Can an 18-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD) who has been taking 72mg of Concerta (methylphenidate) for 6 months continue their current medication regimen?

Continuing 72mg Concerta in an 18-Year-Old Patient

Yes, you can and should continue the 72mg Concerta regimen in this 18-year-old patient who has been stable on this dose for 6 months. This dose is within FDA-approved limits and represents appropriate continuation of care from a previous provider 1.

Rationale for Continuation

The maximum FDA-approved daily dose of methylphenidate is 60mg for most formulations, but extended-release preparations like Concerta can be dosed higher due to their unique delivery system. 2, 1 The 72mg Concerta dose falls within the therapeutic range used in clinical practice for adults with ADHD, particularly given that:

• Adults with ADHD often require total daily doses up to 1 mg/kg of methylphenidate for optimal symptom control 2
• Extended-release methylphenidate formulations like Concerta provide gradual ascending plasma concentrations throughout the day without requiring the traditional "ramp effect," making higher single doses both safe and effective 2
• The patient has already demonstrated 6 months of stability on this regimen, indicating both tolerability and efficacy 3

Essential Monitoring Requirements

Before continuing this medication, you must establish appropriate monitoring protocols 4:

• Cardiovascular monitoring: Check blood pressure and heart rate at baseline and each visit, as stimulants cause modest increases in both parameters 4, 1
• Growth parameters: Monitor height and weight at each visit, though this is less critical in an 18-year-old who has likely completed growth 4
• Psychiatric screening: Assess for new or worsening psychiatric symptoms including anxiety, mood changes, psychotic symptoms, or manic episodes 1
• Substance use assessment: Screen for any history of substance abuse or diversion risk, as this is a controlled substance (Schedule II) with abuse potential 2, 1

Critical Safety Considerations

Concerta is specifically designed to be resistant to diversion and abuse because the methylphenidate is in paste form that cannot be ground up or snorted, making it particularly appropriate for adolescents and young adults 2. This formulation advantage is especially relevant for an 18-year-old patient.

Absolute contraindications to continuing this medication include 1:

• Known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmias, or coronary artery disease
• Current or recent (within 14 days) MAOI use
• Known hypersensitivity to methylphenidate
• Active substance abuse disorder with ongoing alcohol or drug use 5

Documentation and Prescribing Considerations

When assuming care from another provider 2, 3:

• Document the previous provider's treatment history and the patient's response to the 72mg dose
• Verify the diagnosis of ADHD meets DSM criteria with symptoms causing moderate to severe impairment in at least two settings
• Establish that the patient has been compliant with the medication and has not exhibited signs of misuse or diversion
• Schedule monthly follow-up appointments initially until you establish the patient's stability, then adjust frequency based on response and adherence 4

Long-Term Efficacy and Tolerance

Stimulants maintain therapeutic efficacy over extended periods without diminishing effectiveness 4, 3. Prospective randomized controlled trials lasting 12-24 months demonstrate persistent medication effects with no tolerance development 4. The patient's 6-month history on this dose suggests continued benefit is likely.

Common Pitfalls to Avoid

• Do not arbitrarily reduce the dose simply because it exceeds the commonly cited 60mg maximum, as this patient has demonstrated stability on 72mg and Concerta's unique delivery system supports this dosing 2, 6
• Do not assume the patient needs psychiatric specialty referral for routine continuation of a stable regimen, though complex cases with multiple comorbidities may warrant specialist involvement 2
• Do not overlook substance use screening, as stimulant medications carry significant abuse and diversion potential, particularly in young adults 2, 5, 1
• Do not fail to educate the patient and family about proper storage, the risks of sharing medication, and signs of misuse 1