What is the typical starting dose of Adderall (amphetamine and dextroamphetamine) for a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Starting Dose for Adderall

For immediate-release (IR) Adderall, start with 2.5 mg twice daily in children or 5 mg twice daily in adults; for extended-release (XR) Adderall, start with 10 mg once daily in the morning for both children and adults. 1, 2, 3

Age-Specific Starting Doses

Children (Ages 3-5 years)

• Begin with 2.5 mg daily of immediate-release formulation 3
• Increase by 2.5 mg weekly increments until optimal response is achieved 3
• Give first dose upon awakening, with additional doses at 4-6 hour intervals if needed 1, 3

Children (Ages 6-12 years)

• Immediate-release: Start with 5 mg once or twice daily (typically after breakfast and lunch) 1, 3
• Extended-release: Start with 10 mg once daily in the morning 2, 4
• Increase by 5 mg weekly increments based on response 1, 2, 3

Adolescents and Adults (Ages 12+ years)

• Immediate-release: Start with 5 mg twice daily 1, 4
• Extended-release: Start with 10 mg once daily in the morning 2, 5
• Increase by 5 mg weekly increments until symptom control is achieved 2, 5

Titration Protocol

Increase doses gradually in weekly increments, allowing sufficient time to evaluate both therapeutic response and side effects before each adjustment 1, 2:

• For IR formulation: Increase by 5-10 mg per dose weekly 1
• For XR formulation: Increase by 5 mg weekly 2, 5
• Maintain weekly telephone contact during initial titration, with in-person visits at least monthly until symptoms stabilize 1, 2

Maximum Dosing Limits

The FDA-approved maximum total daily dose is 40 mg for amphetamines, though more recent guidelines suggest up to 50 mg daily for adults 1, 2, 3:

• Children weighing less than 25 kg should not receive single doses exceeding 10 mg 1, 2
• Rarely exceed 40 mg total daily dose in children 1, 3
• Adults may receive up to 50 mg daily based on recent guidelines 2, 5

Timing of Administration

Always administer the first dose in the morning upon awakening to minimize sleep disturbances 1, 2, 4:

• IR formulation: Give first dose after breakfast, second dose after lunch (4-6 hours later) 1, 3
• XR formulation: Single morning dose provides coverage throughout the day 2, 4
• Avoid late evening doses due to resulting insomnia 3

Baseline Assessment and Monitoring

Before initiating treatment, obtain the following baseline measurements 2, 4:

• Blood pressure and pulse 2, 4
• Height and weight 2, 4
• Substance abuse screening in adolescents and adults 4

During titration and maintenance, systematically assess 1, 2:

• Target ADHD symptoms using parent and teacher reports (and self-reports in adolescents/adults) 1
• Side effects: insomnia, anorexia, headaches, social withdrawal, tics, weight loss 1, 2
• Weight at each visit to monitor appetite suppression 1, 2
• Blood pressure and pulse quarterly in adults 2

Special Population Considerations

Older Adults

• Start with more conservative dosing (5 mg XR or 2.5 mg IR) 4, 5
• Use slower titration schedule: increase by 5 mg every 2 weeks instead of weekly 2, 5
• Monitor vital signs more carefully due to age-related pharmacokinetic changes 5

Patients with Substance Abuse Risk

• Consider alternative medications (such as Vyvanse) due to lower abuse potential 4
• Avoid prescribing Adderall XR to adults with active substance abuse disorder 2

Common Pitfalls to Avoid

Do not start at too high a dose, as this leads to unnecessary side effects and decreased adherence 2, 5:

• Starting above recommended doses increases risk of appetite suppression, insomnia, and cardiovascular effects 6
• Amphetamines increase systolic blood pressure by approximately 2 mmHg and heart rate by 3.7 beats per minute 6

Do not increase doses too rapidly without allowing at least one week between adjustments to properly evaluate response 2, 5

Do not continue escalating beyond maximum recommended doses if symptoms persist 1, 2:

• If maximum dose is ineffective, more is not necessarily better 1, 2
• Consider switching to a different stimulant class or adding non-stimulant medications 2, 5
• Reevaluate the diagnosis and assess for comorbid conditions affecting treatment response 2, 5

Do not fail to systematically assess both benefits and side effects during each titration step 1, 2, 5