Concerta Dosing for a 6-Year-Old with ADHD on Guanfacine
Start Concerta at 18 mg once daily in the morning, which is the FDA-approved starting dose for children 6 years and older, and titrate by 18 mg weekly based on response up to a maximum of 54 mg daily for this age group. 1
Starting Dose and Titration Schedule
- Begin with 18 mg Concerta once daily in the morning, as this is the standard starting dose for children 6 years and older with ADHD 1
- Titrate upward by 18 mg increments weekly (18 mg → 36 mg → 54 mg) based on symptom response and tolerability 1
- The maximum approved dose for children in Japan is 54 mg daily, though some guidelines allow up to 72 mg daily in older children and adolescents 1
Expected Timeline and Monitoring
- Stimulants like Concerta work within days, providing rapid assessment of ADHD symptom response, unlike the guanfacine already on board which required 2-4 weeks for full effect 2
- Monitor ADHD symptoms systematically at each dose adjustment using parent and teacher reports 2
- Obtain baseline blood pressure and heart rate before starting Concerta, then monitor at each dose adjustment, as stimulants increase both parameters (opposite effect of guanfacine which decreases them) 2
- Track height and weight at each visit, as stimulants can affect growth 3
Safety of Combining Concerta with Guanfacine
- This combination is FDA-approved and explicitly safe—both extended-release guanfacine and extended-release clonidine have FDA approval specifically for adjunctive therapy with stimulants 1, 2
- The combination allows for lower stimulant dosages while maintaining efficacy and potentially reducing stimulant-related adverse effects 2, 4, 5
- Drug-drug interaction studies demonstrate that adjunctive guanfacine with long-acting methylphenidate (like Concerta) does not change exposure to either medication in a clinically meaningful way 4
- Monitor for opposing cardiovascular effects: stimulants increase heart rate and blood pressure by modest amounts, while guanfacine decreases both by 1-4 mmHg and 1-2 bpm 2
Duration of Action and Coverage
- Concerta provides 12-hour symptom coverage throughout the school day and into early evening with once-daily morning dosing 6, 7
- The guanfacine already prescribed provides "around-the-clock" coverage lasting approximately 24 hours, complementing Concerta's daytime effects 2
- Evening administration of guanfacine is generally preferable to minimize daytime somnolence while Concerta provides daytime symptom control 2
Common Adverse Effects to Monitor
- Decreased appetite and weight loss are the most common stimulant side effects—monitor weight at each visit 3
- Insomnia can occur with Concerta; ensure morning administration and avoid late-day dosing 3
- Headache may occur but often decreases over time 2
- The combination with guanfacine may help mitigate some stimulant-related adverse effects like sleep disturbances 2, 5
Critical Safety Warnings
- Never abruptly discontinue guanfacine—it must be tapered by 1 mg every 3-7 days to avoid rebound hypertension 2
- Screen for personal or family history of cardiac conditions including Wolf-Parkinson-White syndrome, sudden death, hypertrophic cardiomyopathy, and long QT syndrome before initiating Concerta 2
- Avoid Concerta in patients with uncontrolled hypertension or symptomatic cardiovascular disease 3
Why This Combination Makes Sense
- Stimulants like Concerta have 70-80% response rates and the largest effect sizes (approximately 1.0) for ADHD treatment 2, 3
- Adding Concerta to existing guanfacine addresses any residual ADHD symptoms not fully controlled by guanfacine alone (which has smaller effect sizes around 0.7) 2
- The combination is particularly appropriate when ADHD co-occurs with disruptive behavior disorders, oppositional symptoms, tics, or sleep disturbances—all scenarios where guanfacine provides additional benefits beyond ADHD symptom control 2, 3