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Table.  

Starting Dose Maximum Dose Approximate Effect Duration
Methylphenidate agents
Ritalin SR 10-20 mg QD 2 mg/kg/day 6 hours
Concerta 18-36 mg QD 2 mg/kg/day 12 hours
Metadate CD 20 mg QD 2 mg/kg/day 8-10 hours
Ritalin LA 10-20 mg QD 2 mg/kg/day 8 hours
Focalin XR (d-methylphenidate) 10 mg QD 1 mg/kg/day 8-10 hours
Amphetamine agents
Adderall XR (mixed amphetamine salts) 10 mg QD 1.5 mg/kg/day 10-12 hours
Dexedrine Spansule 5-10 mg QD 1.5 mg/kg/day 6+ hours

Long-Acting Stimulants for ADHD*

*Only Adderall XR and Focalin XR are indicated for use in adults, and dosing guidelines indicated here are not all FDA approved. In young children and individuals with lower body weight, lower initial starting doses may be advisable. Stimulant dose should advance every several days until response is adequate, unless adverse effect is noted.

Table.  

Starting Dose Maximum Dose Approximate Effect Duration
Methylphenidate agents
Ritalin SR 10-20 mg QD 2 mg/kg/day 6 hours
Concerta 18-36 mg QD 2 mg/kg/day 12 hours
Metadate CD 20 mg QD 2 mg/kg/day 8-10 hours
Ritalin LA 10-20 mg QD 2 mg/kg/day 8 hours
Focalin XR (d-methylphenidate) 10 mg QD 1 mg/kg/day 8-10 hours
Amphetamine agents
Adderall XR (mixed amphetamine salts) 10 mg QD 1.5 mg/kg/day 10-12 hours
Dexedrine Spansule 5-10 mg QD 1.5 mg/kg/day 6+ hours

Long-Acting Stimulants for ADHD*

*Only Adderall XR and Focalin XR are indicated for use in adults, and dosing guidelines indicated here are not all FDA approved. In young children and individuals with lower body weight, lower initial starting doses may be advisable. Stimulant dose should advance every several days until response is adequate, unless adverse effect is noted.

Managing ADHD With Long-Acting Stimulant Agents

Authors: Craig B.H. Surman, MD; Joseph Biederman, MDFaculty and Disclosures

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Introduction

The prevalence of attention deficit/hyperactivity disorder (ADHD) in school-aged children is between 8% and 10% in the United States.[1,2] A recent study suggests that at least 50% of these children will continue to have the disorder as adults.[3] ADHD impacts all daily activities but appears to be favorably mitigated by medication, and pharmacotherapy remains the mainstay of treatment. In this article, we review the long-acting stimulant preparations currently approved for the management of ADHD.

Although few studies directly compare stimulant and nonstimulant agents, stimulants remain among the most effective means for managing the disorder. One review of 55 studies suggests that there is greater benefit from treatment with stimulants (average effect size of 0.91 for immediate-release and 0.95 for long-acting) compared with nonstimulant treatment (average effect size of 0.62), but that this benefit is related to the amount of the stimulant taken.[4] Immediate-release formulations, typically effective for 3 to 6 hours, require multiple daily doses (usually 2 to 3 daily doses) to manage symptoms. Because patients often find it hard to remember to take multiple doses of a stimulant during the course of a day, the reduced dose frequency of the longer-acting agents add convenience as well as more continuous coverage.

Although long-acting stimulants have recently been examined primarily in children and adolescents, earlier studies of some agents showed that adults did have less robust response rates than those seen in pediatric studies - ie, approximately 70%. For example, in 5 studies evaluating methylphenidate treatment in adults, the average response rate was only 50%.[5] However, in these studies, the average daily dose of 0.6 mg/kg was below the average weight-corrected dose of 1 mg/kg used in pediatric methylphenidate studies. In the more recent adult ADHD stimulant treatment trials that included dosing up to ≥ 1.0 mg/kg/day, adults did have higher response rates. Data are emerging to suggest that, where needed and tolerated, such robust stimulant treatments can be safe in adults.

Even though individual patients may respond differently to various stimulants, the spectrum of possible benefits and side effects is similar for adults and children.[6] One controlled study in children, for example, demonstrated that they responded preferentially to either methylphenidate or dextroamphetamine.[7] Common side effects of stimulant use in general include insomnia, diminished appetite, dysphoria, and headaches.Tapering up slowly from the initial starting dose may prevent or limit some of these side effects. Stimulants can also produce mild elevations of systolic and diastolic blood pressure, so these parameters should be monitored during treatment. Contraindications to stimulant use include prior sensitivity to stimulants, glaucoma, symptomatic cardiovascular disease, hyperthyroidism, hypertension, active substance use, or a history of psychotic disorder.