Methylphenidate HCl Extended-Release 24-Hour Tablet Dosing
Initial Dosing
Start methylphenidate extended-release 24-hour formulations at 18 mg once daily in the morning for stimulant-naïve patients, which is equivalent to methylphenidate immediate-release 5 mg three times daily. 1
- For children and adolescents, begin with 18 mg once daily (Concerta/OROS-MPH formulation) 1
- Adults should also start at 18 mg once daily in the morning 1
- Administer in the early morning to avoid sleep disturbances 2
Titration Strategy
Increase the dose weekly by 18 mg increments based on clinical response and tolerability, using standardized rating scales from teachers and parents (for children) or from the patient and significant others (for adults) to guide adjustments. 1, 3
- Titrate through the range of 18-54 mg daily for most patients 1
- Continue dose increases until symptoms resolve and impairment diminishes, or until side effects become prohibitive 1, 3
- Stop titration when adequate symptom control is achieved or troublesome side effects emerge 1
Maximum Dosing
The typical maximum daily dose is 54-72 mg for children and adolescents, though some patients may require up to 60 mg total daily dose of methylphenidate (any formulation). 1
- For adults, maximum doses generally mirror those for children, with some requiring up to 65 mg total daily dose (approximately 1.0 mg/kg) 1
- Higher doses require clear documentation that lower doses failed to control symptoms and that the higher dose produces no significant side effects (weight loss, blood pressure elevation, agitation) 1
- Monitor for tolerance development at higher doses 1
Special Populations
Small Children
- Exercise extreme caution when titrating in children weighing less than 25 kg 3
- For children under 20 kg (45 lbs), omit the 15 mg dose step in titration schedules 3
Older Adults
- Use more conservative titration (increase by smaller increments every 2 weeks instead of weekly) due to increased sensitivity to both therapeutic and adverse effects 2
- Monitor vital signs particularly carefully in this population 2
Monitoring Requirements
Obtain standardized ADHD rating scales before each dose adjustment and monitor vital signs (blood pressure, pulse, height, weight) at baseline and with each dose increase. 3, 2
- For children: collect ratings from both teachers and parents 1, 3
- For adults: obtain symptom and side-effect ratings from patient and significant others 1, 3
- These ratings can be collected via phone contact between visits 1
Pharmacokinetic Considerations
The 24-hour extended-release formulations (particularly OROS-MPH/Concerta) produce an ascending plasma drug level pattern that provides coverage throughout the school/work day 1
- Onset of action occurs within 1-2 hours of morning dosing 4
- Duration of effect extends 10-12 hours 4
- Once-daily dosing eliminates the need for in-school administration, improving compliance especially in adolescents 1
Common Pitfalls to Avoid
- Do not use weight-adjusted dosing - standard tablets are unscored, making fractional doses impractical, and research does not uniformly support weight-adjusted titration 1
- Do not rely on plasma levels - methylphenidate plasma concentrations do not correlate with clinical response and provide no more predictive power than rating scales 1
- Do not increase doses too rapidly - allow at least one week between increases to properly evaluate response 2
- Do not skip systematic assessment - failure to collect standardized ratings before each dose change is a major error 2
Alternative Formulations
If the 24-hour extended-release formulation proves inadequate, consider combining with immediate-release methylphenidate for breakthrough symptoms or switching to alternative extended-release preparations with different release profiles 1