What is the proper procedure for converting a patient from short-acting (SA) stimulants, such as Ritalin (methylphenidate), to long-acting (LA) stimulants, like Concerta (methylphenidate)?

From the Guidelines

When converting a patient from short-acting Ritalin (methylphenidate) to long-acting Concerta (methylphenidate), start by calculating the total daily dose of the short-acting medication and prescribe an equivalent daily dose of Concerta, typically with a conversion ratio that may not always be exact, necessitating potential dose adjustments. For example, if a patient takes 10 mg of Ritalin three times daily (30 mg total), prescribe an equivalent daily dose of Concerta, typically 36 mg once daily, as guided by clinical practice parameters 1. The conversion is not always straightforward, so some dose adjustment may be necessary, taking into account the patient's response and potential side effects.

Key Considerations for Conversion

• Begin the long-acting medication the morning after the last dose of short-acting medication.
• Monitor the patient closely during the first few weeks for efficacy and side effects, as the pharmacokinetic profiles differ despite containing the same active ingredient 1.
• Long-acting formulations provide more consistent coverage throughout the day, potentially improving adherence and reducing stigma associated with taking medication at school or work.
• Some patients may benefit from a supplemental short-acting dose in the late afternoon if coverage from the long-acting formulation wanes before the end of the day.
• Titrate the dose based on clinical response, typically waiting 5-7 days between dose adjustments, as part of a consistent titration schedule 1.
• Be aware that some patients may experience different side effect profiles with long-acting formulations compared to short-acting ones, despite containing the same medication.

Monitoring and Adjustment

• Follow-up assessment should include evaluation of target symptoms of ADHD, asked regularly of the parent and of a teacher 1.
• These clinical assessments may be supplemented by the use of parent and teacher rating scales.
• It is important to obtain self-ratings from adolescents and from adults.
• Side effects should be systematically assessed by asking specific questions of patients and of parents about known side effects, such as insomnia, anorexia, headaches, social withdrawal, tics, and weight loss 1.
• Weighing the patient at each visit provides an objective measure of loss of appetite.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Conversion Procedure

To convert a patient from short-acting (SA) stimulants to long-acting (LA) stimulants, the following steps can be considered:

• Evaluate the patient's current dosage and response to SA stimulants 2
• Consider the patient's age, as long-acting agents are more commonly prescribed for pediatric patients (age 0-17) than for adults (patients aged 18+) 2
• Choose a suitable long-acting stimulant, such as Concerta (methylphenidate), and determine the equivalent dosage based on the patient's current SA stimulant dosage 3
• Monitor the patient's response to the new medication and adjust the dosage as needed to minimize side effects and optimize efficacy 4

Factors to Consider

When converting from SA to LA stimulants, consider the following factors:

• Pharmacokinetic variability: different formulations of long-acting stimulants can affect the medication's duration of action and peak concentration 4
• Food consumption: some long-acting stimulants, such as those using pH-dependent bead technology, may be affected by food consumption or concomitant administration of medications that alter gastric pH 4
• Patient preference: adolescents may prefer short-acting methylphenidate (MPH) over long-acting pemoline, despite the latter producing greater adherence 5
• Adherence: long-acting stimulants may improve adherence compared to short-acting stimulants, especially in naturalistic settings 5

Special Considerations

• Cardiovascular, psychiatric, and abusive side effects: monitor patients for potential side effects, especially when using methylphenidate or other stimulants 3
• Combination treatment: combining stimulant medication with behavioral treatments may produce superior effects compared to either treatment alone 6