What is the next dosing step for a patient with Attention Deficit Hyperactivity Disorder (ADHD) who has been started on 5mg Adderall (amphetamine/dextroamphetamine) and is being considered for a dose increase if tolerated?

Next Dosing Step After 5mg Adderall Trial

If the patient tolerates 5mg Adderall, increase to 10mg total daily dose (either 5mg twice daily or 10mg once daily in the morning) for the next week, then continue weekly titration in 5-10mg increments until optimal symptom control is achieved. 1, 2

Standard Titration Protocol

The American Academy of Child and Adolescent Psychiatry provides clear guidance for amphetamine/dextroamphetamine (Adderall) dose escalation:

Week-by-Week Titration Schedule:

• Week 1: 2.5mg (for children) or 5mg (for adults/adolescents) 1
• Week 2: 5mg (children) or 10mg (adults/adolescents) 1
• Week 3: 7.5mg (children) or 15mg (adults/adolescents) 1
• Week 4: 10mg (children) or 20mg (adults/adolescents) - omit this step in children weighing <45 lbs 1
• Week 5+: Continue further titration as needed 1

For adults and older adolescents specifically, the FDA label and guidelines recommend starting at 5mg with titration upward in 5-10mg intervals each week until symptoms are controlled. 1, 2

Dosing Frequency Considerations

Immediate-release Adderall should initially be dosed twice daily (morning and noon), with a third afternoon dose added at the clinician's discretion to cover homework and evening activities. 1

• Give the first dose upon awakening 2
• Additional doses should be spaced 4-6 hours apart 2
• Avoid late evening doses due to insomnia risk 2
• Some patients may achieve adequate coverage with once-daily dosing, particularly if using extended-release formulations 1

Critical Monitoring Before Each Dose Increase

Before advancing to the next dose, systematically assess:

• ADHD symptom severity using standardized rating scales (ADHD-RS-IV from parents/teachers for children, or from patient/significant other for adults) 1, 3, 4
• Blood pressure and pulse at each visit 1, 3, 4
• Height and weight 1, 3
• Side effects, particularly anorexia, insomnia, headaches, agitation, and cardiovascular symptoms 1, 3, 4

These assessments can be obtained through phone contact between visits if needed to guide titration decisions. 1

Target Dose Range and Maximum Limits

Most patients achieve optimal response between 20-40mg total daily dose, though some may require higher doses. 1, 4, 2

Maximum dosing thresholds:

• Children (ages 6+): Rarely necessary to exceed 40mg/day 2
• Adults: Maximum FDA-approved dose is 40mg/day 1, 2, though some guidelines cite up to 50mg/day in clinical practice 3
• Maximum documented in literature: Up to 0.9 mg/kg or 40mg total daily dose 1

When to Stop Titration

Stop increasing the dose when:

• Optimal symptom control is achieved with minimal side effects 1
• Prohibitive or major side effects emerge (severe anorexia, severe insomnia >1.5 hours, marked behavioral changes) 1
• Maximum recommended dose is reached without adequate response - consider switching to alternative stimulant 1

If approaching maximum doses, clearly document that symptoms could not be controlled at lower doses and that higher doses are not producing intolerable side effects (weight loss, blood pressure increase, agitation). 1, 4

Common Pitfalls to Avoid

• Advancing doses too quickly: Allow a full week at each dose level to properly evaluate response 3, 4
• Failing to use standardized rating scales: Subjective impressions alone are insufficient for dose optimization 1
• Missing cardiovascular monitoring: Blood pressure and pulse must be checked at each dose adjustment 1, 3, 4
• Ignoring side effects: Even mild side effects may warrant dose reduction or medication switch 1, 5
• Continuing escalation when plateaued: If symptoms don't improve further with dose increases, consider switching to methylphenidate or adding non-stimulant medication rather than continuing to escalate 1, 5

Special Population Considerations

For children weighing <45 lbs (20 kg): Skip the 15mg dose level and proceed more cautiously with smaller increments 1

For older adults: Use more conservative titration (5mg every 2 weeks instead of weekly) due to increased sensitivity to both therapeutic and adverse effects 3

For treatment-naive patients: Approximately 70% respond to amphetamines, and nearly 90% respond if both amphetamines and methylphenidate are tried sequentially 1