What is the recommended protocol for uptitration of Concerta (methylphenidate)?

Concerta (Methylphenidate) Uptitration Protocol

Start Concerta at 18 mg once daily in the morning, increase by 18 mg weekly intervals based on symptom response and tolerability, up to a maximum of 54-72 mg daily, with most patients achieving optimal control between 36-54 mg. 1, 2

Starting Dose

• Pediatric patients (6 years and older): Begin with 18 mg once daily in the morning 1, 2
• Adults: Begin with 18 mg once daily in the morning, though some clinicians may start at 36 mg if the patient has prior stimulant exposure 1
• Patients switching from immediate-release methylphenidate: Use conversion of approximately 1:1 for total daily dose (e.g., 15 mg IR three times daily = 45 mg Concerta) 3, 4

Titration Schedule

• Increase by 18 mg increments weekly if symptom control is inadequate and the current dose is well-tolerated 1, 2
• Assess response after 1 week at each dose level before making adjustments 1, 5
• Obtain rating scales from teachers and parents at each dose level to guide titration decisions 1
• Continue uptitration until symptoms are controlled, side effects become limiting, or maximum dose is reached 1

Dose Levels and Maximum Dosing

• Available strengths: 18 mg, 27 mg, 36 mg, 54 mg, and 72 mg 3, 6
• Typical therapeutic range: 36-54 mg once daily 1, 7
• Maximum recommended daily dose: 72 mg for adolescents and adults; 60 mg for children under 45 pounds (20 kg) 1, 2
• Total daily doses above 60 mg should be clearly documented with rationale that lower doses were insufficient and higher doses produce no prohibitive side effects 1

Monitoring During Uptitration

• Cardiovascular monitoring: Check blood pressure and heart rate at baseline and after each dose increase 2
• Growth parameters: Monitor height and weight in pediatric patients, as stimulants can suppress growth 2
• Symptom assessment: Use standardized ADHD rating scales from multiple informants (parents, teachers, patient) 1
• Side effect monitoring: Assess for decreased appetite, insomnia, headache, abdominal pain, and anxiety at each visit 2
• Nausea: Monitor specifically during the first week, as it occurs in up to 25% of patients starting methylphenidate 5

Duration of Action Considerations

• Concerta provides 10-12 hours of symptom control with once-daily morning dosing 4, 7
• Peak plasma concentrations occur 7-9 hours post-dose due to the ascending delivery profile 4
• For patients requiring coverage beyond 12 hours (homework, evening activities), consider adding 5-10 mg immediate-release methylphenidate in the late afternoon 1, 5

Alternative Titration Strategy: Forced Titration

• Some clinicians use a "forced titration" approach where patients trial all dose levels (18 mg, 36 mg, 54 mg, 72 mg) for 1 week each 1
• Rating scales are collected at each dose level, then the optimal dose is selected based on best efficacy with fewest side effects 1
• This approach is particularly useful when response patterns are unclear or when systematic comparison is needed 1

Common Pitfalls to Avoid

• Undertitration: Many patients are maintained on suboptimal doses; continue titration until clear symptom control is achieved or side effects emerge 1
• Premature discontinuation: Allow at least 4 weeks at a therapeutic dose before determining treatment failure 5
• Ignoring time-of-day effects: Concerta's ascending delivery profile means effects strengthen throughout the day; morning assessments may underestimate efficacy 4, 8
• Inadequate monitoring: Failure to obtain objective rating scales from teachers can result in missed opportunities for dose optimization 1

Special Populations

• Small children (<20 kg): Start at lower end of dosing range and increase more cautiously; maximum 60 mg daily 1
• Adolescents: Concerta's once-daily dosing and abuse-deterrent formulation make it particularly suitable for this population 1
• Patients with tics: Monitor for emergence or worsening of tics; if they develop, consider adding alpha-agonists (clonidine or guanfacine) rather than discontinuing Concerta 9

When to Stop Uptitration

• Optimal symptom control achieved: Significant improvement in ADHD symptoms across home and school settings 1
• Intolerable side effects: Persistent adverse effects that don't resolve with continued treatment 1, 2
• Maximum dose reached: 72 mg daily (or 60 mg in smaller children) 1, 2
• Cardiovascular concerns: Clinically significant increases in blood pressure or heart rate 2