What is the proper usage and dosage of Adderall (amphetamine and dextroamphetamine) for treating Attention Deficit Hyperactivity Disorder (ADHD)?

Adderall Dosing and Administration for ADHD

For adults with ADHD, start Adderall XR at 10 mg once daily in the morning, or Adderall IR at 5 mg twice daily, titrating by 5 mg weekly increments based on response and tolerability up to a maximum of 50 mg daily. 1, 2, 3

Initial Dosing Strategy

Immediate-Release (IR) Formulation

• Start at 5 mg twice daily (after breakfast and lunch) for adults 1, 4
• For children ages 6 and older: start at 5 mg once or twice daily 4
• For children ages 3-5: start at 2.5 mg daily 4
• For older or frail adults: consider starting at 2.5 mg, which requires cutting a 5 mg tablet 2

Extended-Release (XR) Formulation

• Start at 10 mg once daily in the morning for both adults and children 1, 2, 3
• Morning administration is critical to minimize sleep disturbances 1, 3

Titration Protocol

Increase the dose in 5 mg weekly increments for both IR and XR formulations until achieving symptom control or reaching maximum dose 1, 2, 4

• Allow at least one full week between dose increases to properly evaluate response 1
• Maintain weekly telephone contact during initial titration, with in-person visits at least monthly until symptoms stabilize 1
• For older adults, use a more conservative schedule: increase by 5 mg every 2 weeks instead of weekly 1, 3

Maximum Dosing Limits

The maximum recommended daily dose is 50 mg for both IR and XR formulations according to current American Academy of Child and Adolescent Psychiatry guidelines 1, 2, 3

• The FDA label states a maximum of 40 mg daily, though more recent guidelines support up to 50 mg 1, 4
• For children weighing less than 25 kg, single doses should not exceed 10-15 mg 1, 2
• For adults, doses may be calculated up to approximately 1.0 mg/kg per day 2

Critical Pitfall to Avoid

If the maximum dose of 50 mg does not provide adequate symptom control, do not exceed this limit—instead, switch to an alternative stimulant or add a non-stimulant medication like atomoxetine. 1, 2, 3 More is not better beyond maximum recommendations, and exceeding these limits increases cardiovascular, neurological, and metabolic risks 2

Monitoring Requirements

Baseline Assessment

• Measure blood pressure, pulse, height, and weight before starting treatment 1

Ongoing Monitoring

• Check blood pressure and pulse quarterly in adults 1, 3
• Weigh patients at each visit to monitor for appetite suppression 1
• Evaluate target ADHD symptoms using standardized rating scales when possible 1, 3
• Assess for side effects: insomnia, anorexia, headaches, social withdrawal, tics, weight loss 1

Special Monitoring for Older Adults

Older adults are more sensitive to both therapeutic and adverse effects due to age-related pharmacokinetic changes, requiring particularly careful vital sign monitoring 1, 3

Administration Considerations

IR Formulation Flexibility

• IR tablets can be safely cut for dose titration when finding the optimal therapeutic dose 2
• IR tablets can be crushed and mixed with a small amount of soft food or liquid immediately before administration if swallowing is difficult 2
• Administer crushed medication promptly to minimize degradation 2
• Consider requesting a liquid suspension from a compounding pharmacy if crushing becomes a regular necessity 2

XR Formulation Warning

Never crush Adderall XR capsules or tablets—this destroys the sustained-release mechanism and can result in dangerous immediate release of the full dose, leading to potential overdose and increased abuse potential. 2

Dosing Schedule for IR

• Give first dose upon awakening 4
• Give additional doses (1 or 2) at intervals of 4 to 6 hours 4
• Avoid late evening doses due to resulting insomnia 4

Common Prescribing Pitfalls

• Starting at too high a dose, which leads to unnecessary side effects and decreased adherence 1, 3
• Failing to systematically assess both benefits and side effects during titration 1, 3
• Not allowing sufficient time between dose increases to evaluate response 1, 3
• Overlooking morning administration, which is essential to minimize sleep disturbances 1, 3
• Continuing to increase dose beyond maximum recommendations when ineffective—consider alternative medications instead 1, 2

When Treatment Is Inadequate

Before increasing the dose, confirm:

• Consistent use of the current dose 3
• Rule out other factors contributing to perceived lack of efficacy (sleep issues, comorbid conditions) 3
• Evaluate for potential drug interactions 3

If maximum dose is reached without adequate response:

• Switch to a different stimulant formulation 3
• Add a non-stimulant medication like atomoxetine 3
• Reevaluate the diagnosis and consider comorbid conditions affecting treatment response 1, 3

Special Populations

Substance Use Disorder

Avoid prescribing Adderall XR to adults with active substance abuse disorder due to abuse potential, as these are DEA Schedule II controlled substances 1, 5

Pregnancy

The maximum dose remains 50 mg, but treatment decisions require careful risk-benefit analysis given possible increased risks for preterm birth, spontaneous abortion, poor neonatal adaptation, and NICU admission 6, 2

Hepatic Impairment

Use Adderall carefully in individuals with underlying liver conditions, as rare cases of acute liver injury have been reported 7

Efficacy Evidence

Clinical trials demonstrate that amphetamines at an average dose of 54 mg daily (administered in two doses) produce a 42% decrease in ADHD Rating Scale scores compared to placebo, with 70% of patients showing clinically meaningful improvement (≥30% reduction) versus 7% with placebo 8, 9