Recommended Titration Schedule for Focalin (Dexmethylphenidate)
For patients new to methylphenidate, Focalin (dexmethylphenidate) should be started at 5 mg once daily in the morning for pediatric patients and 10 mg once daily for adults, with weekly titration increases of 5 mg for children and 10 mg for adults until optimal symptom control is achieved, not exceeding maximum daily doses of 30 mg for children and 40 mg for adults. 1
Initial Dosing
Patients New to Methylphenidate:
- Start with 5 mg once daily in the morning for pediatric patients 1
- Start with 10 mg once daily in the morning for adult patients 1
- Can be taken with or without food 1
Patients Currently on Methylphenidate:
- For patients already on racemic methylphenidate (Ritalin), the starting dose of Focalin should be half (1/2) the total daily dose of racemic methylphenidate 1
- For patients currently using immediate-release dexmethylphenidate tablets, the same daily dose of extended-release Focalin can be given 1
Titration Process
- Increase dose weekly in increments of 5 mg in pediatric patients 1
- Increase dose weekly in increments of 10 mg in adult patients 1
- Base decisions to change doses on standardized, validated rating scales for assessing ADHD behavior 2
- Collect symptom and side-effect ratings from teachers and parents for children, or from the patient and significant other for adults before each dose increase 2
- These ratings can be obtained through phone contact or office visits 2
Maximum Recommended Doses
- Daily doses above 30 mg in pediatric patients are not recommended 1
- Daily doses above 40 mg in adults are not recommended 1
Administration Options
- Capsules may be swallowed whole 1
- Alternatively, capsules may be opened and the entire contents sprinkled on applesauce (should be consumed immediately without chewing) 1
- The dose of a single capsule should not be divided 1
Monitoring and Adjustment
- Stop titration upward when symptoms have resolved and impairment has been diminished 2
- Different target symptoms may require different doses, so prioritize which symptoms are to be chosen as a basis for titration 2
- Monitor for side effects and reduce or reverse dose increases if troublesome side effects occur 2
- For small children (weighing less than 45 lb/20 kg), titrate more slowly and consider omitting the 15-20 mg dosing step 2
Alternative Titration Method
- A "forced titration" trial may be used, where the patient takes all four dosages of stimulant (5,10,15,20 mg), with each dose condition lasting 1 week 2
- At follow-up, rating scales from all weeks are examined along with reports of side effects, and the clinician selects the dose that produced the most benefit with the fewest side effects 2
Important Considerations
- Titrate slowly with small children to avoid unnecessary side effects 2
- Experiencing unnecessary side effects may decrease willingness of children or parents to use stimulants 2
- Dexmethylphenidate provides effective management of ADHD at half the dose of racemic methylphenidate 3
- The extended-release formulation provides a bimodal release profile that mimics two doses of immediate-release dexmethylphenidate given 4 hours apart, allowing once-daily administration 4, 5
Follow-up Schedule
- Week 1: Initial dose with office visit to assess ADHD rating scales and side effects 2
- Week 2: Dose increase with office visit or phone contact to assess ADHD rating scales and side effects 2
- Week 4: Further dose increase (if needed) with office visit or phone contact 2
- Week 5: Office visit to review scales and determine optimal maintenance dose 2
If improvement is not observed after appropriate dosage adjustment over a one-month period, consider discontinuing the medication 1.