Management of Accidental Co-Ingestion of Concerta 36 mg and Adderall IR 22.5 mg
This accidental co-ingestion of two stimulants represents a sympathomimetic overdose requiring immediate assessment, supportive care with benzodiazepines as first-line treatment for agitation, and observation until symptoms resolve—typically 12-24 hours given the extended-release formulation of Concerta. 1, 2
Immediate Assessment and Stabilization
Assess airway, breathing, and circulation immediately with continuous cardiorespiratory monitoring, as sympathomimetic overdose can cause cardiovascular instability 3, 2
Check vital signs focusing on heart rate, blood pressure, temperature, and respiratory rate, as both methylphenidate and amphetamine cause tachycardia, hypertension, and hyperthermia through excessive extracellular dopamine and norepinephrine 2
Perform bedside glucose testing to rule out hypoglycemia as a cause of any altered mental status 4
Obtain IV access for potential medication administration 4
Expected Clinical Presentation
The patient may exhibit sympathomimetic syndrome including:
Neurological effects: Mydriasis, tremor, agitation, hyperreflexia, anxiety, confusion, hallucinations, or delirium 2
Cardiovascular effects: Tachycardia, hypertension (or paradoxically hypotension), and potential for tachyarrhythmias 1, 2
Other effects: Hyperhidrosis, hyperthermia, decreased appetite, nausea, vomiting, and abdominal pain 1, 5
Note: The total dose (approximately 58.5 mg methylphenidate equivalent) is significant but typically not life-threatening with appropriate management 6, 7
Specific Management Strategies
First-Line Treatment: Benzodiazepines
Administer benzodiazepines as first-line therapy for agitation, anxiety, tachycardia, hypertension, and potential seizures associated with sympathomimetic overdose 4, 2
Titrate benzodiazepines (e.g., lorazepam 1-2 mg IV or diazepam 5-10 mg IV) to achieve adequate sedation and control of sympathomimetic symptoms 4, 2
Benzodiazepines address the core pathophysiology by reducing CNS stimulation and preventing secondary complications like hyperthermia and rhabdomyolysis 2
Decontamination Considerations
Do NOT administer activated charcoal if more than 2 hours have elapsed since ingestion, as it is unlikely to be beneficial and may increase aspiration risk in an agitated patient 6, 7
If presenting within 1-2 hours and the patient is cooperative, activated charcoal (1 g/kg, maximum 50 g) may be considered, though evidence for benefit is limited 6
Cardiovascular Management
For persistent severe hypertension or tachycardia despite adequate benzodiazepine sedation, consider short-acting agents like esmolol or labetalol cautiously 4
Avoid pure beta-blockers (like propranolol) in isolation due to risk of unopposed alpha-adrenergic stimulation leading to paradoxical hypertension 4
Refractory Agitation
- If agitation, delirium, or movement disorders are unresponsive to benzodiazepines, second-line therapies include antipsychotics (ziprasidone or haloperidol), dexmedetomidine, or propofol 2
Critical Pitfalls to Avoid
Do NOT assume naloxone will be helpful—this is a stimulant overdose, not an opioid overdose, and naloxone has no role unless co-ingestion with opioids is suspected 8, 3
Do NOT administer flumazenil if benzodiazepines were given therapeutically, as this can precipitate seizures 4
Do NOT delay emergency evaluation—even though most cases resolve without sequelae, complications like seizures, severe hyponatremia from secondary polydipsia, cardiac arrhythmias, or hyperthermia can occur 5, 6
Laboratory and Diagnostic Workup
Obtain comprehensive metabolic panel to assess electrolytes (particularly sodium, as polydipsia with hyponatremia has been reported), renal function, and glucose 4, 5
Check complete blood count and consider creatine kinase if rhabdomyolysis is suspected from agitation or hyperthermia 4, 2
Perform ECG to assess for tachyarrhythmias or QT prolongation 4, 2
Consider urine drug screen if co-ingestion with other substances is possible 4
Observation and Disposition
Observe in a healthcare setting for a minimum of 12-24 hours given the extended-release formulation of Concerta, which can cause prolonged effects 1, 6, 7
Monitor until vital signs normalize and all sympathomimetic symptoms completely resolve 4, 3
Concerta's extended-release mechanism delivers methylphenidate over 12 hours, with peak effects at 6-8 hours, necessitating prolonged observation even if initial presentation is mild 1, 9
Ensure psychiatric evaluation before discharge to assess for intentional ingestion, suicidal ideation, or medication mismanagement 6, 7
Special Considerations
Monitor for secondary complications including hyperthermia (temperatures >104°F), rhabdomyolysis, acute kidney injury, seizures, and cardiac complications 1, 2
Watch for polydipsia and hyponatremia, which has been reported with methylphenidate overdose in children and can lead to seizures 5
Dialysis is NOT useful as methylphenidate has a large volume of distribution and is rapidly metabolized 1
Consider contacting Poison Control (1-800-222-1222) or a medical toxicologist for additional guidance, particularly if the patient develops severe or refractory symptoms 1