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# Attention-Deficit/Hyperactivity Disorder (ADHD) Medications
## Overview
ADHD pharmacotherapy consists primarily of stimulants (methylphenidate and amphetamine derivatives) and non-stimulants (atomoxetine, alpha-2 agonists, and others). Stimulants act by increasing synaptic concentrations of dopamine and norepinephrine.
## Primary Indications
* ADHD (all agents)
* Narcolepsy (select stimulants)
* Binge Eating Disorder (lisdexamfetamine)
## Adult Dosing
* **Methylphenidate (Immediate Release):** Start 5 mg PO 2–3 times daily; titrate weekly. Max 60 mg/day.
* **Methylphenidate (Extended Release):** Start 18–36 mg PO once daily. Max 72 mg/day.
* **Amphetamine/Dextroamphetamine (Mixed Salts IR):** Start 5 mg PO 1–2 times daily. Max 40 mg/day.
* **Lisdexamfetamine:** Start 30 mg PO once daily. Max 70 mg/day.
* **Atomoxetine:** Start 40 mg/day; may increase to 80 mg/day after 3 days. Max 100 mg/day.
## Pediatric Dosing (Age 6+)
* **Methylphenidate (IR):** 0.3–0.7 mg/kg/dose 2–3 times daily. Max 60 mg/day.
* **Lisdexamfetamine:** 30 mg once daily; titrate by 10–20 mg/week. Max 70 mg/day.
* **Atomoxetine:** Weight-based, start 0.5 mg/kg/day; increase to target 1.2 mg/kg/day. Max 100 mg/day.
* *Note: Dosing is highly protocol-dependent; verify current institutional guidelines and child-specific weight-based charts.*
## Dose Adjustments
* **Renal Impairment:** Atomoxetine requires 50% dose reduction for moderate/severe impairment.
* **Hepatic Impairment:** Atomoxetine requires 50% dose reduction for moderate and 75% for severe impairment.
* **Stimulants:** Generally no formal renal/hepatic adjustment, but use caution with lower starting doses.
## Contraindications
* Known hypersensitivity
* Symptomatic cardiovascular disease or moderate-to-severe hypertension
* Hyperthyroidism
* Glaucoma
* Use of MAOIs within 14 days
* Agitated states or history of substance abuse (stimulants considered high risk)
## Adverse Effects
* **Common:** Decreased appetite, insomnia, headache, dry mouth, irritability.
* **Serious:** Cardiovascular events (tachycardia, hypertension), QT prolongation, psychiatric exacerbation (new-onset psychosis/mania), growth suppression in children, peripheral vasculopathy (Raynaud’s).
## Key Drug Interactions
* **MAOIs:** Risk of hypertensive crisis; contraindicated.
* **SSRIs/SNRIs:** Increased risk of serotonin syndrome.
* **CYP2D6 Inhibitors (e.g., Fluoxetine, Paroxetine):** Increases plasma levels of atomoxetine and stimulants.
* **Antacids/PPIs:** May reduce absorption of certain extended-release stimulants.
## Monitoring
* **Baseline:** Cardiovascular history, baseline blood pressure (BP), heart rate (HR), weight, and height.
* **Ongoing:** BP, HR, weight, and height at every visit. Monitor for tics, suicidal ideation, and behavioral changes.
## Clinical Pearls
* **Stimulant Selection:** Choice between methylphenidate vs. amphetamine salts is often based on patient preference and individual side effect profiles.
* **Non-stimulants:** Atomoxetine and alpha-2 agonists (clonidine/guanfacine) are preferred if there is a history of substance abuse, tics, or severe anxiety.
* **Administration:** Consistent timing (usually morning) is crucial to prevent insomnia. High-fat meals can decrease the absorption of certain formulations.
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**EDUCATIONAL DISCLAIMER:** This information is for educational purposes only. Clinical practice involves complex patient-specific decisions. Always verify current prescribing information, institutional protocols, and FDA-approved labeling before administering any medication.
