What is the starting dose of Concerta (methylphenidate) for adults?

Concerta Starting Dose for Adults

For adults with ADHD, start Concerta at 18 mg once daily in the morning, then titrate upward in 18 mg increments at weekly intervals based on response and tolerability, up to a maximum of 72 mg daily. 1

Initial Dosing Strategy

• Begin with 18 mg once daily administered in the morning, preferably 30-45 minutes before breakfast 1
• The 18 mg starting dose of Concerta is approximately equivalent to methylphenidate immediate-release 5 mg three times daily 2
• Morning administration is critical to minimize potential sleep disturbances 2

Titration Protocol

• Increase by 18 mg increments weekly (moving from 18 mg → 36 mg → 54 mg → 72 mg) based on symptom response and side effect tolerability 3, 4
• The average effective dose in clinical trials ranged from 36-72 mg daily, with some patients requiring up to 108 mg daily in controlled studies 4
• Maximum FDA-approved daily dose is 72 mg, though research protocols have safely used up to 108 mg daily (approximately 1.3 mg/kg/day) 3, 4

Monitoring During Titration

Essential monitoring parameters at each dose adjustment include:

• Blood pressure and heart rate (expect increases of approximately 3-4 mm Hg systolic/diastolic and 4-5 bpm) 3
• ADHD symptom severity using standardized rating scales 5
• Side effects, particularly appetite suppression, insomnia, anxiety, and cardiovascular symptoms 1
• Weight changes, as weight loss is common 1

Response Assessment

• Clinical response typically occurs within 1-2 hours of administration and lasts for the full 12-hour period 2
• Approximately 66% of adults achieve clinical response (defined as "much" or "very much" improved on Clinical Global Impression scale plus >30% symptom reduction) with optimal dosing 3
• If no response occurs after 4 weeks at maximum tolerated dose, consider switching to an alternative stimulant 5

Important Clinical Pitfalls to Avoid

Do not start at higher doses thinking faster titration is better - the gradual onset of Concerta's effect differs from immediate-release formulations, and starting too high increases cardiovascular and psychiatric side effects 2, 1

Do not administer with high-fat meals initially - while Concerta's absorption is relatively food-independent compared to amphetamine formulations, consistent timing with meals helps establish routine 6

Do not use in patients with structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, or coronary artery disease without cardiology consultation 1

Contraindications and Precautions

• Absolute contraindications include concurrent MAOI use (or within 14 days), known hypersensitivity to methylphenidate, and uncontrolled hypertension 1
• Screen for personal or family history of cardiac disease, psychiatric disorders (particularly bipolar disorder or psychosis), and substance use disorders before initiating treatment 1
• Assess for risk factors for acute angle-closure glaucoma in patients with significant hyperopia 1

Special Considerations for Adults

• Adults often require higher total daily doses than children because they need symptom coverage throughout a longer workday 5
• The once-daily formulation improves adherence and reduces stigma compared to multiple daily dosing of immediate-release formulations 7
• Document clearly if doses above 72 mg are needed, noting that lower doses were inadequate and higher doses are not producing prohibitive side effects 5