What are the treatment considerations for a 43-year-old patient with Traumatic Brain Injury (TBI) and Attention Deficit Hyperactivity Disorder (ADHD) taking Adderall XR (amphetamine) 25 mg in the morning and 10 mg twice in the afternoon?

Treatment Considerations for TBI Patient with ADHD on Adderall XR

For a 43-year-old patient with TBI and ADHD, the current regimen of Adderall XR 25 mg in the morning plus two 10 mg doses in the afternoon is excessive and should be modified to a once-daily extended-release formulation to improve adherence and reduce side effects.

Current Medication Analysis

The patient is currently taking:

• Adderall XR 25 mg in the morning
• Adderall IR 10 mg twice in the afternoon
• Total daily dose: 45 mg

This regimen presents several concerns:

• The FDA recommends administering amphetamines at the lowest effective dosage with individualized adjustment 1
• Late evening doses should be avoided due to resulting insomnia 1
• The current multiple daily dosing regimen may reduce medication adherence 2

Medication Recommendations

Primary Recommendation

1. Convert to once-daily dosing with Adderall XR
   • Switch to Adderall XR 30 mg once daily in the morning
   • This provides extended coverage throughout the day without the need for afternoon doses
   • Once-daily dosing should generally be preferred over twice-daily dosing to improve medication adherence 2

Alternative Options

1. Non-stimulant medications if stimulants are poorly tolerated:
   • Atomoxetine (Strattera): Provides "around-the-clock" effects with fewer appetite and growth issues 2
   • Guanfacine or clonidine: May be considered, especially if sleep disturbances are present 2

Special Considerations for TBI Patients with ADHD

TBI and Stimulant Response

• Patients with TBI often present with cognitive complaints including difficulty with attention and concentration that resemble ADHD symptoms 3
• Methylphenidate has shown some benefit for cognitive function, behavior, and arousal in children with TBI 4
• Patients with premorbid ADHD who sustain mild TBI are more likely to be moderately disabled by the injury than patients without ADHD 5

Monitoring Requirements

1. Regular follow-up visits:

   • Within 2-4 weeks after dose adjustment to assess both appetite improvement and ADHD symptom control 6
   • Regular assessment of symptom control, weight monitoring, and vital signs checks 6

2. Side effect monitoring:

   • Weight and appetite changes
   • Sleep disturbances
   • Cardiovascular effects (blood pressure, heart rate)
   • Potential exacerbation of TBI symptoms

Potential Pitfalls and Caveats

1. Medication interactions: Amphetamines interact with numerous medications including:

   • Acidifying/alkalinizing agents (affect absorption and excretion)
   • Adrenergic blockers
   • Tricyclic antidepressants
   • MAO inhibitors (can cause hypertensive crisis)
   • Antihistamines, antihypertensives, and other medications 1

2. Cardiovascular risks: Screen for cardiac risk factors before continuing stimulants, especially in adults 6

3. Substance use risk: Assess for substance use risk before prescribing stimulants, particularly important in TBI patients 6

4. Growth and weight concerns: Regular monitoring of weight and BMI is essential, as stimulants commonly cause appetite suppression 6

5. Timing considerations: Avoid late afternoon/evening dosing of stimulants to prevent insomnia 1

The evidence supports that Adderall XR as a once-daily morning dose can provide effective symptom control throughout the day 7, 8, making it a more appropriate choice than the current multiple daily dosing regimen for this patient with TBI and ADHD.