What is the recommended dosing for an adult patient with Attention Deficit Hyperactivity Disorder (ADHD) starting on Concerta (methylphenidate extended-release tablets)?

Concerta Dosing for Adults with ADHD

For adults with ADHD starting Concerta, begin with 18-36 mg once daily in the morning, then titrate upward by 18 mg weekly based on response and tolerability, with a maximum daily dose of 72 mg (though some patients may require doses up to 378 mg under close monitoring). 1, 2

Initial Dosing Strategy

• Start with 18 mg once daily in the morning for stimulant-naïve adults, which is the standard starting dose for Concerta 3, 1
• Adults already on immediate-release methylphenidate can be converted by calculating their total daily immediate-release dose and switching to the nearest equivalent Concerta dose 4
• The 18 mg Concerta dose is equivalent to methylphenidate 5 mg three times daily 3

Titration Protocol

• Increase the dose by 18 mg weekly based on clinical response and tolerability 1, 4
• Maintain weekly contact during initial titration to assess response and side effects systematically 5
• Use standardized ADHD rating scales from the patient and significant others before each dose increase to objectively track response 5, 6
• Typical therapeutic doses range from 36-72 mg daily, with most adults responding within this range 1, 4

Maximum Dosing Considerations

• The FDA-approved maximum daily dose is 60-72 mg for most formulations 1, 4
• However, case reports document successful treatment with doses up to 378 mg daily in adults with severe, treatment-resistant ADHD and comorbid conditions, though this requires close monitoring of plasma levels and careful clinical oversight 2
• If adequate symptom control is not achieved at 72 mg daily, consider alternative treatments or adding non-stimulant medications rather than routinely exceeding maximum doses 5, 6

Monitoring Requirements

• Systematically assess for specific stimulant side effects at each visit: insomnia, anorexia, headaches, weight loss, tachycardia, palpitations, anxiety, and hypertension 5, 1
• Monitor blood pressure and pulse at baseline and regularly during treatment 1
• Schedule follow-up appointments at least monthly after stabilization to assess ongoing efficacy and side effects 5
• Plasma methylphenidate levels do not correlate with clinical response and are not clinically useful for routine dosing decisions 3

Advantages of Concerta for Adults

• Once-daily morning dosing eliminates the need for workplace administration, maintaining privacy and improving adherence 3
• The OROS delivery system provides consistent ascending plasma levels throughout the day, with duration of action up to 12 hours 3, 4
• Concerta is resistant to diversion (cannot be crushed or snorted), making it particularly suitable for adults 3
• Food does not significantly affect methylphenidate absorption from Concerta, providing consistent early drug exposure regardless of breakfast timing 7

Special Populations and Contraindications

• Avoid Concerta in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmias, coronary artery disease, or other serious cardiac disease 1
• Do not use in patients taking MAOIs or within 14 days of MAOI discontinuation 1
• For adults with comorbid substance abuse disorder, exercise extreme caution and consider non-stimulant alternatives first 3, 8
• Screen for risk factors for mania before initiating treatment; if new psychotic or manic symptoms occur, consider discontinuing 1

Common Pitfalls to Avoid

• Starting at too high a dose leads to unnecessary side effects and decreased adherence 5
• Failing to systematically assess both benefits and side effects during titration compromises optimal dosing 5
• Relying on plasma levels for dose adjustments is not evidence-based and should be avoided 3
• Prescribing to adults without careful evaluation for comorbid substance abuse can lead to misuse 3