Focalin ER Dosing for ADHD
Starting Dose
For patients new to methylphenidate, start Focalin ER at 5 mg once daily in the morning for pediatric patients (ages 6-17) and 10 mg once daily for adults. 1
- For patients currently taking immediate-release methylphenidate, convert to Focalin ER at half (1/2) the total daily methylphenidate dose 1
- For patients already on immediate-release dexmethylphenidate, give the same total daily dose as Focalin ER 1
- Administer once daily in the morning, with or without food 1
Titration Schedule
Increase the dose weekly in increments of 5 mg for pediatric patients and 10 mg for adults until optimal response is achieved or side effects emerge. 1
- The bimodal release profile mimics two doses of immediate-release dexmethylphenidate given 4 hours apart, providing symptom control throughout the day 2
- Monitor response using standardized ADHD rating scales from teachers and parents for children, or from patients and significant others for adults 3
- Maintain weekly contact during initial titration, which typically requires 2-4 weeks to reach optimal dosing 4
Maximum Doses
Efficacy Profile
Focalin ER demonstrates rapid onset and prolonged duration of action:
- Significant improvement in ADHD symptoms begins as early as 0.5 hours after administration 2
- Duration of effect extends 11-12 hours post-dose, covering the full school or work day 2, 5
- All three fixed doses (10,20, and 30 mg) showed significantly greater efficacy than placebo across multiple settings (school, home, clinic) 5
- Average titrated dose of 18.25 mg/day dexmethylphenidate provides equivalent efficacy to 32.14 mg/day of racemic methylphenidate, demonstrating 2:1 potency 6
Administration Options
- Capsules may be swallowed whole or opened and sprinkled on applesauce for patients unable to swallow capsules 1
- This flexibility is particularly useful for pediatric patients who have difficulty with pill swallowing 2
Monitoring Requirements
Systematically assess both therapeutic response and side effects at each visit:
- Monitor blood pressure and pulse regularly 4
- Track height and weight at each visit, as growth suppression can occur with stimulants 4, 1
- Screen for common side effects including decreased appetite, headache, anxiety, dyspepsia, and insomnia 1
- After stabilization, schedule follow-up appointments at least monthly 4
Clinical Considerations
- Dexmethylphenidate contains only the d-threo-enantiomer (active isomer) of methylphenidate, allowing for lower total drug load while maintaining efficacy 6, 7
- In open-label titration studies, 82% of patients achieved "much" or "very much improved" ratings on Clinical Global Impression scales 8
- The once-daily formulation eliminates the need for midday dosing at school, improving adherence and reducing stigma 2
- Discontinuation rates due to adverse events are low, with only 5 of 89 patients discontinuing in clinical trials 8
Common Pitfalls to Avoid
- Do not start at excessively high doses, as this leads to unnecessary side effects and decreased medication adherence 4
- Do not use weight-adjusted dosing for titration, as this method is problematic in practice and not uniformly supported by research 3
- Do not assume the medication has failed if initial doses are inadequate—systematic titration through the full dose range is essential, as 70-80% of patients respond when properly titrated 4
- Never use concurrently with MAO inhibitors or within 14 days of MAOI discontinuation due to risk of hypertensive crisis 1