Over time, patients may benefit from an immediate-release form:
- added for certain times of day—such as in late afternoon, when the morning extended-release dose has worn off (Box 2)12,13
- to use as an alternative to extended-release formulations when more or less flexibly is desired, such as on weekends.
Table 2
Administering medications approved for adult ADHD
| Drug | Recommended dosage* | Comments |
|---|---|---|
| Stimulants | ||
| Extended-release mixed amphetamine (Adderall XR) | 20 mg | Initial prescription of 10-mg XR capsules allows gradual titration |
| Extended-release OROS methylphenidate (Concerta) | 18 to 72 mg/d | Initial prescription of 18-mg OROS MPH capsules allows gradual titration |
| Extended-release dexmethylphenidate (Focalin XR) | 10 mg/d; maximum 20 mg/d | Dosing is one-half the typical dosing of racemic MPH |
| Lisdexamfetamine (Vyvanse) | 30 mg/d; maximum 70 mg/d | May be adjusted weekly in 10-mg or 20-mg increments |
| Nonstimulant | ||
| Atomoxetine (Strattera) | 80 mg/d; maximum 100 mg/d | Initial dosage of 40 mg/d can be increased to target dosage after a minimum of 3 days; can be given as a morning dose or divided evenly between morning and evening doses |
| * FDA-approved dosages as listed in the package inserts of these medications ADHD: attention-deficit/hyperactivity disorder; MPH: methylphenidate; OROS: osmotic release oral system; XR: extended-release formulation | ||
CASE CONTINUED: Feeling ‘calm, less frenetic’
During the next 6 months, you start Mr. Z on stimulant treatment at robust dosing consistent with his weight (90 kg). He complains that extended-duration methylphenidate (MPH)—titrated to 90 mg/d—doesn’t last into the late afternoon, and he feels mildly tense with a low appetite. Because of an apparent partial response and relatively mild adverse effects, you discontinue MPH and try an extended-duration amphetamine, titrated to 60 mg.
Mr. Z’s blood pressure and heart rate remain stable. He begins to exercise regularly and reduce his use of tobacco and caffeine drinks, as you recommend. He says he feels “calm, less frenetic.” He reports no tension on this medication and only mild reduced appetite. With a plan to continue taking the stimulant medication with regular monitoring, he then disappears from treatment.
Promoting adherence
Treatment nonadherence is an issue throughout medicine, and individuals with disorganization, forgetfulness, and impulsivity may be at higher-than-usual risk of not following through on medication regimens.
Strategies to cover ‘wear-off ‘ of long-acting stimulants
Combining short- and long-acting stimulants may cover hours when attention-deficit/hyperactivity (ADHD) symptoms emerge despite therapy with a long-acting agent.12,13 Ask patients who report lack of full-day coverage if the once-daily, extended-duration formulation they are taking works well until a certain time of day. Then consider adding a similar-class immediate-release stimulant at this time to cover the later hours.
If a patient reports partial response throughout the day—such as early in treatment—begin by optimizing the long-acting agent’s dosage. Keep a target daily dose in mind, based on FDA recommendations and clinical trial data. For example, an adult weighing 80 kg may respond optimally to a combination of 60 mg of a long-acting methylphenidate (MPH) in the morning, followed by 10 to 20 mg of an immediate-release MPH in mid-afternoon.
The later stimulants are taken in the day, the more likely insomnia may emerge as an adverse effect. Some patients adjust to this problem within the first weeks of treatment. If insomnia remains impairing, reduce the stimulant dose or consider switching to a shorter duration medication or to the nonstimulant atomoxetine.
In addition, restrictions on stimulant-class medications do not permit multiple-month prescribing (refills), as is allowed with non-scheduled medications such as atomoxetine. Discuss with patients how they will obtain stimulant medications on a regular, monthly or bimonthly basis. In our experience, the practical challenges of remaining in treatment at times may limit patients’ adherence to ADHD medications more than a lack of response or tolerability concerns.
Explain to patients early in treatment that they might need to try several different medications before settling on 1 that is optimally tolerated and efficacious. Because stimulants are generally quite effective for ADHD symptoms, set your goal to identify adverse effects and aim for a patient response of “this works well, and I don’t feel any different on it.”
CASE CONTINUED: Ready to try again
Three years later, Mr. Z returns and reports gradually discontinuing the stimulant because he “wanted to go it on my own.” He functioned relatively well at first, but errors and conflicts at his job led to his dismissal.
Since then, he has been unemployed. He is increasingly depressed and reports drinking and smoking “more heavily than in college.” He asks about resuming ADHD treatment.