What is the recommended titration schedule for Adderall (amphetamine and dextroamphetamine)?

Adderall Titration Protocol

Start with 5 mg twice daily (IR) or 10 mg once daily in the morning (XR), increase by 5 mg weekly increments based on response and tolerability, up to a maximum of 40-50 mg daily. 1

Initial Dosing Strategy

Immediate-Release (IR) Formulation

• Adults: Begin with 5 mg twice daily, administered after breakfast and lunch 1
• Children: Start with 2.5 mg twice daily 1
• Morning and early afternoon timing prevents sleep disturbances 1

Extended-Release (XR) Formulation

• Standard starting dose: 10 mg once daily in the morning 1, 2, 3
• XR formulation eliminates in-school dosing and improves adherence 3
• Morning administration is mandatory to minimize insomnia 1, 3

Titration Schedule

Increase by 5-10 mg weekly for IR or 5 mg weekly for XR formulations. 1

Key Titration Principles

• Wait at least one full week between dose increases to properly evaluate therapeutic response 1, 3
• Assess both symptom control and side effects before each increase 2, 3
• Use standardized ADHD rating scales to guide adjustments 2
• Maintain weekly telephone contact initially, with in-person visits at least monthly until stabilized 1

Special Population Considerations

• Older adults: Use more conservative titration—increase by 5 mg every 2 weeks instead of weekly due to age-related pharmacokinetic changes 1, 2
• Children <25 kg: Single doses should not exceed 10 mg 1

Maximum Dosing Thresholds

The maximum daily dose is 40-50 mg for adults. 1, 2, 3

• Physician's Desk Reference lists 40 mg as the maximum 1
• More recent guidelines support up to 50 mg daily for adults 1, 2
• If maximum dose is ineffective, do not increase further—consider switching medications or adding non-stimulant alternatives like atomoxetine 2

Monitoring Parameters

Baseline Assessment

• Blood pressure and pulse 1, 3
• Height and weight 1
• Cardiac history screening 1

Ongoing Monitoring

• At each visit: Weight to monitor appetite suppression 1, 3
• With each dose increase: Blood pressure and pulse 2, 3
• Quarterly for adults: Blood pressure and pulse checks 1, 3
• Systematic evaluation of target ADHD symptoms 1
• Side effect assessment: insomnia, anorexia, headaches, social withdrawal, tics, weight loss 1

Critical Pitfalls to Avoid

• Starting too high: Leads to unnecessary side effects and poor adherence 1, 3
• Rushing titration: Insufficient time between increases prevents accurate response assessment 1, 3
• Afternoon/evening dosing: Causes sleep disturbances 1, 3
• Exceeding maximum dose when ineffective: More is not better—reevaluate diagnosis and consider alternative treatments 1, 3
• Failing to systematically assess benefits and side effects at each titration step 1, 3

When Treatment Fails at Maximum Dose

Switch to a different stimulant formulation or add non-stimulant medication rather than exceeding 50 mg daily. 2

• Reevaluate the ADHD diagnosis 2
• Screen for comorbid conditions affecting treatment response (sleep disorders, mood disorders, substance use) 2
• Consider environmental and psychosocial interventions 1
• Consult with or refer to psychiatry for complex cases 2