From the Guidelines
For a 17-year-old girl with ADHD who has not responded to maximum-dose Concerta, the next step would be to try a different stimulant medication, specifically lisdexamfetamine, as it is preferred over non-stimulants as the next option after methylphenidate, according to the National Institute for Health and Care Excellence, 2018 1. The dosage for lisdexamfetamine could start at 30 mg daily and increased to 50-70 mg if necessary, as seen in clinical practice guidelines for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents 1. Some key points to consider when switching medications include:
- A comprehensive assessment of her symptoms, potential side effects from Concerta, adherence patterns, and any comorbid conditions that might be affecting treatment response
- Lifestyle modifications, such as regular exercise and a balanced diet, to help manage ADHD symptoms
- Therapy approaches like cognitive-behavioral therapy (CBT) to address any underlying issues
- Educational accommodations, such as extra time to complete assignments or a quiet workspace, to help her succeed in school
- Regular monitoring of medication adherence and potential issues, as lack of adherence may lead to reduced effectiveness and increased adverse events 1 It's also important to note that medication adherence is a common problem in ADHD treatment, and factors such as attitudes of patients and parents toward pharmacological treatment, a trustful physician-patient relationship, family support, and knowledge about the disorder and the intended medication should be evaluated and improved if possible to increase medication adherence 1.
From the Research
Next Steps for Treatment
If a 17-year-old girl with TDA (presumably referring to Attention Deficit Hyperactivity Disorder, given the context of the medication mentioned) is not responding to the maximum dose of Concerta (a formulation of methylphenidate), the next steps in treatment should be considered carefully.
- Assessment of Current Treatment: Before switching medications, it's crucial to ensure that the current medication has been optimized and that the diagnosis of ADHD is accurate 2.
- Alternative Medications: Other medications within the same class (e.g., other stimulants like amphetamines) or different classes (e.g., non-stimulants like atomoxetine) could be considered 2, 3.
- Dosing Considerations: The dosages of alternative medications will depend on the specific medication chosen. For example:
- Amphetamines: The dosage can vary widely, but typical starting doses for adolescents might be around 5-10 mg per day, with gradual increases as needed and under close supervision.
- Atomoxetine: Starting doses for adolescents are often around 40 mg per day, with the possibility of increasing to 80 mg per day or more, based on response and tolerability.
- Monitoring and Follow-Up: It's essential to closely monitor the patient's response to any new medication, including both efficacy and potential side effects, and to adjust the treatment plan as necessary 4.
Considerations for Switching Medications
Switching medications can be beneficial for improving outcomes but also carries risks, such as side effects or lack of efficacy 5. The decision to switch should be based on a thorough evaluation of the patient's current treatment response and potential alternatives.
- Efficacy and Tolerability: The choice of a new medication should consider both its potential efficacy for the patient's specific symptoms and its tolerability profile 2, 3.
- Cardiovascular Safety: Recent studies have highlighted the importance of considering the cardiovascular safety of ADHD medications, particularly in terms of effects on blood pressure and heart rate 4.
Given the complexity of ADHD treatment and the individual variability in response to medications, consultation with a healthcare professional is essential for determining the best course of action for a patient not responding to their current medication regimen.