What is the treatment for an Adderall (amphetamine and dextroamphetamine) overdose?

Treatment for Adderall Overdose

Management of Adderall overdose is largely symptomatic and supportive, with benzodiazepines as the cornerstone for controlling the sympathomimetic syndrome, including agitation, seizures, and cardiovascular effects. 1

Initial Management and Decontamination

• Consult a Certified Poison Control Center immediately for up-to-date guidance on acute amphetamine intoxication 1
• Perform gastric lavage if presentation is within 1-2 hours of ingestion 1
• Administer activated charcoal to reduce drug absorption 1
• Give a cathartic agent to enhance gastrointestinal elimination 1

Clinical Presentation to Anticipate

The sympathomimetic syndrome from Adderall overdose presents with:

• Neurological effects: Restlessness, tremor, hyperreflexia, confusion, agitation, combative behavior, hallucinations, panic states, delirium, anxiety, paranoia, movement disorders, and seizures 1, 2
• Cardiovascular effects: Tachycardia, arrhythmias, hypertension (or hypotension), and potential circulatory collapse 1, 2
• Other manifestations: Hyperpyrexia, rapid respiration, mydriasis, rhabdomyolysis, nausea, vomiting, diarrhea, and abdominal cramps 1, 2, 3
• Severe cases: Fatal poisoning is usually preceded by convulsions and coma 1

Pharmacologic Management Algorithm

First-Line: Benzodiazepines

• Use benzodiazepines as the primary intervention to interrupt the sympathomimetic syndrome, control agitation, prevent seizures, and reduce cardiovascular stress 2
• Administer in escalating doses until adequate sedation is achieved 2

Second-Line Agents (if benzodiazepines fail)

When agitation, delirium, and movement disorders are unresponsive to benzodiazepines:

• Antipsychotics: Ziprasidone or haloperidol 2
• Note: Chlorpromazine specifically antagonizes the central stimulant effects of amphetamines and can be used to treat amphetamine intoxication 1
• Central alpha-agonists: Dexmedetomidine 2
• Propofol for refractory cases 2

Cardiovascular Management

• For severe acute hypertension: Intravenous phentolamine has been suggested, though blood pressure usually drops gradually once adequate sedation is achieved 1
• For tachyarrhythmias: Beta-blockers such as propranolol can be used 3
• Monitor for myocardial infarction: Maintain high suspicion for cardiac ischemia, especially in patients presenting with chest pain and abnormal ECG, even in young patients without cardiovascular risk factors 4, 5

Critical Supportive Care Measures

• Intravenous fluids: Essential for managing hyperthermia, maintaining renal function (especially if rhabdomyolysis is present), and promoting amphetamine elimination 3
• Temperature control: Aggressive cooling measures for hyperpyrexia 2, 3
• Monitor for rhabdomyolysis: Check creatine kinase levels and urine myoglobin 1, 2

Controversial: Urinary Acidification

• Avoid urinary acidification despite increased amphetamine excretion because it increases the risk of acute renal failure if myoglobinuria is present from rhabdomyolysis 1
• This represents a shift from older practices that emphasized acidification 1

Hemodialysis Consideration

• Experience with hemodialysis or peritoneal dialysis is inadequate to permit routine recommendation for amphetamine overdose 1
• Reserve for severe cases with refractory symptoms or significant end-organ damage 1

Dose-Toxicity Relationship

• Toxic symptoms occasionally occur at doses as low as 2 mg (idiosyncratic), but are rare with doses less than 15 mg 1
• 30 mg can produce severe reactions 1
• Doses of 400-500 mg are not necessarily fatal, though individual response varies widely 1
• Fatalities are rare with appropriate intensive care, though major morbidity requiring ICU admission and prolonged hospitalization is common 2

Special Monitoring Considerations

• Secondary complications can involve renal failure, muscle breakdown, pulmonary effects, and gastrointestinal symptoms requiring specific monitoring 2
• Hypoglycemia, hypersegmentation of neutrophils, and mild thrombocytopenia have been reported in severe intoxications 3
• Concurrent alcohol use creates a particularly dangerous situation with serious cardiovascular adverse effects, including increased risk of myocardial infarction 4, 5

Common Pitfall to Avoid

Do not delay benzodiazepine administration while attempting other interventions—sedation is the foundation of treatment and often resolves cardiovascular complications without additional pharmacologic intervention 1, 2