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# Attention-Deficit/Hyperactivity Disorder (ADHD) Medications
## Overview
ADHD medications are primarily categorized into **Stimulants** (methylphenidate and amphetamine derivatives) and **Non-Stimulants** (atomoxetine, guanfacine ER, clonidine ER). Stimulants function by increasing intrasynaptic levels of dopamine and norepinephrine.
## Primary Indications
* ADHD (Attention-Deficit/Hyperactivity Disorder)
* Narcolepsy (specific agents: methylphenidate, amphetamines, modafinil)
* Binge Eating Disorder (lisdexamfetamine only)
## Adult Dosing
* **Methylphenidate (Immediate Release):** 5 mg PO BID–TID; titrate weekly. Max: 60 mg/day.
* **Methylphenidate (Long-Acting/Concerta):** 18–36 mg PO daily in the morning. Max: 72 mg/day.
* **Amphetamine/Dextroamphetamine (Adderall XR):** 20 mg PO daily. Max: 60 mg/day.
* **Lisdexamfetamine (Vyvanse):** 30 mg PO daily. Max: 70 mg/day.
* **Atomoxetine:** 40 mg PO daily, increase to target 80 mg total daily dose after 3 days. Max: 100 mg/day.
## Pediatric Dosing
* **Methylphenidate:** Age ≥6 years: Initial 5 mg PO BID. Titrate by 5–10 mg weekly. Max: 60 mg/day.
* **Lisdexamfetamine:** Age ≥6 years: 30 mg PO daily. Max: 70 mg/day.
* **Atomoxetine:** Weight <70 kg: 0.5 mg/kg/day; increase to 1.2 mg/kg/day target. Weight ≥70 kg: 40 mg/day; increase to 80 mg/day target.
* **Guanfacine ER:** Age ≥6 years: 1 mg daily. Titrate by 1 mg/week. Max: 4 mg/day.
## Dose Adjustments
* **Renal/Hepatic:** Atomoxetine requires dosage reduction (50%) in patients with moderate hepatic impairment (Child-Pugh B) and substantial reduction (75%) in severe impairment (Child-Pugh C). Stimulants generally do not require dose adjustment for renal/hepatic impairment, but use with caution.
## Contraindications
* Symptomatic cardiovascular disease or moderate-to-severe hypertension.
* Hyperthyroidism.
* Glaucoma.
* Use of MAOIs within the last 14 days.
* History of drug abuse (for stimulants).
* Known hypersensitivity to sympathomimetic amines.
## Adverse Effects
* **Common:** Decreased appetite, insomnia, headache, dry mouth, irritability.
* **Serious:** Cardiovascular events (tachycardia, hypertension), QT prolongation (rare), psychiatric symptoms (hallucinations, aggression), peripheral vasculopathy (Raynaud’s phenomenon), growth suppression in children.
## Key Drug Interactions
* **MAOIs:** Hypertensive crisis risk; must have 14-day washout period.
* **SSRIs/SNRIs:** Increased risk of Serotonin Syndrome.
* **Antacids/PPIs:** May increase absorption of amphetamines.
* **CYP2D6 Inhibitors (e.g., fluoxetine, paroxetine):** Atomoxetine levels significantly increased.
## Monitoring
* **Baseline/Routine:** Blood pressure, heart rate, weight, height (in children), and assessment for psychiatric symptoms (e.g., suicidal ideation, anxiety).
* **Safety:** Cardiopulmonary symptoms (chest pain, syncope) or signs of peripheral ischemia.
## Clinical Pearls
* **Drug Holidays:** Some providers suggest weekend or summer "holidays" in children to mitigate growth suppression, though efficacy data is mixed.
* **Administration:** Vyvanse (lisdexamfetamine) is a prodrug; it must be ingested to be activated by red blood cell enzymes, which theoretically lowers abuse potential.
* **Titration:** Always follow the "start low, go slow" principle to minimize agitation and insomnia.
* **Local Protocols:** Institutional protocols may vary regarding drug selection and cardiac clearance requirements; always verify against local formulary and clinical guidelines.
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**EDUCATIONAL DISCLAIMER:** This information is for educational purposes only and does not constitute medical advice. Medication choice and dosing must be based on individual patient clinical judgment. Always verify current prescribing information, dosing guidelines, and contraindications using official manufacturer product labeling or professional clinical databases (e.g., Lexicomp, UpToDate) before prescribing.
