What is the recommended dosing for Adderall XR (amphetamine and dextroamphetamine) in adults with Attention Deficit Hyperactivity Disorder (ADHD)?

Adult Dosing of Adderall XR

Start Adderall XR at 10 mg once daily in the morning, then titrate upward in 5-10 mg weekly increments based on symptom control and tolerability, with most adults achieving optimal response between 40-60 mg total daily dose, not exceeding a maximum of 50 mg daily. 1

Starting Dose

• Begin with 10 mg of Adderall XR (extended-release) once daily in the early morning 1
• For immediate-release formulations, start at 5 mg once or twice daily 2, 1
• Morning administration is essential to minimize sleep disturbances 1
• The lower starting dose minimizes initial side effects while allowing assessment of individual response 1

Titration Protocol

• Increase the dose in 5-10 mg increments weekly based on symptom control and tolerability 2, 1
• Collect symptom and side-effect ratings from the patient and significant other before each dose increase 2, 1
• Continue titration until optimal symptom control is achieved, with symptoms resolved and impairment diminished 2
• Allow sufficient time between dose increases to properly evaluate response 1

Target Dose Range

• Most adults achieve optimal response at total daily doses of 40-60 mg 1
• The maximum recommended dose for extended-release formulations is 50 mg daily for adults 1
• For immediate-release mixed amphetamine salts, the maximum is 40 mg total daily dose 2
• Clinical trials have shown effective doses ranging from 54 mg average (immediate-release, divided doses) 3 to 20-60 mg/day (extended-release) 4

Critical Monitoring Requirements

Before initiating treatment:

• Obtain baseline blood pressure, pulse, height, and weight in the context of a physical examination 2, 1
• Screen for contraindications including substance abuse disorder, as prescribing psychostimulants to adults with comorbid substance abuse is of particular concern 2

During titration:

• Monitor blood pressure and pulse at each dose adjustment 1
• Use standardized ADHD rating scales to objectively track response 1
• Systematically assess for side effects including decreased appetite, insomnia, anxiety, dry mouth, headache, and nervousness 2, 4

Dosing Strategy Considerations

• Adderall XR provides 12-hour duration of action with once-daily dosing 5
• Adults typically require coverage for a longer functional day compared to children 2
• Immediate-release formulations may require 2-3 doses daily (e.g., 5-20 mg three times daily or 5 mg three times daily to 20 mg twice daily) 2
• Amphetamines have greater effects on appetite and sleep compared to methylphenidate due to longer excretion half-lives 2

When Higher Doses Are Needed

• If approaching or exceeding standard maximum doses, clearly document that symptoms could not be controlled at lower doses 2, 1
• Document that higher doses are not producing intolerable side effects such as weight loss, blood pressure increase, or agitation 2, 1
• Monitor the patient for signs of tolerance 2
• Consider that more is not necessarily better—if the top recommended dose doesn't help, a change in medication or addition of psychosocial interventions may be required 1

Common Pitfalls to Avoid

• Starting at too high a dose leads to unnecessary side effects and decreased adherence 1
• Failing to systematically assess both benefits and side effects during titration 1
• Not allowing sufficient time between dose increases to evaluate response 1
• Overlooking the importance of morning administration, which increases sleep disturbances when ignored 1
• Continuing to escalate dose when symptom control plateaus—consider switching medications or adding non-stimulant options instead 1
• Prescribing to patients with comorbid anxiety disorders without caution, as amphetamines may precipitate acute anxiety symptoms in vulnerable individuals 6

Evidence Quality Note

The recommendation is based on convergent evidence from the American Academy of Child and Adolescent Psychiatry practice parameters 2 and recent guideline summaries 1, supported by multiple controlled trials demonstrating efficacy at these dose ranges 4, 3. Response rates of 54-78% have been documented in adults with ADHD treated with amphetamine salts 2, 6, 3, with sustained improvement demonstrated for up to 24 months 4.