What is the recommended treatment approach for a patient with attention deficit hyperactivity disorder (ADHD) starting stimulant treatment?

Starting Stimulant Treatment for ADHD

Begin with long-acting stimulant formulations as first-line treatment after confirming the absence of contraindications through baseline cardiovascular assessment, with methylphenidate or amphetamine-based medications achieving 70-80% response rates when properly titrated. 1

Pre-Treatment Assessment

Before initiating stimulant therapy, complete the following essential steps:

• Confirm DSM-IV or ICD-10 diagnosis of ADHD with documented moderate to severe impairment in at least two different settings (home, school/work, social) 2
• Obtain collateral information from at least two adult sources, preferably from different settings, using validated and age- and sex-normed rating instruments 2
• Perform baseline physical examination including blood pressure, pulse, height, and weight 3
• Screen for contraindications: previous stimulant hypersensitivity, glaucoma, hyperthyroidism, uncontrolled hypertension, active psychotic disorder, symptomatic cardiovascular disease, or current/recent MAOI use (within 14 days) 3, 4
• Assess substance use history carefully, as stimulants must be used with great care in patients with drug abuse history 3
• Screen for bipolar disorder by obtaining personal and family history of bipolar disorder, mania, or hypomania before starting treatment 5

Medication Selection and Initial Dosing

First-Line: Long-Acting Stimulant Formulations

Long-acting formulations are strongly preferred due to better medication adherence, lower risk of rebound effects, more consistent symptom control throughout the day, and reduced diversion potential 1

For Adults:

• Methylphenidate extended-release (Concerta): Start 18 mg once daily in the morning, titrate by 18 mg weekly up to 54-72 mg daily maximum 1
• Lisdexamfetamine (Vyvanse): Start 20-30 mg once daily in the morning, titrate by 10-20 mg weekly up to 70 mg daily maximum 1
• Mixed amphetamine salts XR (Adderall XR): Start 10 mg once daily in the morning, titrate by 5 mg weekly up to 40-50 mg maximum 1

For Children and Adolescents (6 years and older):

• Start at approximately 0.5 mg/kg/day total dose, increase after minimum 3 days to target of approximately 1.2 mg/kg/day 5
• Maximum daily dose: 1.4 mg/kg or 100 mg, whichever is less 5
• For immediate-release formulations: Starting dose is 5 mg twice daily (before breakfast and lunch), increase 5-10 mg weekly, with daily dosage above 60 mg not recommended 4

Alternative: Immediate-Release Formulations (if long-acting unavailable)

For Adults:

• Methylphenidate: 5 mg twice daily initially, titrate to 5-20 mg three times daily (maximum 60 mg/day) 6, 3
• Dextroamphetamine: 2.5 mg twice daily initially, titrate to 5 mg three times daily to 20 mg twice daily 6, 3

Methylphenidate is recommended as the initial stimulant due to more favorable effects on appetite and sleep compared to amphetamines, which have longer excretion half-lives 3

Titration Strategy

• Use minimum effective doses to initiate therapy and establish both minimum and maximum dose targets before starting 3
• Titrate weekly based on response and tolerability, increasing by 5-10 mg for methylphenidate or 5 mg for amphetamines 1
• Stimulants work rapidly, allowing assessment of ADHD symptom response within days 1, 3
• 70-80% of patients respond when properly titrated, with systematic titration to optimal effect being more important than strict mg/kg calculations 1
• If response to one stimulant class is inadequate, trial the other class before considering non-stimulants, as approximately 40% respond to both and 40% respond to only one 1

Monitoring Requirements

Initial Phase (First 4-8 Weeks)

• Weekly contact during titration to assess drug response and side effects 1
• Monitor blood pressure and pulse at each medication adjustment 1
• Assess symptom improvement using standardized rating scales across multiple settings 1

Maintenance Phase

• Quarterly visits for adults, annual visits during routine physical examination for children and adolescents 3
• Monitor for larger changes in heart rate and blood pressure, as 5-15% of individuals may experience substantial increases requiring intervention 3
• Track height and weight at each visit, particularly in pediatric patients, as stimulants can affect growth 1
• Monitor sleep quality and appetite changes as common adverse effects 1

Safety Monitoring

• Watch for appearance or worsening of aggressive behavior, hostility, new psychotic or manic symptoms, and behavioral disturbances 3
• Hold medication immediately and obtain ECG plus cardiology consultation if patient develops dyspnea, exercise-induced symptoms, or other cardiac symptoms 3

Common Adverse Effects

Expect and counsel patients about the following, which are generally mild and/or temporary 3:

• Decreased appetite and weight loss
• Sleep disturbances and insomnia
• Increased blood pressure and pulse (typically 2-4 mmHg systolic, 1-2 mmHg diastolic increase)
• Headaches
• Irritability and anxiety
• Stomach pain, nausea, dry mouth
• Tachycardia and palpitations

Special Populations and Considerations

Comorbid Conditions

• Depression or anxiety: Not contraindications to stimulant therapy; treat both conditions concurrently 1
• Conduct disorder: Only treat if moderate to severe impairment in at least two settings; ensure adolescents are not using non-prescribed stimulants 2
• Substance use disorder: Consider long-acting formulations with lower abuse potential (Concerta's OROS system is tamper-resistant) or non-stimulant alternatives like atomoxetine 1, 3
• Tics or Tourette's syndrome: Assess family history and clinically evaluate before initiating; regularly monitor for emergence or worsening 4

When to Consider Non-Stimulants

Atomoxetine (60-100 mg daily) is the only FDA-approved non-stimulant for adult ADHD and should be considered when 1, 5:

• Active substance abuse disorder present
• Inadequate response or intolerable side effects to two different stimulant classes
• Comorbid tics or severe anxiety
• Patient or family preference for non-controlled substance
• Note: Atomoxetine requires 6-12 weeks to achieve full therapeutic effect, unlike stimulants which work within days 1

Alpha-2 agonists (guanfacine or clonidine) can be used as monotherapy or adjunctive therapy, particularly when sleep disturbances, tics, or disruptive behavior disorders are present 1

Critical Pitfalls to Avoid

• Do not underdose: 54-70% of adults respond to stimulants when properly titrated; many patients require higher doses than initially prescribed 1
• Do not assume tolerance develops: There is little evidence of tolerance to stimulant effects on ADHD symptoms, and children most often continue to respond to the same dose over prolonged treatment 1
• Do not prescribe immediate-release for "as-needed" use: This approach lacks evidence, creates erratic symptom control, and fundamentally undermines treatment goals 1
• Do not discontinue effective treatment solely due to concerns about "taking medication forever": Untreated ADHD is associated with increased risk of accidents, substance abuse, criminality, and functional impairment 1
• Do not combine with MAOIs: At least 14 days must elapse between discontinuation of an MAOI and initiation of stimulants due to risk of hypertensive crisis 1

Multimodal Treatment Approach

Pharmacological treatment should be part of a comprehensive approach including psychoeducation, behavioral therapy, and psychosocial interventions 1. The MTA study showed that stimulants (either alone or combined with behavioral treatments) lead to stable improvements in ADHD symptoms as long as the drug continues to be taken, with medication management being more effective than intensive behavioral interventions alone for core ADHD symptoms 2.