What is the recommended dosing for Focalin (dexmethylphenidate) in a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Focalin Dosing for ADHD

For patients new to methylphenidate, start Focalin (dexmethylphenidate) extended-release at 5 mg once daily in the morning for pediatric patients (ages 6-17) and 10 mg once daily for adults, then titrate weekly by 5 mg increments in children or 10 mg increments in adults up to a maximum of 30 mg daily in pediatrics and 40 mg daily in adults. 1

Initial Dosing Strategy

For Treatment-Naïve Patients

• Pediatric patients (6-17 years): Begin with 5 mg once daily in the morning 1
• Adults: Begin with 10 mg once daily in the morning 1
• Administer with or without food 1

For Patients Switching from Other Methylphenidate Products

• From immediate-release methylphenidate: Use half (1/2) the total daily dose of methylphenidate as the Focalin extended-release dose 1
• From immediate-release dexmethylphenidate: Use the same total daily dose when converting to extended-release formulation 1

This conversion reflects the 2:1 potency ratio of dexmethylphenidate compared to racemic methylphenidate, as the d-isomer is the pharmacologically active component 2

Titration Protocol

Dose Escalation Schedule

• Pediatric patients: Increase by 5 mg weekly based on clinical response and tolerability 1
• Adult patients: Increase by 10 mg weekly based on clinical response and tolerability 1
• Continue titration until optimal symptom control is achieved or maximum dose is reached 3

Maximum Recommended Doses

• Pediatric patients: 30 mg once daily 1
• Adult patients: 40 mg once daily 1
• Special consideration: Children weighing less than 25 kg generally should not receive single doses greater than 15 mg 3

Monitoring Requirements

Assessment at Each Dose Adjustment

• Measure blood pressure and pulse at baseline and with each dose increase 3
• Evaluate both therapeutic effects and side effects before each dose increase 3
• Use standardized ADHD rating scales from teachers and parents for children, or from the patient and significant others for adults 3
• Maintain weekly contact by telephone during initial titration, which typically requires 2-4 weeks to reach optimal dosing 4

Ongoing Monitoring After Stabilization

• Schedule follow-up appointments at least monthly to assess ongoing efficacy, side effects, and growth parameters 3
• Monitor weight regularly as weight loss is a common side effect 4
• Systematically assess for specific stimulant side effects including insomnia, anorexia, headaches, and weight loss 4
• Closely monitor growth (height and weight) in pediatric patients, as treatment interruption may be needed if growth is not progressing as expected 1

Administration Options

Capsule Administration

• Capsules may be swallowed whole 1
• Alternative for patients unable to swallow: Open capsule and sprinkle entire contents on applesauce, then consume immediately without chewing 1

This flexibility in administration is particularly valuable for younger children who have difficulty swallowing capsules 5

Duration of Action

The extended-release formulation provides a bimodal release profile that mimics two doses of immediate-release dexmethylphenidate given 4 hours apart 5. Clinical trials demonstrate:

• Efficacy begins as early as 0.5 hours after administration 5
• Significant improvements persist for 11-12 hours post-dose 5
• Late afternoon (6 PM) assessments show maintained efficacy at 6 hours, confirming sustained duration of action 6, 2

Special Population Considerations

Older Adults and Treatment-Naïve Patients

• Consider more conservative titration (e.g., increasing by 5 mg every 2 weeks instead of weekly) due to age-related changes in pharmacokinetics and increased sensitivity to both therapeutic and adverse effects 3

Patients with Cardiovascular Risk Factors

• Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmias, coronary artery disease, or other serious cardiac disease 1
• More conservative titration is appropriate for those with cardiovascular risk factors 7

Common Pitfalls to Avoid

• Starting at too high a dose leads to unnecessary side effects and decreased medication adherence 4
• Failure to systematically assess both benefits and side effects during titration compromises optimal dosing 4
• Inadequate monitoring frequency during initial titration—weekly contact is essential 4
• Not using standardized rating scales makes it difficult to objectively assess treatment response 3

When Maximum Dose Is Insufficient

If adequate symptom control is not achieved at the maximum recommended dose (30 mg in pediatrics, 40 mg in adults):

• Consider switching to an alternative stimulant formulation before moving to non-stimulants 7
• Lisdexamfetamine should be the preferred next option over non-stimulants if no desired benefit is observed after adequate treatment with methylphenidate 4
• Consider adding non-stimulant medications as an alternative strategy 4