How to initiate stimulant therapy for a male with Attention Deficit Disorder (ADD)?

How to Initiate Stimulant Therapy for a Male with ADD

Begin with methylphenidate 5 mg twice daily (morning after breakfast and noon after lunch) or dextroamphetamine/amphetamine 2.5 mg twice daily, after confirming the absence of contraindications through baseline cardiovascular assessment. 1

Pre-Treatment Assessment

Required Baseline Evaluations

Before initiating any stimulant medication, obtain the following:

• Cardiovascular history including assessment for family history of sudden death, ventricular arrhythmia, structural heart disease, cardiomyopathy, or serious heart rhythm abnormalities 2
• Physical examination with baseline blood pressure, pulse, height, and weight 1, 3
• Psychiatric screening including detailed psychiatric history with family history of suicide, bipolar disorder, and depression to rule out bipolar disorder risk 2
• Substance use history particularly important in adults, as stimulants must be used with great care if there is a history of drug abuse 1

Absolute Contraindications

Do not initiate stimulants if the patient has: 1, 2

• Previous sensitivity to stimulant medications
• Symptomatic cardiovascular disease (including known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities)
• Glaucoma
• Hyperthyroidism
• Uncontrolled hypertension
• Active psychotic disorder
• Current or recent (within 14 days) MAO inhibitor use
• History of illicit stimulant use or abuse (unless in controlled/supervised setting)

Medication Selection and Dosing

First-Line Stimulant Choice

Methylphenidate is recommended as the initial stimulant due to more favorable effects on appetite and sleep compared to amphetamines, which have longer excretion half-lives. 1 However, either methylphenidate or amphetamine/dextroamphetamine may be selected based on clinician and patient preference. 1

Starting Doses

• Methylphenidate: 5 mg twice daily (morning after breakfast and around noon after lunch) 1
• Dextroamphetamine/Amphetamine: 2.5 mg twice daily (same timing) 1
• Adult dosing range: Methylphenidate 5-20 mg three times daily or dextroamphetamine 5 mg three times daily to 20 mg twice daily 3

Formulation Considerations

Long-acting formulations are associated with better medication adherence and lower risk of rebound effects, while short-acting formulations allow more flexibility with dosing frequency and titration. 1 Consider long-acting formulations for around-the-clock symptom control and reduced abuse potential. 3

Titration Strategy

Systematic Dose Adjustment

• Use minimum effective doses to initiate therapy 1
• Establish both minimum and maximum dose targets before starting 1
• Use a consistent titration schedule with regular assessment of drug response 1
• Obtain teacher ratings of ADHD symptoms using validated, age- and sex-normed instruments at baseline and after treatment (for school-age patients) 1
• Gather information from at least two adult sources from different settings about symptoms 1

Response Assessment

Stimulants work rapidly, allowing quick assessment of ADHD symptom response within days, unlike non-stimulants which require 2-4 weeks. 3 Expected response rate is 70-80% for pure ADHD treatment. 3

Monitoring Requirements

Ongoing Cardiovascular Monitoring

• Children and adolescents: Check vital signs annually during routine physical examination 1
• Adults: Check blood pressure and pulse quarterly by treating physician or primary care physician 1
• Monitor for larger changes in heart rate and blood pressure, as 5-15% of individuals may experience substantial increases requiring intervention 4

Growth Monitoring

Monitor height and weight during treatment, as consistently medicated children may experience temporary slowing in growth rate (average 2 cm less height and 2.7 kg less weight over 3 years). 2 Patients not growing or gaining as expected may need treatment interruption. 2

Psychiatric Monitoring

Monitor for: 2

• Appearance or worsening of aggressive behavior or hostility
• New psychotic or manic symptoms (hallucinations, delusional thinking, mania)
• Behavioral disturbances in patients with pre-existing conditions

Common Adverse Effects

Expect and counsel patients about: 1

• Decreased appetite
• Sleep disturbances
• Increased blood pressure and pulse (modest increases of 2-4 mmHg and 3-6 bpm on average) 2
• Headaches
• Irritability
• Stomach pain

These effects are generally mild and/or temporary. 1

Critical Safety Considerations

Cardiac Symptoms Requiring Immediate Evaluation

Hold medication immediately and obtain ECG plus cardiology consultation if patient develops: 5, 2

• Exertional chest pain
• Unexplained syncope
• Dyspnea
• Exercise-induced symptoms

Special Populations Requiring Caution

• Patients with seizure history: Best to initiate after seizure disorder is controlled with anticonvulsants 1
• Patients with comorbid depression: Can treat both conditions concurrently; depression is not a contraindication to stimulant therapy 3
• Patients with substance abuse history: Consider long-acting formulations with lower abuse potential or non-stimulant alternatives like atomoxetine 3

Documentation Requirements

Before initiating stimulants, document: 1

• Adequate assessment completion
• Previous psychosocial treatments attempted
• Previous psychotropic medication trials (name, dosage, duration, response, side effects, compliance)
• Special school placements
• Behavioral interventions (behavioral modification, parent training, daily report card)

Alternative Considerations

If stimulants are contraindicated, not tolerated, or ineffective after optimization, atomoxetine (60-100 mg daily) is the only FDA-approved non-stimulant for adult ADHD, though it requires 2-4 weeks to achieve full effect. 3 Alpha-2 agonists (guanfacine 1-4 mg daily or clonidine) are additional options, particularly if sleep disturbances or tics are present. 3