What are the considerations for increasing the dose of Adderall XR (amphetamine and dextroamphetamine) in a 62-year-old male with Attention Deficit Hyperactivity Disorder (ADHD) who feels his current dose of 30mg is inadequate?

Increasing Adderall XR Dose in a 62-Year-Old with ADHD

The maximum recommended daily dose of Adderall XR for adults with ADHD is 50 mg, so an increase from the current 30 mg dose may be appropriate if the patient is experiencing inadequate symptom control and has no contraindications. 1

Dose Considerations for Older Adults

• The FDA label for amphetamines states that they should be administered at the lowest effective dosage with individual adjustment based on response 2
• While the maximum recommended daily dose is 50 mg for adults, careful consideration should be given to increasing the dose in older adults due to potential age-related changes in metabolism and increased cardiovascular risk 1
• Dose increases should be made gradually, typically in 5 mg weekly increments to minimize side effects 1, 2

Assessment Before Dose Increase

• Before increasing the dose, evaluate:
  • Current symptom control using standardized ADHD rating scales 1
  • Presence of side effects at the current dose 3
  • Vital signs, particularly blood pressure and heart rate, as stimulants can increase cardiovascular parameters 1
  • Potential drug interactions with other medications the patient may be taking 3

Recommended Approach

1. Initial Evaluation:

   • Confirm that the current 30 mg dose has been taken consistently as prescribed 3
   • Rule out other factors that might be contributing to perceived lack of efficacy (sleep issues, substance use, comorbid conditions) 3

2. Dose Titration:

   • If appropriate to increase, add 5 mg to the current dose (to 35 mg daily) 1
   • Reassess after one week for both therapeutic effects and side effects 3
   • Continue increasing by 5 mg increments weekly as needed, up to the maximum of 50 mg daily 1

3. Monitoring:

   • Schedule follow-up appointments at least monthly until symptoms are stabilized 3
   • Monitor blood pressure, heart rate, weight, and sleep patterns with each dose increase 3
   • Systematically assess for common side effects such as insomnia, decreased appetite, and anxiety 3

Special Considerations for Older Adults

• Cardiovascular risk increases with age, making careful monitoring of vital signs particularly important in this 62-year-old patient 3
• Older adults may be more sensitive to both therapeutic and adverse effects of stimulants due to age-related changes in pharmacokinetics 3
• Consider a more conservative titration schedule (e.g., increasing by 5 mg every 2 weeks instead of weekly) if there are concerns about tolerability 3

Common Pitfalls to Avoid

• Increasing the dose too rapidly can lead to unnecessary side effects and decreased medication adherence 1
• Failing to systematically assess both benefits and side effects during titration 1
• Not allowing sufficient time (at least one week) between dose increases to properly evaluate response 1
• Overlooking the importance of morning administration to minimize sleep disturbances 1

Alternative Considerations

• If the patient reaches the maximum dose of 50 mg without adequate symptom control, or experiences intolerable side effects, consider:
  • Switching to a different stimulant formulation 4
  • Adding or switching to a non-stimulant medication such as atomoxetine 3
  • Reevaluating the diagnosis and considering comorbid conditions that might be affecting treatment response 3