What is the appropriate use and dosage of Dexadrine (dextroamphetamine) for Attention Deficit Hyperactivity Disorder (ADHD)?

Dexedrine (Dextroamphetamine) for ADHD

Dexedrine is an FDA-approved, highly effective first-line medication for ADHD in children aged 3 years and older, adolescents, and adults, with dosing starting at 2.5-5 mg daily depending on age and titrating weekly by 2.5-5 mg increments until optimal response is achieved, typically not exceeding 40 mg/day in children. 1

Age-Specific Treatment Recommendations

Preschool Children (3-5 years)

• Start with 2.5 mg daily and increase in 2.5 mg increments at weekly intervals until optimal response 1
• Behavioral therapy should be first-line treatment for 4-5 year olds, with stimulants like dextroamphetamine reserved for cases where behavioral interventions fail and moderate-to-severe functional impairment persists 2

Elementary School Children (6-11 years)

• Start with 5 mg once or twice daily, titrating upward in 5 mg increments weekly 1
• FDA-approved stimulant medications are strongly recommended as first-line treatment, with or without behavioral therapy (preferably both) 2
• Maximum dose rarely exceeds 40 mg/day total 1
• Give first dose upon awakening, with additional doses (1-2) at 4-6 hour intervals 1

Adolescents (12-18 years)

• Begin with 10 mg daily, increasing in 10 mg increments weekly until optimal response 1
• FDA-approved medications with adolescent assent are strongly recommended, with behavioral therapy as an optional adjunct 2
• Maximum doses similar to school-age children, though some may require higher total daily doses to cover longer days 2

Adults

• Start with 5 mg, titrating upward in 5-10 mg intervals weekly until symptom control 2
• Maximum daily doses typically reach 40 mg, though some adults may require up to 0.9 mg/kg or 40 mg total daily dose 2
• Adults need more frequent dosing to cover longer functional days 2

Titration Strategy and Monitoring

Forced Titration Protocol

• Use a systematic 4-week trial with weekly dose escalations: 2.5,7.5, and 10 mg for dextroamphetamine (or 5,10,15,20 mg for methylphenidate equivalent) 2
• Obtain ADHD rating scales from parents/teachers at each dose level 2
• Monitor for side effects including blood pressure, pulse, height, and weight at baseline and key intervals 2
• Select the dose producing maximum benefit with fewest side effects after reviewing all 4 weeks of data 2

Clinical Monitoring

• Maintain weekly contact (by phone or visit) during initial titration to assess response and tolerability 3
• Systematically ask about specific stimulant side effects: insomnia, decreased appetite, headaches, and weight loss 3
• Monitor weight regularly as weight loss is common 3
• After stabilization, schedule follow-up appointments at least monthly 3

Pre-Treatment Assessment Requirements

Before initiating dextroamphetamine, assess for:

• Cardiac disease: Obtain careful personal and family history of sudden death or ventricular arrhythmia, and perform physical examination 1
• Tics or Tourette's syndrome: Evaluate family history and clinically assess for motor or verbal tics 1
• Substance abuse history: Particularly important in adolescents and adults, as this may warrant consideration of non-stimulant alternatives first 4

Comparative Efficacy

• Approximately 70% of children respond to either dextroamphetamine or methylphenidate alone, and nearly 90% respond if both are tried 2
• If first stimulant fails or causes prohibitive side effects, switch to the alternative stimulant 2
• Dextroamphetamine demonstrates large effect sizes (1.1) with number needed to treat of 2-3 for clinically meaningful response 5
• Evidence quality for stimulants is particularly strong, superior to non-stimulants like atomoxetine, extended-release guanfacine, and extended-release clonidine 2

Dosing Formulations and Timing

Immediate-Release Dosing

• Administer first dose upon awakening 1
• Give additional doses at 4-6 hour intervals (typically 1-2 additional doses) 1
• Avoid late evening doses due to insomnia risk 1

Sustained-Release Options

• Dexedrine Spansules available: add morning and noon immediate-release doses together to determine spansule dose 2
• Can combine short-acting with sustained-release formulations for increased efficacy, duration, and dosing flexibility 2

Common Adverse Effects and Management

Most Frequent Side Effects

• Insomnia and decreased appetite are the only adverse events significantly associated with stimulants compared to placebo 6
• Most adverse events are mild to moderate in severity 7
• Withdrawal due to adverse events occurs more frequently with amphetamines than placebo (RR 2.69) 8

Safety Considerations

• Lower risk than previously thought for tic disorders and seizures 7
• Cardiovascular parameters require monitoring but serious cardiac events are rare 7
• If bothersome adverse reactions appear (insomnia, anorexia), reduce dosage 1

Individual Variability

• Side-effect profiles appear similar between dextroamphetamine and methylphenidate at group level 6
• At individual patient level, 39% of children show clinically valid differences in adverse events between the two stimulants 6
• Having both stimulants available provides opportunity to minimize adverse events while maintaining symptom control 6

Critical Pitfalls to Avoid

• Starting at too high a dose leads to unnecessary side effects and decreased adherence 3
• Failing to systematically assess both benefits and side effects during titration 3
• Not documenting justification when using higher doses (must clearly document that symptoms could not be controlled at lower doses and higher doses produce no side effects) 2
• Ignoring drug holidays: Interrupt administration occasionally to determine if behavioral symptoms recur sufficiently to require continued therapy 1

Special Populations

Substance Abuse Concerns

• Consider non-stimulant medications (atomoxetine, extended-release guanfacine, extended-release clonidine) as first-line when substance abuse history exists 4
• If stimulants necessary despite substance abuse history, maintain close monitoring 4

Comorbid Conditions

• Treat severe or primary depression first before addressing ADHD 4
• For comorbid anxiety, non-stimulants may be preferred initially as stimulants can exacerbate anxiety 4