What are the guidelines for using Dexedrine (dextroamphetamine) in treating Attention Deficit Hyperactivity Disorder (ADHD) and narcolepsy?

Guidelines for Using Dexedrine (Dextroamphetamine) in ADHD and Narcolepsy

Dextroamphetamine (Dexedrine) is indicated for the treatment of narcolepsy and as part of a comprehensive treatment program for ADHD in patients ages 3-16 years, with dosing regimens tailored to the specific condition being treated. 1

Dosing Guidelines for ADHD

Adults with ADHD

• Starting dose: 5 mg PO twice daily
• Titration: Increase by 5 mg weekly increments
• Maximum dose: 50 mg daily
• Available formulations:
  • Immediate release tablets
  • Spansule (extended-release capsules): Start with 10 mg PO once daily in the morning

Children with ADHD (3-16 years)

• Dextroamphetamine is indicated as part of a total treatment program that includes psychological, educational, and social interventions 1
• The medication is appropriate for children with:
  • Moderate to severe distractibility
  • Short attention span
  • Hyperactivity
  • Emotional lability
  • Impulsivity

Dosing Guidelines for Narcolepsy

• Dextroamphetamine is effective for treating excessive daytime sleepiness and cataplexy in narcolepsy 2
• The American Academy of Sleep Medicine suggests using dextroamphetamine for narcolepsy in adults (conditional recommendation) 2
• Dosing similar to ADHD protocol:
  • Starting dose: 5 mg PO twice daily
  • Titration: Increase by 5 mg weekly increments
  • Maximum dose: 50 mg daily

Efficacy and Evidence

For ADHD

• Low to very low-quality evidence suggests amphetamines reduce the severity of ADHD symptoms as rated by both clinicians and patients 3
• Different types of amphetamines show varying efficacy, with lisdexamfetamine and mixed amphetamine salts showing stronger evidence than dextroamphetamine alone 3

For Narcolepsy

• Evidence from clinical trials demonstrates clinically significant improvements in excessive daytime sleepiness and cataplexy 2
• Considered a second-line option after modafinil/armodafinil for treating excessive daytime sleepiness 4, 5

Important Safety Considerations

1. Controlled Substance Status:

   • Schedule II federally controlled substance with high potential for abuse 2
   • Black box warning regarding potential for dependence with prolonged administration

2. Pregnancy Considerations:

   • Based on animal data, may cause fetal harm
   • Human data insufficient to determine risk 2
   • For pregnant patients with ADHD, the risks and benefits should be carefully weighed 2

3. Common Adverse Effects:

   • Sweatiness
   • Edginess/irritability
   • Loss of appetite
   • Weight changes
   • Insomnia 2

4. Cardiovascular Effects:

   • Stimulates α- and β-adrenergic receptors
   • Can cause vasoconstriction, increased peripheral resistance
   • May increase heart rate and stroke volume 6

5. Overdose Risks:

   • Hyperactivity, hyperthermia, tachycardia, tachypnea
   • Mydriasis, tremors, seizures
   • Hypoglycemia may occur 6

Monitoring Parameters

• Regular assessment of vital signs (blood pressure, heart rate)
• Weight monitoring
• Evaluation of sleep quality
• Assessment for signs of dependence or misuse
• Monitoring for emergence or worsening of psychiatric symptoms

Special Populations

Breastfeeding Mothers

• Lactation risk category L3
• Monitor breastfed infants for irritability, insomnia, and feeding difficulties 2

Patients with History of Substance Use

• Use with caution due to high abuse potential
• Consider alternative non-stimulant medications when appropriate

Treatment Alternatives

For ADHD

• Non-stimulant options include:
  • Atomoxetine
  • Bupropion (norepinephrine and dopamine reuptake inhibitor)
  • Viloxazine
  • Guanfacine or clonidine 2

For Narcolepsy

• First-line options:
  • Modafinil/armodafinil (recommended over dextroamphetamine due to better safety profile) 2
  • Sodium oxybate (only drug approved for both cataplexy and excessive daytime sleepiness) 4
• Alternative stimulants:
  • Methylphenidate 2

Common Pitfalls to Avoid

1. Inappropriate diagnosis - Ensure proper diagnosis before initiating treatment, particularly for ADHD 2

2. Inadequate monitoring - Regular follow-up is essential to assess efficacy and monitor for side effects

3. Abrupt discontinuation - Can lead to withdrawal symptoms; taper medication when discontinuing

4. Medication diversion - Be aware of potential for misuse, particularly in college-aged patients 6

5. Drug interactions - Consider potential interactions with other medications, particularly those affecting the cardiovascular system

6. Ignoring non-pharmacological approaches - For ADHD, medication should be part of a comprehensive treatment program that includes psychological, educational, and social interventions 1