic and diastolic blood pressure by activating the central nervous system α2A norepinephrine autoreceptors, which results in reduced peripheral sympathetic outflow and thus a reduction in peripheral sympathetic tone.
Guanfacine is currently approved and marketed in the United States as Intuniv and has been filed and is under investigation by the European Medicines Agency for the treatment of ADHD in children and adolescents aged 6–18 years.
It has been shown to reduce hypertension not just in the short-term, but also in long-term studies to be able to achieve normalization in the of blood pressure of 54% of patients treated over a year and 66% over two years. The average reduction in mean arterial pressure of all patients was 16% at the end of the first year and 17% at the end of the second year. 
Attention deficit hyperactivity disorder
The US Food and Drug Administration (FDA) has approved guanfacine for the treatment of attention deficit hyperactivity disorder (ADHD), like clonidine, alone or with stimulants in 2010, for pediatric patients aged 6–17 years. Its beneficial actions are likely due to its ability to strengthen prefrontal cortical regulation of attention and behavior. Guanfacine is also used in conjunction with stimulants to augment therapeutic actions, reduce rebound, and when taken at evening, to induce sleep. Guanfacine is thought to improve regulation of behavior, attention, and emotion through actions at post-synaptic α2A adrenergic receptors on prefrontal cortical neurons, which strengthen prefrontal cortical network connections. In animal models, guanfacine is seen to affect a number of cognitive factors, including working memory improvement, distractibility reduction, response inhibition improvement, and enhanced attention and impulse control. Improvement is most evident in subjects with cognitive deficits; more subtle effects are seen in healthy young animals. Performance increases in spatial working memory have also been observed in humans. Another study found no effect on healthy male adults' executive functions and working memory, and small decrements on 2 tasks relating to the sedative effect of guanfacine. Recent studies suggest that guanfacine may help patients with a variety of prefrontal cortical disorders, including traumatic brain injury to the frontal lobe, strokes affecting higher cognitive function, and dysregulated emotional behavior, e.g. in children who have been traumatized.
Side effects of guanfacine are dose-dependent.
Another psychiatric use of guanfacine is for treatment of anxiety, such as generalized anxiety disorder and post-traumatic stress disorder symptoms. Guanfacine and other α2A agonists reduce sympathetic arousal in the emotional responses of the amygdala, and strengthen prefrontal cortical regulation of emotion, action and thought. Due to its prolonged half-life, it also has been seen to improve sleep interrupted by nightmares in PTSD patients. All of these actions likely contribute to the relief of the hyperarousal, re-experiencing of memory, and impulsivity associated with PTSD. However, a recent study showed no benefit for patients suffering from PTSD.
According to recent studies (Srour et al., 2008) there is controversy as to guanfacine’s usefulness in treating tics. There has been success when tic symptoms are co-morbid with ADHD, and as such, guanfacine and other α2A-adrenergic agonists (clonidine) are commonly the first choice for treatment.
Treatment of withdrawal syndrome
Adverse effects incidence:
Very common (>10% incidence) adverse effects include:
Common (1-10% incidence) adverse effects include:
- Alopecia (hair loss)
- Asthenia (weakness)
- Bradycardia (low heart rate)
- Decreased appetite
- Diaphoresis (sweating without a physiologic reason)
- Dyspepsia (indigestion)
- Dysphagia (being unable to swallow)
- Dyspnoea (air hunger)
- Hypotension (low blood pressure)
- Leg cramps
- Pruritus (itching)
- Tachycardia (high heart rate)
Unknown frequency adverse effects include:
- Abnormal liver function tests
- Alterations in taste
- Arthralgia (joint pain)
- Blurred vision
- Chest pain
- Exfoliative dermatitis
- Leg pains
- Myalgia (muscle pain)
- Nocturia (waking to urinate)
- Oedema (swelling)
- Orthostatic hypotension
- Paresthesia (pins and needles)
- Urinary frequency
- Vertigo (dizziness)
- CYP3A4/5 inhibitors — Use caution. Elevates plasma concentration of guanfacine.
- CYP3A4 inducers — Recommended increase in guanfacine dose.
- Valproic acid — Use caution. Elevates plasma concentration of valproic acid.
- Antihypertensive drugs — Use caution. Potential for additive pharmacodynamic effects (hypotension, syncope, etc.)
- CNS depressant drugs — Use caution. Potential for additive pharmacodynamic effects (sedation, somnolence, etc.)
Pharmacokinetics and metabolism
Guanfacine has an oral bioavailability of 80%. There is no clear evidence of any first-pass metabolism. Elimination half-life is 17 hours with the major elimination route being renal. The principal metabolite is the 3-hydroxy-derivative, with evidence of moderate biotransformation, and the key intermediate being an epoxide. It is also shown that elimination in patients with impaired renal function does not differ significantly from those with normal renal function. As such, metabolism by liver is the assumption for those with impaired renal function, as supported by increased frequency of known side effects of orthostatic hypotension and sedation. In animal models, guanfacine’s enhancing effects on the working-memory functions of the pre-frontal cortex are thought to be due to inhibition of cAMP-mediated signaling, which is effected by the Gi proteins that are generally coupled to the post-synaptic alpha-2a-adrenoceptors that guanfacine stimulates through binding.
Guanfacine is a highly selective agonist of the α2A adrenergic receptor, with negligible affinity for any other receptor. However, a recent study happen to identify that guanfacine may be a potent Serotonin (5-HT2B) receptor agonist, potentially contributing to valvulopathy.
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