Dexmethylphenidate Extended-Release Dosing in Children with ADHD
For children aged 6 years and older who are new to methylphenidate, start dexmethylphenidate extended-release at 5 mg once daily in the morning, then titrate weekly in 5 mg increments up to a maximum of 30 mg daily based on symptom control and tolerability. 1
Initial Dosing Strategy
For Treatment-Naïve Patients
- Begin with 5 mg once daily administered in the morning for children aged 6-17 years who have never received methylphenidate 1
- For children weighing less than 25 kg, ensure single doses do not exceed 15 mg 2
For Patients Currently on Other Methylphenidate Formulations
- Use half (1/2) the total daily dose of methylphenidate when converting to dexmethylphenidate extended-release 1
- For patients already taking dexmethylphenidate immediate-release, give the same total daily dose as extended-release once daily 1
Titration Protocol
- Increase by 5 mg increments weekly based on clinical response and side effect profile 1
- Continue titration until optimal symptom control is achieved without adverse effects 2
- The maximum recommended daily dose is 30 mg for pediatric patients 1
Monitoring Requirements
Symptom Assessment
- Use standardized ADHD rating scales (such as ADHD-RS-IV) from both parents and teachers before each dose increase to objectively assess response 3
- Rating scales should be obtained through phone contact between visits if needed to guide titration decisions 3
Physical Parameters
- Assess blood pressure, pulse, height, and weight at each visit, as stimulants can affect growth and cardiovascular parameters 3, 4
- Monitor for common adverse events including decreased appetite (18.5%), headache, abdominal pain, and irritability 5
Administration Details
- Administer in the early morning to provide coverage throughout the school day 3
- Capsules may be swallowed whole or opened and the entire contents sprinkled on applesauce 1
- The extended-release formulation provides symptom control for up to 12 hours 6
Evidence for Efficacy by Dose
- 20 mg daily demonstrated significant improvement from baseline, with symptom reduction evident as early as 0.5 hours post-dose and sustained for 8 hours 7
- 30 mg daily provided superior late-day symptom control (hours 10-12) compared to 20 mg in children previously stabilized on higher methylphenidate doses (40-60 mg/day) 8
- All three doses (10,20, and 30 mg) showed significant efficacy compared to placebo, with mean ADHD symptom score reductions of 49% versus 16% with placebo 6, 9
Special Considerations for Preschool Children (Ages 4-5)
- Behavior therapy should be first-line treatment for preschool-aged children 4
- Medication should be reserved only for those with moderate-to-severe dysfunction who have not responded adequately to behavioral interventions after at least 9 months 4
- When medication is necessary, start with lower doses (typically 2.5 mg) due to slower metabolism in this age group 2
Contraindications and Precautions
- Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmias, coronary artery disease, or other serious cardiac disease 1
- Do not use concurrently with monoamine oxidase inhibitors (MAOIs) or within 14 days of MAOI use 1
- Screen for risk factors for developing manic episodes prior to initiation 1
Common Pitfalls to Avoid
- Do not start at adult doses: The pediatric starting dose is 5 mg, not the 10 mg used in adults 1
- Do not exceed weight-based limits: Children under 25 kg should not receive single doses exceeding 15 mg 2
- Do not skip monitoring: Growth suppression is a real concern requiring regular height and weight assessment 4
- Do not ignore cardiovascular screening: Assess for cardiac disease before initiating treatment, as stimulants are contraindicated in serious cardiac conditions 1