Please check your internet connection and try again.
# Attention Deficit Hyperactivity Disorder (ADHD) Medications
## Overview
Pharmacological management of ADHD primarily involves central nervous system (CNS) stimulants and non-stimulants. Stimulants (e.g., methylphenidate, amphetamine salts) increase synaptic concentrations of dopamine and norepinephrine. Non-stimulants (e.g., atomoxetine, guanfacine ER, clonidine ER) serve as alternatives, particularly for patients with substance use history, tic disorders, or intolerance to stimulants.
## Primary Indications
* Attention-Deficit/Hyperactivity Disorder (ADHD)
* Narcolepsy (stimulants specifically)
* Binge-Eating Disorder (lisdexamfetamine specifically)
## Adult Dosing
* **Methylphenidate (Immediate Release):** 5 mg PO BID–TID; titrate weekly. Max 60 mg/day.
* **Methylphenidate (Extended Release/Concerta):** 18–36 mg PO daily; titrate weekly. Max 72 mg/day.
* **Mixed Amphetamine Salts (Adderall XR):** 20 mg PO daily; titrate weekly. Max 60 mg/day.
* **Lisdexamfetamine:** 30 mg PO daily; titrate by 10–20 mg weekly. Max 70 mg/day.
* **Atomoxetine:** 40 mg PO daily; increase after 3+ days to 80 mg/day target. Max 100 mg/day.
## Pediatric Dosing
* **Methylphenidate (Concerta):** Age ≥6 years: 18 mg PO daily. Max 54 mg/day.
* **Mixed Amphetamine Salts (Adderall XR):** Age ≥6 years: 10 mg PO daily. Max 30 mg/day.
* **Lisdexamfetamine:** Age ≥6 years: 30 mg PO daily. Max 70 mg/day.
* **Atomoxetine:** Weight <70 kg: 0.5 mg/kg/day; target 1.2 mg/kg/day. Weight >70 kg: 40 mg/day; target 80 mg/day. Max 100 mg/day.
## Dose Adjustments
* **Renal/Hepatic Impairment:** Atomoxetine requires dosage reduction (50% reduction in moderate hepatic impairment; 75% in severe).
* **CYP2D6 Poor Metabolizers:** Require lower starting doses for atomoxetine to avoid toxicity.
## Contraindications
* Known hypersensitivity to sympathomimetic amines.
* Advanced arteriosclerosis, symptomatic cardiovascular disease, or moderate-to-severe hypertension.
* Hyperthyroidism.
* Glaucoma.
* Concurrent or recent (within 14 days) use of Monoamine Oxidase Inhibitors (MAOIs).
* Agitated states or history of substance abuse (applies to stimulant class).
## Adverse Effects
* **Common:** Decreased appetite, insomnia, headache, dry mouth, nausea, abdominal pain, tachycardia, and elevated blood pressure.
* **Serious:** Potential for cardiovascular events, treatment-emergent psychiatric symptoms (hallucinations, psychosis, mania), peripheral vasculopathy (Raynaud phenomenon), and growth suppression in children.
## Key Drug Interactions
* **MAOIs:** Risk of hypertensive crisis; must have 14-day washout period.
* **Antihypertensives:** Stimulants may antagonize the efficacy of blood pressure-lowering agents.
* **SSRIs/SNRIs:** Additive risk of serotonin syndrome, particularly with atomoxetine or high-dose stimulants.
* **CYP2D6 Inhibitors:** (e.g., fluoxetine, paroxetine) significantly increase atomoxetine plasma concentrations.
## Monitoring
* Baseline and periodic blood pressure and heart rate.
* Weight and height (in pediatric patients).
* Presence of new or worsening psychiatric symptoms.
* Cardiac assessment (history/physical) prior to therapy initiation.
## Clinical Pearls
* **Drug Holidays:** Some clinicians suggest planned weekend or summer breaks for pediatric patients; however, evidence on long-term benefit is debated.
* **Titration:** Always start low and titrate weekly to find the lowest effective dose; response is highly idiosyncratic.
* **Formulation:** Do not crush or chew extended-release formulations, as this destroys the delivery mechanism and leads to immediate overdose risk.
* **Non-Stimulants:** Atomoxetine has a delayed onset of action (2–4 weeks for full effect) compared to stimulants.
***
**Educational Disclaimer:** This information is for educational purposes only. Clinical protocols vary by institution. Always consult the latest package insert, the *Physicians' Desk Reference*, or institutional formulary guidelines before prescribing or administering any medication. Contact a licensed pharmacist or clinical pharmacologist for specific patient cases.
