What is the recommended treatment and dosage for Attention Deficit Hyperactivity Disorder (ADHD) using Concerta (methylphenidate)?

Concerta (Methylphenidate Extended-Release) for ADHD Treatment

Concerta is a first-line pharmacological treatment for ADHD in children aged 6 years and older, adolescents, and adults, with a starting dose of 18 mg once daily in the morning, titrated weekly by 18 mg increments to a maximum of 72 mg/day based on clinical response and tolerability. 1, 2

Age-Specific Treatment Recommendations

Elementary School-Aged Children (6-11 years)

• FDA-approved stimulant medications like Concerta are strongly recommended as first-line treatment, preferably combined with behavioral therapy. 1
• Start with 18 mg once daily before breakfast 1, 2
• Increase by 18 mg weekly increments as needed 1
• Maximum dose: 72 mg/day (or 54 mg/day in some guidelines) 1, 2
• Behavioral parent training and classroom management should be implemented concurrently for optimal outcomes 1

Adolescents (12-18 years)

• Prescribe FDA-approved ADHD medications with the adolescent's assent as first-line treatment. 1
• Concerta's once-daily dosing and abuse-resistant formulation (cannot be crushed or snorted) makes it particularly well-suited for this population 1, 3
• Maintains privacy by eliminating school-day dosing 1
• Same dosing parameters as school-aged children: start 18 mg, titrate weekly, maximum 72 mg/day 1, 2

Adults

• Administer in divided doses 2-3 times daily, preferably 30-45 minutes before meals 2
• Average effective dose: 20-30 mg daily 2
• Maximum recommended dose: 60 mg/day 2
• For patients with sleep difficulties, administer last dose before 6 PM 2

Preschool Children (4-5 years)

• Methylphenidate should only be prescribed if behavioral interventions fail and moderate-to-severe functional impairment persists. 1, 4
• Use lower starting doses with smaller incremental increases due to slower metabolism 4
• This age group requires more cautious approach with behavioral therapy as primary intervention 1

Mechanism of Action and Clinical Effects

Concerta works by blocking reuptake of dopamine and norepinephrine without actively promoting neurotransmitter release, enhancing prefrontal cortex efficiency for executive function and attention. 3, 5, 6

• The osmotic-release oral system (OROS) provides 12-hour duration of action 5, 7
• Behavioral effects peak when plasma concentrations are rising (1-3 hours post-dose) 5
• Direct dopamine transporter (DAT) inhibition is the primary mechanism 3, 6

Titration Protocol

Titrate doses to achieve maximum benefit with minimum adverse effects, adjusting weekly based on clinical response. 1, 2

• Start: 18 mg once daily in morning 1, 2
• Increase: 18 mg weekly increments 1
• Target: Individualized based on symptom control and tolerability 1
• Maximum: 72 mg/day (54-72 mg depending on guideline) 1, 2
• If no benefit after adequate trial at appropriate dose, switch to lisdexamfetamine before trying non-stimulants. 1

Mandatory Pre-Treatment Screening

Before prescribing Concerta, assess for cardiac disease through careful history, family history of sudden death or ventricular arrhythmia, and physical examination. 2

• Screen for structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, or coronary artery disease 2
• Evaluate family history and clinically assess for motor/verbal tics or Tourette's syndrome 2
• Assess each patient's risk for abuse, misuse, and addiction 2
• Screen for risk factors for manic episodes in patients with psychiatric history 2

Required Monitoring Parameters

Monitor height, weight, pulse, and blood pressure throughout treatment. 1, 2

• Height and weight: Closely monitor in pediatric patients; interrupt treatment if not growing as expected 1, 2
• Cardiovascular: Regular blood pressure and heart rate monitoring required 1, 3, 2
• Psychiatric symptoms: Monitor for emergence of psychotic or manic symptoms 2
• Tics: Regularly monitor for emergence or worsening; discontinue if clinically appropriate 2
• Abuse/misuse: Frequently reassess risk and monitor for signs of diversion 2

Common Adverse Effects

The most common adverse effects are decreased appetite, insomnia, tachycardia, headache, anxiety, and abdominal pain. 1, 3, 2, 8

• Appetite suppression and sleep disturbances are most frequent 1, 3, 5
• Increased blood pressure and pulse are dose-dependent 1, 8
• Headaches, dry mouth, nausea, and hyperhidrosis occur commonly 2
• Most adverse effects are transient, dose-dependent, and resolve with dosage adjustment 8
• Statistically significant but clinically minor reductions in height/weight gain with long-term use 3, 8

Critical Contraindications

Concerta is absolutely contraindicated in patients with known hypersensitivity to methylphenidate and those receiving MAOIs or within 14 days of MAOI discontinuation. 2

• Avoid in patients with known structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, or coronary artery disease 2
• Do not use in patients with hyperthyroidism, glaucoma, or during/within 14 days of MAOI therapy 2

Special Clinical Situations

Comorbid Conditions

• For patients with tic disorders or Tourette's syndrome who develop tics on Concerta, add alpha-agonists (clonidine/guanfacine) as adjunctive therapy rather than discontinuing. 3
• Positive effects on comorbid conduct disorder and oppositional defiant disorder 1
• For substance abuse concerns, consider non-stimulants or Vyvanse (lower abuse potential) instead 1, 3

Dosage Adjustments

• If paradoxical aggravation or adverse reactions occur, reduce dosage or discontinue. 2
• If no improvement after one month of appropriate dosage adjustment, discontinue 2
• Adjustments are the rule, not the exception, due to symptom changes, psychosocial factors, and normal development 1

Abuse Potential

• Concerta has high potential for abuse and misuse; educate patients and families about proper storage (preferably locked) and disposal. 2
• The OROS delivery system provides some abuse deterrence compared to immediate-release formulations 3
• Misuse can result in overdose and death, particularly with unapproved administration methods 2

Comparative Advantages

Concerta's 12-hour duration eliminates school-day dosing, improving adherence and privacy compared to immediate-release formulations. 1, 5, 7

• Superior symptom control during school hours compared to some other long-acting formulations 7
• Rapid onset of treatment effects (1-3 hours) 1, 5
• Large effect sizes for reducing ADHD core symptoms 1
• Available in multiple extended-release formulations allowing treatment individualization 1