What considerations should be taken when starting an adult patient on stimulants, such as Ritalin (methylphenidate) or Adderall (amphetamine), for Attention Deficit Hyperactivity Disorder (ADHD)?

Starting an Adult Patient on Stimulants for ADHD: Key Considerations

Before prescribing stimulants for adult ADHD, conduct thorough pretreatment screening for cardiovascular disease, psychiatric comorbidities, and risk of substance abuse, as these medications carry significant risks including potential for abuse and addiction. 1, 2

Pretreatment Assessment

• Cardiovascular screening:

  • Assess for structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, coronary artery disease 1, 2
  • Check baseline blood pressure and heart rate 1, 2
  • Consider ECG for patients with cardiac risk factors

• Psychiatric evaluation:

  • Screen for history of psychosis, mania, anxiety disorders, depression 3
  • Assess for tics or Tourette's syndrome (family history and clinical evaluation) 2
  • Evaluate substance use disorders (stimulants contraindicated in active substance abuse) 3

• Risk assessment for stimulant abuse/misuse:

  • History of substance use disorders
  • Family history of addiction
  • Environmental factors (e.g., others in household with substance use)

Medication Selection and Dosing

First-line: Stimulants

1. Methylphenidate (Ritalin):

   • Starting dose: 5 mg twice daily (before breakfast and lunch)
   • Titration: Increase by 5-10 mg weekly based on response
   • Maximum daily dose: 60 mg 1
   • Available as immediate and extended-release formulations

2. Dexmethylphenidate (Focalin):

   • Starting dose: 10 mg once daily in the morning
   • Titration: Increase by 10 mg weekly
   • Maximum daily dose: 40 mg 2
   • Can be taken with or without food

3. Amphetamine formulations (e.g., Adderall):

   • Starting dose: 5-10 mg daily
   • Maximum daily dose: 50 mg 4

Second-line: Non-stimulants

• Consider for patients with:

  • Inadequate response to stimulants
  • Intolerable side effects from stimulants
  • Concerns about stimulant abuse or diversion 5
  • Comorbid substance use disorders

• Options include:

  • Atomoxetine
  • Bupropion
  • Tricyclic antidepressants (less favorable side effect profile) 3, 5

Monitoring and Follow-up

• Initial phase:

  • Follow-up every 3-4 weeks during dose titration 4
  • Monitor vital signs, weight, sleep patterns, mood changes
  • Assess efficacy using standardized rating scales

• Maintenance phase:

  • Once stable, follow-up every 3-6 months 4
  • Continue monitoring for side effects and therapeutic efficacy
  • Periodically reassess need for continued medication

Managing Common Side Effects

• Cardiovascular: Monitor blood pressure and pulse; consider dose reduction if significant increases 1, 2

• Sleep disturbances: Adjust timing of doses; avoid late afternoon/evening dosing

• Appetite suppression/weight loss: Monitor weight; consider nutritional counseling

• Anxiety/irritability: May require dose adjustment or switch to alternative medication

• Dry mouth: Encourage adequate hydration

Special Considerations

• Comorbid anxiety/depression: Stimulants may improve both ADHD and mild anxiety/depression symptoms; for more severe depression, consider additional treatment 3

• Tics/Tourette's syndrome: Monitor for emergence or worsening of tics; discontinue if clinically significant worsening 2

• Glaucoma: Use with caution in patients with open-angle glaucoma; monitor intraocular pressure 1, 2

• Substance use history: Exercise extreme caution; consider non-stimulant alternatives 3

Common Pitfalls to Avoid

• Starting with doses that are too high, leading to intolerable side effects
• Inadequate dose titration resulting in suboptimal treatment response
• Failing to monitor for cardiovascular side effects
• Not addressing comorbid conditions that may affect treatment response
• Prescribing stimulants to patients with active substance use disorders

Remember that stimulant medications have a high potential for abuse and misuse. Educate patients about proper medication storage, risks of sharing medications, and proper disposal of unused medication 1, 2.