Dexedrine (Dextroamphetamine) Clinical Guide
Primary Indications
Dexedrine is FDA-approved for narcolepsy and ADHD in patients aged 6-17 years 1. For narcolepsy in adults, dextroamphetamine is conditionally recommended as an effective treatment option 2.
ADHD Indication Criteria
- Symptoms must have caused impairment before age 7 years
- Clinically significant impairment in ≥2 settings (school/work and home)
- For Inattentive Type: ≥6 symptoms persisting ≥6 months (inattention to details, poor sustained attention, poor listening, failure to follow through, disorganization, avoids sustained mental effort, loses things, easily distracted, forgetful)
- For Hyperactive-Impulsive Type: ≥6 symptoms persisting ≥6 months (fidgeting, leaving seat, inappropriate running/climbing, difficulty with quiet activities, excessive talking, blurting answers, can't wait turn, intrusive behavior)
- Combined Type requires both criteria sets 1
Absolute Contraindications
Do not prescribe Dexedrine if the patient has:
- Previous hypersensitivity to amphetamine products
- Current or recent (within 14 days) MAOI use, including linezolid or IV methylene blue
- Active psychotic disorder
- History of illicit stimulant abuse (unless in controlled/supervised setting)
- Glaucoma
- Symptomatic cardiovascular disease
- Hyperthyroidism
- Hypertension 3, 1
Relative Contraindications (Use with Extreme Caution)
- Household member with stimulant abuse history (requires supervision measures)
- Pregnancy (animal data shows fetal harm; human data insufficient) 2, 1
- Breastfeeding (drug passes into breast milk) 1
Important Note: The FDA package insert lists motor tics, marked anxiety, and Tourette's disorder as contraindications, but recent clinical trial literature suggests these conditions may not worsen with stimulant treatment 3. However, proceed cautiously and document your clinical reasoning.
Dosing Regimen
ADHD in Children and Adolescents (Ages 6-17)
Starting Dose: 2.5 mg once daily in early morning 3
Titration Schedule:
| Week | Dose | Contact Method | Required Monitoring |
|---|---|---|---|
| Baseline | - | Office visit | ADHD rating scale, side effects, BP, pulse, height, weight |
| 1 | 2.5 mg | Office visit | ADHD rating scale, side effects |
| 2 | 5 mg | Office or phone | ADHD rating scale, side effects |
| 3 | 7.5 mg* | Office or phone | ADHD rating scale, side effects |
| 4 | 10 mg | Office visit | ADHD rating scale, side effects, BP, pulse, height, weight |
*Omit this dose in children weighing <20 kg (45 lbs) 3
Dosing Strategy:
- Start once daily in early morning
- Add noon dose if effect doesn't last through school day
- May add third (afternoon) dose at clinician's discretion for homework/social activities 3
- Increasing the morning dose may extend duration of action 3
Maximum Doses:
- Children <25 kg: Up to 35 mg total daily dose (may be exceeded if showing improvement without side effects) 3
- School-age children: No specific maximum established, but titrate cautiously 3
Alternative "Forced Titration" Method:
Give all four doses (2.5,7.5,10 mg) sequentially, each for 1 week. At follow-up, review all rating scales and side effects, then select the dose with most benefit and fewest side effects 3.
ADHD in Adults and Older Adolescents
Starting Dose: 5 mg dextroamphetamine 3
- Titrate upward in 5-10 mg intervals each week until symptoms controlled
- Maximum: Up to 0.9 mg/kg/day or 40 mg total daily dose 3
- Higher doses may be needed to cover longer adult day
- If prescribing >40 mg/day: Document that lower doses were inadequate AND higher doses produce no side effects (weight loss, BP increase, agitation) 3
- Monitor for tolerance 3
Narcolepsy in Adults
Dextroamphetamine is conditionally recommended for narcolepsy treatment 2. Clinical studies show:
- Mean effective dose: 16 mg/24h (range 5-60 mg)
- Reduces excessive daytime sleepiness by approximately 20%
- Also reduces cataplexy propensity 4
- In comparative studies, 10-30 mg daily roughly halved narcolepsy attack frequency 5
Monitoring Requirements
Baseline (Before Starting Treatment)
- Complete physical examination
- Blood pressure and pulse
- Height and weight
- ADHD rating scales from teachers and parents (for children)
- Document prior treatments, medication trials, compliance history 3
During Titration (Weekly)
- ADHD rating scales (from teachers/parents for children; from patient/significant other for adults)
- Side effect assessment
- Can be obtained via phone contact 3
Maintenance Monitoring
Children:
- Vital signs checked annually during routine physical examination 3
- Height and weight at regular intervals 3
Adults:
- Blood pressure and pulse quarterly (by treating or primary care physician) 3
- Monitor for signs of tolerance 3
All Patients:
- Use standardized, validated ADHD rating scales to guide dose adjustments 3
- Assess for side effects at each visit
- Monitor for signs of abuse, misuse, or diversion 1
Common Pitfalls and Management
Side Effect Management
Most Common Side Effects:
- Appetite suppression (does NOT typically occur in narcolepsy patients) 5
- Sleep onset delay
- Headache
- Irritability/edginess
- Weight changes (long-term use associated more with weight gain than loss) 4
Cardiovascular Concerns:
- Sudden death has occurred in patients with heart defects or serious heart disease 1
- Check carefully for heart problems before starting
- Call emergency services immediately if chest pain, shortness of breath, or fainting occurs 1
Psychiatric Monitoring:
- New or worse behavior/thought problems
- New or worse bipolar illness
- New psychotic symptoms (hallucinations, delusions)
- New manic symptoms
- Obtain family history of suicide, bipolar illness, depression 1
Optimizing Efficacy
If inadequate response:
- Approximately 70% respond to dextroamphetamine alone
- Nearly 90% respond if both dextroamphetamine and methylphenidate are tried 3
- Switch to alternative stimulant if first choice fails or causes prohibitive side effects 3
Timing adjustments:
- Adjust afternoon/evening dose timing and strength to minimize dinner appetite suppression and sleep onset delay 3
- Consider sustained-release formulation (Dexedrine Spansule): add morning and noon immediate-release doses together for SR dose 3
Abuse Prevention
Dexedrine is Schedule II with high abuse potential 1:
- Assess abuse risk before starting and monitor throughout treatment
- Keep in safe place; properly dispose of unused medicine
- Never share with others
- If household member has abuse history, implement supervision measures 3, 1
Special Populations
Pregnancy and Breastfeeding
- Animal data shows fetal harm; human data insufficient 2, 1
- Recent case series (n=10) in narcolepsy patients showed favorable outcomes when continued through pregnancy, though individualized counseling essential 6
- Passes into breast milk; breastfeeding not recommended during treatment 1
Children <6 Years
- FDA package insert warns against use, though 8 published reports show efficacy in this age range 3
- Not officially approved for this population 1
Small Children (<20 kg)
- Omit 7.5 mg dose during titration
- Maximum 35 mg total daily dose (may exceed if showing improvement) 3
- Titrate slowly and carefully 3
Alternative Formulations
Dextroamphetamine Transdermal System (d-ATS) is now FDA-approved for ADHD in patients ≥6 years 7, 8:
- Provides alternative for patients unable/unwilling to take oral medication
- Flexible wear time (approved for 9-hour application with effects lasting through 12 hours)
- Bioequivalent across five bilateral application sites (10 unique locations)
- Dermal irritation occurs but typically resolves within 2-4 hours; site rotation minimizes issues 9, 7, 8