Long-Acting ADHD Medications
Long-acting ADHD medications include methylphenidate-based formulations (Concerta/OROS-MPH, Ritalin-SR, Metadate, Methylin-SR, dexmethylphenidate extended-release) and amphetamine-based formulations (Dexedrine Spansules, Adderall XR, lisdexamfetamine), with Concerta being particularly well-suited for adolescents due to its once-daily dosing, 12-hour duration, and resistance to diversion. 1, 2
Methylphenidate-Based Long-Acting Formulations
Concerta (OROS-MPH)
- Concerta is the preferred long-acting methylphenidate formulation, delivering medication through an osmotic release system that produces ascending plasma levels throughout the day 1
- Provides 12-hour symptom control with once-daily morning dosing, eliminating the need for in-school administration 1, 3
- Particularly advantageous for adolescents because it cannot be ground up or snorted, reducing diversion risk 1
- Demonstrated equal efficacy to methylphenidate immediate-release given three times daily in a 14-site randomized controlled trial 1
- Starting dose for stimulant-naïve patients is 18 mg, equivalent to methylphenidate 5 mg three times daily 1
Older Sustained-Release Methylphenidate Formulations
- Ritalin-SR, Metadate, and Methylin-SR use wax-matrix technology for slow release but are less effective than immediate-release formulations 1
- These formulations have delayed onset (90 minutes vs 30 minutes), lower peak plasma levels, and peak benefit at 3 hours rather than 2 hours 1
- Clinicians find these less effective than short-acting versions, with one study showing MPH-SR20 was less effective than standard methylphenidate 10 mg twice daily 1
Dexmethylphenidate Extended-Release
- Dexmethylphenidate extended-release capsules are a long-acting CNS stimulant formulation containing the active d-enantiomer of methylphenidate 4
- Should be used as part of a total treatment program including counseling or other therapies 4
- Carries the same warnings as other stimulants regarding misuse, abuse, cardiovascular risks, and psychiatric effects 4
Amphetamine-Based Long-Acting Formulations
Dexedrine Spansules
- Capsule containing small medication particles designed for extended release 1
- Shown to maintain attention on tasks for up to 9 hours after dosing in laboratory studies 1
- Equally effective as MPH-SR20 and pemoline for sustained attention over 9-hour periods 1
Lisdexamfetamine (Vyvanse)
- Prodrug formulation of dexamfetamine that is therapeutically inactive until enzymatically hydrolyzed in the blood 2
- Provides 13-hour duration in children and 14-hour duration in adults, the longest-acting stimulant available 2
- Conversion to active drug is unaffected by gastrointestinal pH or transit time variations 2
- Developed specifically to provide consistent effect throughout the day with reduced abuse potential due to prodrug design 2, 5
- Demonstrates large effect size with dose-dependent improvements in ADHD core symptoms 2
Adderall XR
- Extended-release formulation of mixed amphetamine salts providing prolonged symptom control 6
- Note: This formulation has been withdrawn from the market in some jurisdictions 3
Clinical Advantages of Long-Acting Formulations
Adherence and Practical Benefits
- Eliminate in-school dosing, avoiding need for school nurse visits, medication storage at school, and peer ridicule 1
- Particularly important for adolescents who often refuse in-school dosing due to privacy concerns and fear of stigma 1
- Address the problem that children with ADHD frequently forget afternoon doses 1
- Schools may have policies prohibiting medication administration or may not reliably administer doses 1
Pharmacological Advantages
- Provide coverage during unstructured times when plasma levels of immediate-release formulations trough (lunchtime, recess, bus rides) 1
- Reduce "rebound" effects reported by parents and clinicians in late afternoon with immediate-release formulations 1
- Enable symptom control during after-school activities including day care, sports, and homework 1
- Concerta's ascending plasma pattern overcomes acute tolerance development, maintaining efficacy for 12 hours 3
Augmentation Strategy for Adolescents
For teenagers on methylphenidate extended-release, immediate-release methylphenidate can be added in late afternoon at 30-50% of the total daily ER dose to cover homework, driving, and evening activities. 7
- Using the same medication class avoids introducing different side effect profiles and maintains pharmacological consistency 7
- Particularly important for providing medication coverage during driving, a high-risk activity for adolescents with ADHD 7
- Dose should be titrated based on response while monitoring for rebound effects and sleep disturbances 7
- Avoid dosing after 5-6 PM to prevent sleep onset interference 7
Critical Prescribing Considerations
Substance Abuse Screening
- Before prescribing any stimulant to an adolescent, screen for substance abuse symptoms as diversion and misuse are particular concerns 7
- If substance abuse is identified, assessment must precede ADHD treatment 7
- Monitor prescription refill requests for signs of misuse or diversion 7
Monitoring Requirements
- Regular blood pressure and pulse monitoring is required, as stimulants cause small but potentially clinically relevant increases 7
- Track appetite, sleep, and growth parameters as these are the most common adverse effects requiring dose adjustment 7
- Assess for rebound irritability or symptom worsening as ER formulation wears off 7
Common Pitfalls to Avoid
- Do not assume all long-acting methylphenidate formulations are equivalent—Concerta has superior pharmacokinetics compared to older wax-matrix formulations 1, 3
- Do not use older sustained-release formulations (Ritalin-SR, Metadate) as first-line long-acting options due to delayed onset and lower efficacy 1
- Afternoon doses of immediate-release stimulants should not be identical to or smaller than morning doses, as this may lead to symptom increase 1