What is the typical starting dose of Adderall (amphetamine and dextroamphetamine) for a patient with attention deficit hyperactivity disorder (ADHD) or narcolepsy?

Adderall Starting Dose

For adults with ADHD, start Adderall at 5 mg once daily in the early morning, with a noon dose added if the effect does not last through the school or work day, then titrate upward in 5-10 mg weekly increments until symptoms are controlled. 1, 2

Starting Dose by Age Group

Adults and Older Adolescents

• Begin with 5 mg of immediate-release amphetamine/dextroamphetamine given once daily in the early morning 1, 2
• Add a noon dose of 5 mg if the morning dose does not provide coverage through the functional day 1
• For extended-release formulations, start at 10 mg once daily in the morning 2

Children (Ages 6 and Older)

• Start with 5 mg once or twice daily 3
• Administer the first dose upon awakening, with additional doses at 4-6 hour intervals if needed 3

Young Children (Ages 3-5)

• Start with 2.5 mg daily 3
• This lower starting dose accounts for smaller body size and increased sensitivity to stimulant effects 3

Adolescents (Ages 13-17)

• Begin with 10 mg once daily in the morning for extended-release formulations 4
• For immediate-release, follow the adult dosing of 5 mg once or twice daily 1

Titration Protocol

Weekly Dose Escalation

• Increase by 5-10 mg increments weekly based on symptom control and tolerability 1, 2
• Wait at least one full week between dose adjustments to properly evaluate response 1, 2
• Continue titration until optimal symptom control is achieved or side effects become limiting 1, 2

Monitoring During Titration

• Obtain standardized ADHD rating scales from the patient (and significant other for adults, or teachers/parents for children) before each dose increase 1, 2
• Systematically assess for side effects at each adjustment, particularly appetite suppression, insomnia, blood pressure elevation, and agitation 1, 2
• Monitor blood pressure and pulse at each dose adjustment 2

Target Dose Range

Adults

• Most adults achieve optimal response at total daily doses of 40-60 mg 5, 2
• The maximum recommended dose is 40 mg for immediate-release amphetamine salts 5, 3
• Extended-release formulations have a maximum recommended dose of 50 mg daily 5
• Some patients may require doses up to 60 mg daily when symptoms cannot be controlled at lower levels, though this should be carefully documented 1, 5

Children and Adolescents

• Rarely necessary to exceed 40 mg total daily dose in children 3
• Adolescents in clinical trials showed efficacy with doses ranging from 10-40 mg daily 4

Dosing Schedule Considerations

Timing of Administration

• Always administer the first dose upon awakening or with breakfast 1, 2
• If using immediate-release formulations, give additional doses at 4-6 hour intervals 3
• Avoid doses after 2:00 PM to minimize sleep disturbances 1

Multiple Daily Doses

• Adults typically require 2-3 doses daily with immediate-release formulations to cover a longer functional day 2
• Extended-release formulations are dosed once daily in the morning 2, 4

Special Population Dosing

Narcolepsy

• For adults and adolescents 12 years and older, start with 10 mg daily 3
• Increase in 10 mg increments weekly until optimal response is obtained 3
• Usual dose range is 5-60 mg per day in divided doses 3
• For children ages 6-12 with narcolepsy, start with 5 mg daily and increase in 5 mg increments weekly 3

Medically Ill Patients

• Use approximately one-half the standard starting dose for ADHD (2.5 mg) when treating apathy or depression in medically ill patients 1
• Titrate slowly with careful monitoring for side effects 1

Critical Monitoring Requirements

Baseline Assessment

• Obtain baseline blood pressure, pulse, height, and weight before initiating treatment 2
• Document baseline ADHD symptom severity using standardized rating scales 1, 2

Ongoing Monitoring

• Assess blood pressure, pulse, height, and weight at each visit 2
• Use standardized ADHD rating scales to objectively track response 1, 2
• Systematically evaluate both target symptoms and side effects at each dose adjustment 5, 2

Common Pitfalls to Avoid

Starting Too High

• Starting at doses higher than 5 mg (or 2.5 mg in young children) leads to unnecessary side effects and decreased adherence 5, 2
• The lower starting dose allows assessment of individual response while minimizing initial adverse effects 2

Inadequate Time Between Adjustments

• Failing to wait at least one week between dose increases prevents proper evaluation of response 1, 2
• Premature dose escalation increases the risk of overshooting the optimal dose 2

Poor Timing of Doses

• Administering doses too late in the day (after 2:00 PM) significantly increases sleep disturbances 1, 2
• Morning administration is essential regardless of formulation 2

Continuing Escalation Without Benefit

• If approaching 40-50 mg without adequate symptom control, switch to an alternative stimulant rather than continuing to increase the dose 5, 2
• Approximately 70% of patients respond to either amphetamine or methylphenidate alone, but nearly 90% will respond if both are tried 5

Inadequate Systematic Assessment

• Failing to use standardized rating scales and relying solely on subjective impressions leads to suboptimal dosing decisions 1, 2
• Objective measurement is essential for determining optimal dose 1, 2