What is the recommended first-line treatment with psychostimulant medication?

From the Guidelines

The recommended first-line treatment with psychostimulant medication for attention-deficit/hyperactivity disorder (ADHD) is either methylphenidate or amphetamine-based medications, with a recent meta-analysis proposing methylphenidate for children and adolescents and amphetamines for adults as the preferred therapy 1.

Key Considerations

• Treatment typically begins with a low dose that is gradually increased until optimal symptom control is achieved with minimal side effects.
• For methylphenidate, starting doses are usually 5-10mg once or twice daily for immediate-release formulations, or 18-36mg once daily for extended-release forms.
• For amphetamine preparations, initial doses typically range from 5-10mg daily.
• Titration should occur every 1-2 weeks based on response and tolerability.

Medication Choice

• The medication choice should be individualized, considering the patient's symptom pattern, comorbidities, potential side effects, and preference for dosing schedule.
• Methylphenidate and amphetamine-based medications work by increasing dopamine and norepinephrine availability in the brain, which improves attention, reduces impulsivity, and decreases hyperactivity.

Monitoring and Assessment

• Regular monitoring for side effects (appetite suppression, sleep disturbances, cardiovascular effects) and periodic assessment of height, weight, blood pressure, and heart rate are essential components of ongoing care.
• Stimulant medications are associated with statistically significant increases in blood pressure and heart rate, and may be clinically relevant for a small subgroup of patients, especially those with preexisting cardiovascular diseases 1.

Pregnancy and Breastfeeding

• The use of psychostimulants during pregnancy and breastfeeding should be carefully considered, with limited published information on the use of lisdexamfetamine in pregnancy, and possible increased risks for cardiac malformations, gastroschisis, preeclampsia, preterm birth, and poor neonatal adaptation associated with methylphenidate use 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Amphetamines should be administered at the lowest effective dosage and dosage should be individually adjusted. Narcolepsy: Usual dose is 5 mg to 60 mg per day in divided doses, depending on the individual patient response In patients 12 years of age and older, start with 10 mg daily; daily dosage may be raised in increments of 10 mg at weekly intervals until an optimal response is obtained. Attention Deficit Disorder with Hyperactivity: Not recommended for pediatric patients under 3 years of age. In pediatric patients from 3 to 5 years of age, start with 2.5 mg daily, by tablet; daily dosage may be raised in increments of 2. 5 mg at weekly intervals until optimal response is obtained. In pediatric patients 6 years of age and older, start with 5 mg once or twice daily; daily dosage may be raised in increments of 5 mg at weekly intervals until optimal response is obtained.

The recommended first-line treatment with psychostimulant medication, specifically amphetamine, varies depending on the condition and age of the patient.

• For Narcolepsy in patients 12 years of age and older, the recommended starting dose is 10 mg daily.
• For Attention Deficit Disorder with Hyperactivity:
  • In pediatric patients from 3 to 5 years of age, the recommended starting dose is 2.5 mg daily.
  • In pediatric patients 6 years of age and older, the recommended starting dose is 5 mg once or twice daily. It is essential to individualize the dosage and adjust as needed to achieve the optimal response while minimizing adverse reactions 2.

From the Research

Psychostimulant Medication as First-Line Treatment

• The recommended first-line treatment with psychostimulant medication for attention-deficit/hyperactivity disorder (ADHD) is methylphenidate 3, 4.
• Methylphenidate has a well-established evidence base for treating ADHD, although its long-term benefits are unclear 3.
• Other psychostimulants, such as lisdexamfetamine, mixed amphetamine salts, and modafinil, are also effective in reducing ADHD symptoms 5.
• The choice of psychostimulant medication depends on individual patient needs and lifestyle 4.

Efficacy of Psychostimulants

• Lisdexamfetamine has been shown to have a high effect size in reducing ADHD symptoms in adults 5.
• Methylphenidate and mixed amphetamine salts have moderate effect sizes in reducing ADHD symptoms 5.
• Modafinil has not been shown to be effective in reducing ADHD symptoms 5.

Use of Psychostimulants in Other Conditions

• Psychostimulants, such as modafinil and methylphenidate, are also used to treat narcolepsy and hypersomnia 6.
• Prescription psychostimulants, particularly prescription amphetamines, have been shown to be effective in promoting abstinence in individuals with stimulant use disorder, specifically those with cocaine use disorder 7.