Is it appropriate to increase the dose of Concerta (methylphenidate) from 18 mg to 27 mg in an adult patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Increasing Concerta from 18 mg to 27 mg in Adults with ADHD

Yes, increasing Concerta from 18 mg to 27 mg is appropriate for an adult with ADHD, as guideline-recommended titration involves weekly dose increases of 18 mg increments based on clinical response and tolerability. 1

Recommended Titration Strategy

The standard approach for adults involves:

• Starting at 18 mg once daily in the morning for stimulant-naïve adults, which is the established initial dose 1
• Increasing by 18 mg weekly based on systematic assessment of symptom control and side effects 1
• The 27 mg dose represents the first appropriate titration step, though note that Concerta is typically available in 18 mg, 36 mg, 54 mg, and 72 mg strengths (27 mg is not a standard manufactured dose) 2

If 27 mg is not available as a single tablet, consider using 18 mg + immediate-release methylphenidate 5 mg to achieve intermediate dosing, or proceed directly to 36 mg Concerta if 18 mg provides insufficient symptom control. 3

Clinical Monitoring During Titration

During dose adjustments, systematically assess:

• Target ADHD symptoms (inattention, hyperactivity, impulsivity) through patient self-report and reports from significant others 3
• Specific side effects including insomnia, anorexia, headaches, weight loss, anxiety, tachycardia, palpitations, and hypertension 1
• Blood pressure and pulse at each visit 3
• Functional impairment in work, social, and home settings 3

Weekly contact during initial titration (by phone or visit) allows timely assessment of response and side effects 3, 1

Dosing Context and Maximum Limits

Adult methylphenidate dosing guidelines indicate:

• Average effective doses range from 20-30 mg daily of immediate-release methylphenidate 4
• Maximum recommended daily dose is 60 mg for immediate-release formulations 3, 4
• Some adults may require up to 1.0 mg/kg of methylphenidate daily (approximately 65 mg for a 65 kg adult) to achieve symptom control, particularly when coverage is needed throughout a longer adult workday 3
• For Concerta specifically, if adequate control is not achieved at 72 mg daily, consider alternative treatments rather than routinely exceeding maximum doses 1

Duration of Action Considerations

Concerta provides:

• 10-12 hours of continuous symptom control after a single morning dose 5
• The 18 mg Concerta dose is approximately equivalent to methylphenidate 5 mg three times daily 1, 5
• For patients requiring coverage beyond 12 hours, short-acting stimulant boosters can be added in late afternoon, though timing is critical to avoid insomnia 5

Important Clinical Caveats

Common pitfalls to avoid:

• Do not assume linear dose-response relationships - approximately 40% of patients respond idiosyncratically to methylphenidate formulations 5
• Plasma methylphenidate levels do not correlate with clinical response, so dose adjustments should be based solely on symptom control and tolerability, not blood levels 1
• Document clearly if higher doses are needed, noting that symptoms could not be controlled at lower doses and that higher doses are not producing problematic side effects (weight loss, blood pressure increase, agitation) 3
• Monitor for signs of tolerance if escalating doses are required 3

If the patient fails to respond adequately after appropriate dose titration over one month, consider switching to an alternative stimulant (amphetamine-based preparations) rather than continuing to escalate methylphenidate doses, as approximately 90% of patients respond when both stimulant classes are tried 3

Special Population Considerations

For adults with comorbid substance abuse disorder, exercise extreme caution with any stimulant dosing and consider non-stimulant alternatives first 1. Concerta's formulation is resistant to diversion (cannot be crushed or snorted), making it particularly suitable for adults when stimulant treatment is deemed necessary 1, 6.

Schedule follow-up appointments at least monthly after dose stabilization to assess ongoing efficacy and side effects 1