What is the recommended starting dose of Focalin (dexmethylphenidate) for an adult patient with Attention Deficit Hyperactivity Disorder (ADHD) and no history of substance abuse?

Focalin Dosing for Adults with ADHD

For adults with ADHD and no history of substance abuse, start Focalin (dexmethylphenidate) extended-release at 10 mg once daily in the morning, then titrate weekly in 10 mg increments up to a maximum of 40 mg daily based on symptom control and tolerability. 1

Starting Dose

• Begin with 10 mg of dexmethylphenidate extended-release once daily in the morning for adults who are new to methylphenidate or currently on other stimulants 1
• If the patient is already taking immediate-release dexmethylphenidate, convert to the same total daily dose of extended-release formulation 1
• For patients currently on racemic methylphenidate (Ritalin), start dexmethylphenidate at half the total daily dose of the racemic form 1

Titration Protocol

• Increase the dose by 10 mg weekly based on clinical response and side effect profile 1
• Continue weekly titration until optimal symptom control is achieved without intolerable adverse effects 2, 1
• The maximum studied and recommended dose is 40 mg daily for adults 1
• Doses above 40 mg have not been studied and are not recommended 1

Administration Details

• Take once daily in the morning with or without food 1
• The capsule may be swallowed whole or opened and sprinkled on applesauce (consume immediately without chewing) 1
• Do not divide capsule contents—take the entire capsule dose 1

Monitoring Requirements During Titration

• Before starting treatment: Obtain baseline blood pressure, pulse, height, and weight; assess for cardiac disease through careful history and physical exam 2, 1
• During titration: Collect ADHD symptom ratings from the patient and significant others before each dose increase 2
• Systematically assess for common stimulant side effects including insomnia, decreased appetite, headaches, weight loss, blood pressure elevation, and agitation 2
• Monitor blood pressure and pulse at each dose adjustment 2
• Maintain weekly contact (can be by phone) during initial titration phase 2

Expected Therapeutic Response

• Dexmethylphenidate provides rapid onset of action (as early as 0.5 hours post-dose) with duration up to 12 hours 3, 4
• Adults typically respond to total daily doses between 20-40 mg 1, 4
• Approximately 78% of adults show marked improvement on methylphenidate-based stimulants at adequate doses (equivalent to 1.0 mg/kg/day of racemic methylphenidate) 5

When to Adjust or Discontinue

• If no improvement occurs after appropriate dosage adjustment over one month, discontinue the medication 1
• If paradoxical aggravation of symptoms or intolerable adverse reactions occur, reduce the dosage or discontinue 1
• If approaching maximum dose without adequate response: Clearly document that lower doses were insufficient and that higher doses are not causing intolerable side effects (weight loss, blood pressure increase, agitation) before exceeding standard recommendations 2
• Consider switching to an alternative stimulant or adding non-stimulant medications if maximum dose is ineffective 2

Critical Safety Considerations

• Screen for substance abuse risk before prescribing, as dexmethylphenidate has high potential for abuse and misuse 1
• Do not prescribe to adults with active substance use disorder 2
• Screen for cardiac disease, family history of sudden death or ventricular arrhythmia before initiating 1
• Assess for motor/verbal tics or Tourette's syndrome before starting treatment 1
• Monitor for signs of abuse, misuse, and addiction throughout treatment 1

Common Pitfalls to Avoid

• Starting too high: Beginning above 10 mg leads to unnecessary side effects and decreased adherence 2
• Inadequate titration time: Failing to allow one week between dose increases prevents accurate assessment of response 2
• Missing side effect assessment: Not systematically asking about specific stimulant side effects at each visit 2
• Continuing escalation without benefit: If symptoms plateau at maximum dose, switch medications rather than exceeding recommendations 2
• Ignoring longer functional day needs: Adults may require coverage for longer waking hours than children; consider timing and duration of effect 2