What are the guidelines for increasing the dose of dextroamphetamine (Adderall) for Attention Deficit Hyperactivity Disorder (ADHD) or narcolepsy?

Increasing Dextroamphetamine Dose

For ADHD, start dextroamphetamine at 5 mg once or twice daily and increase by 5 mg weekly increments until optimal response is achieved, with a maximum of 40 mg/day in children and 50 mg/day in adults; for narcolepsy, start at 5-10 mg daily and increase by 5-10 mg weekly up to 60 mg/day. 1

ADHD Dosing Protocol

Pediatric Patients (Ages 6 and Older)

• Starting dose: 5 mg once or twice daily upon awakening 1
• Titration schedule: Increase by 5 mg weekly increments based on clinical response 1
• Maximum dose: 40 mg/day (rarely necessary to exceed this) 1
• Dosing frequency: Give first dose on awakening, with additional doses (1-2) at 4-6 hour intervals 1

Preschool-Aged Children (Ages 3-5)

• Starting dose: 2.5 mg daily 1
• Titration schedule: Increase by 2.5 mg weekly increments 1
• Important caveat: Dextroamphetamine is FDA-approved for this age group, but evidence for safety and efficacy is insufficient; methylphenidate has better evidence despite being off-label 2
• Metabolic consideration: Preschoolers metabolize stimulants more slowly, requiring lower starting doses and smaller increments 2

Adult Patients

• Starting dose: 10 mg once daily in the morning 2, 3
• Titration schedule: Increase by 5 mg weekly increments 2, 3
• Maximum dose: 50 mg/day 2, 1
• Timing: Morning administration is critical to minimize sleep disturbances 3, 4

Narcolepsy Dosing Protocol

Pediatric Patients (Ages 6-12)

• Starting dose: 5 mg daily 1
• Titration schedule: Increase by 5 mg weekly increments 1
• Dosing frequency: First dose on awakening, additional doses at 4-6 hour intervals 1

Adolescents and Adults (Age 12+)

• Starting dose: 10 mg daily 1
• Titration schedule: Increase by 10 mg weekly increments 1
• Usual therapeutic range: 5-60 mg/day in divided doses 1
• Alternative evidence: Practice parameters suggest dextroamphetamine is effective for narcolepsy-associated excessive sleepiness, though modafinil and sodium oxybate are also reasonable first-line options 5, 6

Assessment Before Each Dose Increase

Before increasing the dose, systematically evaluate: 3

• Current symptom control using standardized ADHD rating scales 3
• Presence and severity of side effects 3, 4
• Medication adherence and consistent use of current dose 3
• Vital signs (blood pressure and pulse) 3, 4
• Sleep quality and timing of last dose 3
• Comorbid conditions that might affect treatment response 3

Monitoring During Titration

Cardiovascular Monitoring

• Baseline assessment: Perform careful history for cardiac disease, family history of sudden death or ventricular arrhythmia, and physical exam before initiating treatment 1
• Ongoing monitoring: Check blood pressure and pulse at baseline and with each dose increase 3, 4

Neuropsychiatric Monitoring

• Pre-treatment screening: Evaluate family history and clinically assess for motor/verbal tics or Tourette's syndrome 1
• Common side effects to monitor: Decreased appetite, sleep disturbances, headaches, irritability, insomnia 2, 4
• Mood changes: Monitor for subdued or depressed behavior, which may necessitate dose reduction 7

Growth Monitoring (Pediatric Patients)

• Growth attenuation can occur with stimulant treatment, particularly in children who require higher doses 7
• Height and weight z-scores should be tracked over time 7
• Most growth attenuation occurs early in treatment rather than specifically at higher doses 7

When Maximum Dose Is Inadequate

If the patient reaches maximum recommended dose without adequate symptom control or experiences intolerable side effects: 3

• Do not exceed maximum recommended doses without careful consideration 4
• Consider switching to a different stimulant formulation (e.g., methylphenidate, lisdexamfetamine) 3
• Consider adding a non-stimulant medication such as atomoxetine 3
• Re-evaluate the diagnosis and assess for comorbid conditions affecting treatment response 3

Evidence on Exceeding Recommended Doses

• A retrospective study found that some children required doses exceeding standard recommendations (>1 mg/kg/day for dextroamphetamine) 7
• These children experienced more growth attenuation but no other serious complications 7
• The most common reason for dose increases was diminishing effectiveness, with persistent anger/aggression being prominent 7
• However, this represents off-label use and should only be considered after exhausting standard alternatives 7

Special Populations

Older Adults

• More conservative approach: Older adults are more sensitive to both therapeutic and adverse effects due to age-related pharmacokinetic changes 3
• Modified titration: Consider increasing by 5 mg every 2 weeks instead of weekly 3
• Enhanced monitoring: Particularly careful monitoring of vital signs is essential 3

Adolescents with Substance Use Risk

• Assess for symptoms of substance abuse before initiating treatment 2
• Monitor for signs of medication misuse or diversion 2
• Consider formulations with lower abuse potential (lisdexamfetamine, extended-release formulations) 2

Palliative Care/Daytime Sedation

• Starting dose: 2.5-5 mg orally with breakfast 2
• Second dose timing: If effect doesn't last through lunch, give second dose at lunch, preferably no later than 2:00 PM 2
• Titration: Escalate as needed for refractory daytime sedation 2

Common Pitfalls to Avoid

• Starting too high: Leads to unnecessary side effects and decreased adherence 3, 4
• Insufficient time between increases: Allow at least one week to properly evaluate response 3, 4
• Late-day dosing: Avoid late evening doses due to resulting insomnia 1
• Failure to systematically assess: Not evaluating both benefits and side effects before each increase 3, 4
• Continuing ineffective escalation: If maximum dose provides no benefit, switch strategies rather than exceeding recommendations 4
• Ignoring comorbidities: Sleep disorders, anxiety, depression, or other conditions may masquerade as inadequate ADHD treatment 3

Drug Interruption Considerations

• Periodic assessment: Where possible, interrupt drug administration occasionally to determine if behavioral symptoms recur sufficiently to require continued therapy 1
• This helps establish ongoing need for treatment and optimal dosing 1