What is a suitable plan for initiating stimulant therapy in a 14-year-old patient weighing 85 pounds (39 kilograms) who is highly sensitive to stimulants and wants to taper up to an effective dose using 2.5 milligram (mg) tablets?

Stimulant Initiation Plan for a Sensitive 14-Year-Old Patient

For a 14-year-old patient weighing 85 pounds (39 kg) who is highly sensitive to stimulants, start with dextroamphetamine or mixed amphetamine salts at 2.5 mg once daily in the morning after breakfast, then increase by 2.5 mg weekly until therapeutic effect is achieved or side effects emerge. 1

Pre-Treatment Requirements

Before initiating any stimulant therapy, obtain the following baseline assessments: 1

• Physical examination with baseline blood pressure, pulse, height, and weight 1
• Personal and family cardiac history, specifically asking about sudden death, cardiovascular symptoms, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, and long QT syndrome 1
• If any cardiac risk factors are present, obtain an ECG and consider cardiology consultation before starting stimulants 1

Medication Selection and Starting Dose

The 2.5 mg amphetamine tablets align perfectly with guideline-recommended starting doses for sensitive patients: 1

• The American Academy of Child and Adolescent Psychiatry explicitly recommends 2.5 mg as the minimum starting dose for dextroamphetamine/amphetamine (DEX/AMP) in children and adolescents 1
• This patient weighs less than 25 kg (39 kg = 86 pounds), so single doses should generally not exceed 10 mg of DEX/AMP 1
• Start with 2.5 mg once daily in the morning after breakfast 1

Titration Schedule

Use a conservative weekly titration schedule given the patient's sensitivity: 1

• Week 1: 2.5 mg once daily in morning 1
• Week 2: If tolerated and insufficient response, increase to 2.5 mg twice daily (morning and noon after lunch) 1
• Week 3 onward: Increase by 2.5 mg increments weekly until therapeutic effect is achieved 1
• The guideline specifically states dose increases should be in increments of 2.5 to 5 mg for DEX/AMP 1

Maximum dosing parameters for this patient: 1

• Single dose maximum: 10 mg (given weight <25 kg) 1
• Total daily dose maximum: 40 mg per day (though rarely needed) 1
• Most patients respond well below these maximums 1

Monitoring During Titration

Weekly contact is essential during the initial titration phase: 1

• Maintain weekly telephone or in-person contact during dose adjustments 1
• The titration phase typically requires 2 to 4 weeks 1
• Assess target ADHD symptoms regularly from both parent and teacher 1
• For adolescents, obtain self-ratings in addition to parent/teacher reports 1

Systematically assess for common side effects at each contact: 1

• Insomnia (most common with amphetamines due to longer half-life) 1
• Decreased appetite and weight loss 1
• Headaches 1
• Abdominal pain 1
• Social withdrawal 1
• Tics 1
• Jitteriness 1

Weigh the patient at each visit to objectively monitor appetite suppression 1

Managing Side Effects in Sensitive Patients

If side effects emerge, use these strategies before abandoning the medication: 1

• Lower the dose or adjust timing of administration 1
• Most side effects are dose-dependent and reversible 1
• If side effects persist at the lowest effective dose, consider switching to methylphenidate (which has somewhat less impact on appetite and sleep compared to amphetamines) 1

Alternative Approach: Fixed-Dose Trial

An alternative strategy that may work well for this patient is a systematic fixed-dose trial: 1

• Try different doses (2.5 mg, 5 mg, 7.5 mg, 10 mg) each for one week 1
• At the end of the trial, meet with patient and parent to decide which dose worked best 1
• The advantage is that the patient is less likely to miss a higher dose that might yield additional improvement 1

Transition to Maintenance Phase

Once optimal dose is identified: 1

• Schedule monthly follow-up appointments until symptoms are fully stabilized 1
• Check vital signs (blood pressure and pulse) at each visit, as 5-15% of patients may experience substantial increases requiring intervention 1
• Continue monitoring height and weight, as stimulants can affect growth velocity by 1-2 cm from predicted adult height, particularly at higher doses 1

Critical Pitfalls to Avoid

Do not use weight-based dosing for this patient: 1

• Weight-adjusted dosing (e.g., 0.3 mg/kg) is problematic in practice and not uniformly supported by research 1
• It may restrict titration for some patients who require higher doses 1
• Fixed-dose titration using whole or half tablets reflects typical U.S. practice and is more practical 1

Do not assume "more is better" if response is inadequate at maximum recommended doses: 1

• If the top recommended dose doesn't help, consider switching to methylphenidate or adding psychosocial interventions rather than exceeding dose limits 1
• Response rates to stimulants are 70-80% for pure ADHD, so 20-30% may need alternative approaches 2

Do not overlook adherence issues: 3

• Noncompliance rates with stimulants range from 20-65% 3
• The need for multiple daily doses is a major barrier 3
• If the patient struggles with twice-daily dosing, consider long-acting formulations once therapeutic dose is established 3