What are the next steps for a child or adolescent with Attention Deficit Hyperactivity Disorder (ADHD) who is experiencing decreased efficacy with Concerta (methylphenidate) 27mg?

Concerta 27mg Not Working: Next Steps

Increase the Concerta dose to 36mg or 54mg immediately, as 27mg is likely subtherapeutic and proper dose titration achieves 70-80% response rates in ADHD patients. 1

Why the Current Dose is Insufficient

• 27mg Concerta is at the lower end of the therapeutic range and many patients require higher doses for adequate symptom control throughout the day 1
• The American Academy of Child and Adolescent Psychiatry recommends titrating methylphenidate upward by 18mg weekly until symptoms resolve, with maximum daily doses reaching 54-72mg for adolescents and up to 60mg for adults 1, 2
• Response rates of 78% versus 4% placebo are achieved when methylphenidate is dosed appropriately at approximately 1mg/kg total daily dose, suggesting your current dose may be inadequate 1

Systematic Dose Titration Protocol

Increase to 36mg Concerta for one week, then reassess symptoms:

• If partial improvement but still significant impairment, increase to 54mg 1
• Continue weekly titration by 18mg increments until optimal response or maximum dose (54-72mg depending on age) 1
• Monitor for side effects at each dose increase, including appetite suppression, sleep disturbances, and cardiovascular effects 3

Key monitoring parameters during titration:

• Blood pressure and pulse at each visit 1
• Sleep quality and appetite changes 3
• Functional improvement across multiple settings (school/work, home, social) 1

If Adequate Dose Titration Fails

Switch to the other stimulant class (amphetamine-based) before abandoning stimulants entirely:

• Approximately 40% of patients respond to both methylphenidate and amphetamines, while 40% respond to only one class 1
• Start lisdexamfetamine 20-30mg daily or mixed amphetamine salts 10mg daily, titrating weekly 1, 2
• Amphetamine-based stimulants demonstrate superior efficacy in some adults with effect sizes of -0.79 versus -0.49 for methylphenidate 1

Second-Line Non-Stimulant Options (Only After Stimulant Failure)

If both methylphenidate and amphetamine classes fail or cause intolerable side effects:

• Atomoxetine 60-100mg daily (requires 6-12 weeks for full effect, effect size 0.7 versus 1.0 for stimulants) 1, 4
• Extended-release guanfacine 1-4mg daily or clonidine (effect sizes around 0.7, useful as monotherapy or adjunctive) 1, 4
• Viloxazine (newer serotonin-norepinephrine modulating agent with favorable efficacy in trials) 1, 4

Critical Pitfalls to Avoid

Do not assume 27mg is an adequate trial - this is a common error that leads to premature abandonment of highly effective first-line treatment 1

Do not switch medication classes without first optimizing the dose - 70% of patients respond optimally when proper titration protocols are followed 1

Do not add supplements or non-evidence-based treatments - stimulants have effect sizes of 1.0 compared to supplements with uncertain or minimal effects, supported by over 161 randomized controlled trials 1

Do not discontinue effective ADHD treatment due to concerns about "taking medication long-term" - untreated ADHD is associated with increased risk of accidents, substance abuse, criminality, and functional impairment 1

Special Considerations

For adolescents: Concerta's tamper-resistant OROS delivery system makes it particularly suitable due to lower diversion potential 3, 1

For evening symptom coverage: Consider adding an immediate-release methylphenidate 5-10mg dose in late afternoon if symptoms return before bedtime, even after optimizing morning Concerta dose 3, 1

For comorbid conditions: The presence of anxiety or depression does not contraindicate stimulant use and often improves with adequate ADHD treatment 1, 2