What is the proper usage and dosage of Dextroamphetamine (Amphetamine) Extended Release (ER) for treating Attention Deficit Hyperactivity Disorder (ADHD)?

Dextroamphetamine/Amphetamine Extended-Release (ER) Dosing for ADHD

For adults with ADHD, start Adderall XR at 10 mg once daily in the morning, titrate by 5 mg weekly increments based on response and tolerability, with a maximum dose of 50 mg daily. 1, 2

Adult Dosing Protocol

Initial Dosing

• Start at 10 mg once daily in the morning to minimize sleep disturbances 1
• Administer early in the morning to provide symptom coverage throughout the day 1
• Avoid late evening doses due to insomnia risk 3, 4

Titration Strategy

• Increase by 5 mg weekly increments based on clinical response and tolerability 1, 2
• Assess both therapeutic effects and side effects before each dose increase 1
• Use standardized ADHD rating scales to objectively guide dose adjustments 1
• Maximum recommended daily dose is 50 mg 1, 2

Monitoring Requirements

• Check blood pressure and pulse at baseline and with each dose increase 1
• For adults on stable doses, monitor vital signs quarterly 2
• Confirm consistent medication use before increasing doses 1
• Rule out other factors contributing to perceived lack of efficacy (sleep issues, comorbid conditions) 1

Pediatric Dosing (Ages 6 and Older)

Children 6 Years and Older

• Start with 5 mg once or twice daily 3, 4
• Increase in 5 mg increments at weekly intervals until optimal response 3, 4
• Give first dose on awakening; additional doses at 4-6 hour intervals 3, 4
• Rarely necessary to exceed 40 mg per day 3, 4
• For children weighing less than 25 kg, single doses generally should not exceed 15 mg 2

Young Children (Ages 3-5)

• Start with 2.5 mg daily 3, 4
• Increase in 2.5 mg increments at weekly intervals 3, 4
• Not recommended for children under 3 years of age 3, 4

Special Populations and Considerations

Older Adults

• More conservative titration is warranted due to age-related pharmacokinetic changes 1
• Consider increasing by 5 mg every 2 weeks instead of weekly 1
• Monitor vital signs particularly carefully in this population 1

Adolescents

• Assess for substance abuse symptoms before initiating treatment 5
• Monitor for signs of medication diversion or misuse 5
• Consider longer-acting formulations or medications with lower abuse potential (lisdexamfetamine) for adolescents at risk 5
• Provide medication coverage for driving hours with longer-acting or late-afternoon short-acting medications 5

Preschool-Age Children (Under 6 Years)

• Dextroamphetamine is the only FDA-approved medication for children under 6, though this approval was based on less stringent historical criteria rather than robust empirical evidence 5
• Most safety and efficacy evidence in preschoolers comes from methylphenidate studies, not amphetamines 5
• Medication should only be considered after behavior therapy has not adequately addressed symptoms 5
• Use lower starting doses and smaller dose increments due to slower metabolism in ages 4-5 5

When Maximum Doses Are Inadequate

Alternative Strategies

• Do not exceed the 50 mg maximum dose 2
• Consider switching to a different stimulant formulation 1
• Consider adding a non-stimulant medication like atomoxetine 1
• Reevaluate the diagnosis and assess for comorbid conditions affecting treatment response 1

Extended-Release vs. Immediate-Release Formulations

Extended-Release Advantages

• Designed to reduce abuse potential compared to immediate-release formulations 2
• Provides once-daily dosing with sustained symptom control 1
• Minimizes peaks and troughs in medication levels 2

Immediate-Release Considerations

• Can be split for dose titration when finding optimal therapeutic dose 2
• Useful for supplementing extended-release coverage in late afternoon 5
• Never crush or split extended-release formulations, as this destroys the sustained-release mechanism and can cause dangerous immediate release of the full dose 2

Critical 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 (minimum one week) to evaluate response 1
• Overlooking morning administration timing to minimize sleep disturbances 1
• Exceeding maximum recommended doses when symptoms remain inadequately controlled—switch medications instead 2
• Interrupting medication occasionally to determine if continued therapy is necessary 3, 4

Evidence Quality Note

The adult dosing recommendations are supported by low to very low-quality evidence from short-term studies (mean 5.3 weeks) with restrictive inclusion criteria 6. Amphetamines significantly reduced ADHD symptom severity as rated by clinicians (SMD -0.90) and patients (SMD -0.51), but did not improve retention in treatment and were associated with increased withdrawal due to adverse events 6.