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# Attention Deficit Drugs (Stimulants)
## Overview
Stimulant medications (e.g., Methylphenidate and Amphetamines) are the first-line treatment for Attention-Deficit/Hyperactivity Disorder (ADHD). They increase synaptic concentrations of dopamine and norepinephrine.
## Primary Indications
* ADHD
* Narcolepsy (select agents)
* Binge Eating Disorder (Lisdexamfetamine only)
## Adult Dosing
* **Methylphenidate IR:** Start 5 mg BID–TID; titrate weekly. Max: 60 mg/day.
* **Methylphenidate ER:** Start 18–36 mg daily (Concerta). Max: 72 mg/day.
* **Mixed Amphetamine Salts (Adderall IR):** 5–10 mg daily or BID. Max: 40 mg/day.
* **Lisdexamfetamine:** 30 mg daily; titrate by 10–20 mg weekly. Max: 70 mg/day.
## Pediatric Dosing
* **Methylphenidate (Age ≥6):** IR start 5 mg BID. ER start 18 mg daily (Concerta). Max typically 60 mg/day.
* **Amphetamines (Age ≥3-6 depending on formulation):** IR start 2.5–5 mg daily/BID. Max typically 30–40 mg/day.
* *Note: Dosing is highly titration-dependent based on clinical response and tolerability.*
## Dose Adjustments
* **Renal/Hepatic Impairment:** Generally no specific guidelines, but use caution; lower starting doses are recommended.
* **CYP2D6 status:** Amphetamines are substrates; monitor for efficacy changes in poor/ultrarapid metabolizers.
## Contraindications
* Known hypersensitivity to sympathomimetic amines.
* Advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism.
* Glaucoma.
* History of drug abuse.
* Concomitant use of MAOIs (or within 14 days).
## Adverse Effects
* **Common:** Decreased appetite, insomnia, headache, dry mouth, irritability, abdominal pain, tachycardia, and elevated blood pressure.
* **Serious:** Sudden cardiac death (in patients with underlying structural abnormalities), psychosis/mania, peripheral vasculopathy (Raynaud’s phenomenon), and priapism.
## Key Drug Interactions
* **MAOIs:** Risk of hypertensive crisis.
* **Antihypertensives:** Stimulants may antagonize effects.
* **Serotonergic agents:** Increased risk of serotonin syndrome when combined with SSRIs/SNRIs.
* **Acidifying/Alkanizing agents:** May alter absorption and urinary excretion of amphetamines.
## Monitoring
* Baseline and periodic blood pressure and heart rate.
* Height and weight in pediatric patients (growth tracking).
* Assess for new or worsening psychiatric symptoms.
* Periodic review of need for drug "holidays" or discontinuation.
## Clinical Pearls
* **Switching:** If one class (methylphenidate vs. amphetamine) fails, trial the other class before assuming treatment resistance.
* **Controlled Substance:** These agents are Schedule II and carry high abuse/diversion potential.
* **Tapering:** While not typically required, sudden cessation in long-term high-dose users may precipitate "crashing" or depression.
* **Protocol:** Always check institutional or local prescribing policies, as specific formulations (e.g., beads, ODT, patches) have unique pharmacokinetic profiles and dosing requirements.
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*Disclaimer: This information is for educational purposes. Always verify current prescribing information, package inserts, and local clinical protocols before prescribing or administering any medication.*
