What are the guidelines for using amphetamines (amphetamine) in adults with Attention Deficit Hyperactivity Disorder (ADHD)?

Guidelines for Amphetamine Use in Adults with ADHD

The recommended approach for using amphetamines in adults with ADHD is to start with a low dose (5-10 mg daily) and gradually titrate up to a maximum of 50 mg daily, with regular monitoring every 3-4 weeks during initial treatment and every 3-6 months once stabilized. 1

Medication Selection and Dosing

Initial Medication Selection

• Amphetamine formulations approved for adult ADHD include:
  • Lisdexamfetamine (Vyvanse): 30-70 mg once daily 2
  • Mixed amphetamine salts (Adderall): 5-50 mg daily 1
  • Dexamphetamine: 10-50 mg daily 1

Dosing Recommendations

• Starting doses:
  • Begin with 30 mg once daily for lisdexamfetamine 2
  • Begin with 5-10 mg daily for mixed amphetamine salts and dexamphetamine 1
• Titration:
  • Increase in increments of 10-20 mg at approximately weekly intervals 1, 2
  • Adjust based on symptom control and side effects
• Maximum doses:
  • Lisdexamfetamine: 70 mg once daily 2
  • Mixed amphetamine salts and dexamphetamine: up to 50 mg daily 1

Administration Guidelines

• Take medication in the morning to avoid insomnia 2
• Can be taken with or without food 2
• Avoid afternoon doses due to potential sleep disturbances 2

Monitoring and Follow-up

Initial Treatment Phase

• Monitor every 3-4 weeks during dose titration 1
• Assess:
  • ADHD symptom improvement
  • Side effects (particularly appetite, weight, sleep disturbances)
  • Vital signs (blood pressure, heart rate)

Maintenance Phase

• Once stabilized, monitor every 3-6 months 1
• Regular assessment of:
  • Continued efficacy
  • Cardiovascular parameters (blood pressure, heart rate)
  • Weight changes
  • Sleep quality
  • Mood changes

Common Side Effects and Management

Common Side Effects

• Decreased appetite (27-34%)
• Insomnia (13-27%)
• Dry mouth (26-36%)
• Weight loss (3-9%)
• Increased heart rate/blood pressure (2-7%)
• Anxiety (5-6%)
• Headache (30%) 1, 2

Side Effect Management

• For decreased appetite/weight loss:
  • Take medication with or after meals
  • Monitor weight regularly
  • Consider dose reduction if significant weight loss occurs
• For insomnia:
  • Ensure morning dosing
  • Avoid doses after 2:00 PM
  • Consider dose reduction if persistent
• For cardiovascular effects:
  • Regular monitoring of blood pressure and heart rate
  • Consider dose reduction if clinically significant changes occur

Special Considerations

Pretreatment Screening

• Assess for cardiac disease (careful history, family history of sudden death or ventricular arrhythmia, physical exam) 2
• Evaluate for history of motor or verbal tics or Tourette's syndrome 2

Dietary and Medication Interactions

• Dietary considerations:

  • Limit caffeine intake to less than 300 mg per day 1
  • Avoid tyramine-containing foods (aged cheeses, cured meats, fermented foods) 1
  • Limit alcohol consumption (≤1 drink daily for women, ≤2 drinks for men) 1

• Medication interactions:

  • Avoid combination with MAOIs due to risk of hypertensive crisis 1
  • Use caution with other medications that may increase blood pressure or heart rate

Warning for Abuse and Misuse

• Amphetamines have high potential for abuse and misuse 2
• Assess each patient's risk for abuse before prescribing
• Educate patients about proper storage and disposal
• Regularly reassess risk throughout treatment 2

Treatment Effectiveness and Duration

• Amphetamines show significant improvement in ADHD symptoms with effect sizes of 0.8-1.0 3, 4
• Mixed amphetamine salts extended-release (MAS XR) can control ADHD symptoms for up to 12 hours 5
• Long-term studies (up to 24 months) show sustained effectiveness with continued treatment 6

Important Caveats and Pitfalls

• Avoid in patients with:

  • Significant cardiovascular disease
  • Uncontrolled hypertension
  • History of substance abuse
  • Glaucoma
  • Agitation states

• Common prescribing pitfalls:

  • Inadequate dose titration (stopping at suboptimal doses)
  • Failure to monitor for side effects
  • Not addressing wearing-off effects with proper timing of medication
  • Overlooking comorbid conditions that may affect treatment response

Remember that while amphetamines are effective for adult ADHD, they require careful patient selection, appropriate dosing, and regular monitoring to maximize benefits while minimizing risks.