What is the appropriate dosing of Adderall (amphetamine and dextroamphetamine) for adults with ADHD?

Appropriate Dosing of Adderall for Adults with ADHD

For adults with ADHD, Adderall (amphetamine and dextroamphetamine) should be initiated at 5-10 mg daily and titrated up to a maximum of 50 mg daily based on symptom control and side effects. 1

Initial Dosing and Titration

• Starting dose:

  • 5-10 mg orally in the morning 2, 1
  • For immediate-release formulations: 5 mg twice daily (morning and noon) 2

• Titration schedule:

  • Increase by 5-10 mg weekly for immediate-release formulations 2
  • For extended-release (XR) formulations, increase by 5-10 mg weekly 1
  • Allow at least one week between dose adjustments to properly assess response 2

• Monitoring during titration:

  • Weekly contact (in person or by phone) during initial titration 2
  • Assess target ADHD symptoms at each contact 2
  • Monitor for side effects, particularly insomnia, anorexia, headaches, and social withdrawal 2

Maximum Dosing

• Maximum daily dose: 50 mg per day for adults 2, 1

  • Some clinical guidelines suggest dosing up to 0.9 mg/kg for dextroamphetamine/amphetamine 1
  • The Physician's Desk Reference states a maximum of 40 mg for amphetamines, but clinical practice may allow higher doses in certain cases 2

• Important considerations for higher doses:

  • If using doses above 40 mg daily, clearly document that symptoms could not be controlled at lower doses 2
  • Ensure higher doses are not producing significant side effects (weight loss, blood pressure increase, agitation) 2
  • Monitor for signs of tolerance at higher doses 2

Formulation Options

• Immediate-release (IR): Typically dosed 2-3 times daily due to short duration of action (3-4 hours) 1
• Extended-release (XR): Once-daily dosing with duration of 8-12 hours 1
  • Adderall XR typical starting dose: 10 mg once daily in the morning 2
  • Can be titrated up by 5 mg weekly to maximum of 50 mg 2, 1

Maintenance Phase

• After successful titration, follow-up appointments at least monthly until symptoms are stabilized 2
• Regular monitoring should include:
  • Vital signs (blood pressure, heart rate) at each visit 1
  • Weight to monitor for appetite suppression 2
  • Assessment of sleep quality 1
  • Continued evaluation of target ADHD symptoms 2

Clinical Pearls and Caveats

• Response rates: Approximately 70% of patients respond to either amphetamine or methylphenidate alone; nearly 90% respond if both stimulant classes are tried 2
• Side effect profile: Amphetamines typically have more pronounced effects on appetite and sleep compared to methylphenidate due to longer half-lives 2
• Treatment failure: If a patient fails to respond to the maximum recommended dose, switching to an alternative stimulant is recommended rather than exceeding maximum doses 2
• Contraindications: Advanced cardiovascular disease, moderate to severe hypertension, hyperthyroidism, glaucoma, agitated states, history of drug abuse, and during or within 14 days of MAO inhibitor use 1

Special Considerations

• For patients with comorbid anxiety disorders, monitor closely as stimulants may exacerbate anxiety symptoms 3
• Research suggests that some adults may respond to relatively low doses (average 10.77 mg/day in one study) 3
• Long-term studies (up to 24 months) demonstrate sustained efficacy and tolerability at doses of 20-60 mg/day 4

By following these dosing guidelines and monitoring protocols, clinicians can optimize the therapeutic benefits of Adderall while minimizing potential adverse effects in adults with ADHD.