Methylphenidate Dosing for Adults with ADHD
For adults with ADHD, start methylphenidate at 5 mg orally 2-3 times daily (preferably 30-45 minutes before meals), then titrate upward by 5-10 mg weekly until symptoms are controlled, with a typical maintenance dose of 20-30 mg daily and a maximum of 60 mg daily. 1, 2
Starting Dose and Initial Titration
Begin with 5 mg of immediate-release methylphenidate given 2-3 times daily, administered after breakfast and lunch, with an optional third dose in the afternoon to cover evening activities 1
The FDA-approved starting regimen is 5 mg twice daily before breakfast and lunch, preferably 30-45 minutes before meals 2
Adults may require more frequent dosing than children to cover a longer workday, which explains why some patients need 3 daily doses rather than 2 1
Weekly Dose Escalation
Increase the dose by 5-10 mg weekly based on symptom response and tolerability 1
Obtain symptom and side-effect ratings from the patient and a significant other before each dose increase—these can be collected via phone contact 1
Stop titration when symptoms have resolved and functional impairment has diminished, based on clinical judgment 1
Target and Maximum Doses
The average effective dose is 20-30 mg daily, with a maximum recommended dose of 60 mg daily 1, 2
Some adult patients may require total daily doses up to 1.0 mg/kg of methylphenidate (approximately 65 mg for a 65 kg adult), though this requires clear documentation that lower doses were insufficient and higher doses produce no side effects 1
Research demonstrates that doses of approximately 1 mg/kg total daily dose achieve response rates of 78% versus 4% with placebo 3
The mean effective dose in clinical trials ranges from 0.55 mg/kg to 1.0 mg/kg daily 4, 5
Timing Considerations
For patients who cannot sleep if medication is taken late in the day, administer the last dose before 6 p.m. 2
The timing and strength of the end-of-day dose should be adjusted to minimize side effects like reduced appetite at dinner and delayed sleep onset 1
Alternative: Long-Acting Formulations
After establishing an effective dose with immediate-release methylphenidate, consider converting to extended-release formulations for once-daily dosing 1
Long-acting formulations improve medication adherence, provide more consistent symptom control throughout the day, and reduce rebound effects 6, 3
When converting, add the morning and noon doses together to determine the extended-release dose (e.g., if taking 10 mg twice daily, switch to 20 mg extended-release once daily) 1
Monitoring Requirements
Monitor blood pressure and pulse at baseline and regularly during treatment, as methylphenidate can cause cardiovascular effects 6, 3
Track weight regularly, as appetite suppression and weight loss are common side effects 6, 7
Assess for common adverse effects including insomnia, headache, anxiety, and gastrointestinal symptoms 2, 4
Schedule follow-up appointments at least monthly after dose stabilization to assess ongoing efficacy and side effects 7
Critical Safety Considerations
Screen for cardiovascular disease, substance abuse history, and family history of tics or Tourette's syndrome before initiating treatment 2
Avoid methylphenidate in patients with uncontrolled hypertension, symptomatic cardiovascular disease, or active substance abuse 6, 3
Never use methylphenidate concurrently with MAO inhibitors or within 14 days of MAOI discontinuation due to risk of hypertensive crisis 2
Document clearly when using doses above 60 mg daily that symptoms could not be controlled at lower doses and monitor for signs of tolerance 1
Common Pitfalls to Avoid
Do not use weight-adjusted dosing with fractional pills—standard tablets are unscored, making precise fractional doses impossible and potentially exposing patients to inconsistent medication levels 1
Do not assume the starting 5 mg dose is adequate—systematic titration to optimal effect is essential, as 70-80% of adults respond when properly titrated 6, 3
Do not stop titration prematurely—many patients require 20-40 mg daily for optimal symptom control, and underdosing is common in routine practice 8
Do not prescribe "as needed" dosing—ADHD requires consistent daily symptom control throughout the day to prevent functional impairment 3