What is the recommended dosage and administration of Methylphenidate (Extended Release) for a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Methylphenidate Extended-Release (ER) for ADHD: Dosage and Administration

For children and adolescents aged 6-17 years with ADHD, start methylphenidate ER at 18 mg once daily in the morning, titrating by 18 mg weekly based on response and tolerability, up to a maximum of 54-72 mg daily. 1

Age-Specific Dosing Recommendations

Children and Adolescents (6-17 years)

Starting dose: 5 mg twice daily (immediate-release) or 18 mg once daily (extended-release formulations like OROS-MPH), administered 30-45 minutes before breakfast and lunch 2

Titration schedule:

• Increase by 5-10 mg weekly for immediate-release formulations 2
• Increase by 18 mg weekly for extended-release formulations 1
• Maximum daily dose: 60 mg for most formulations, though 72 mg may be used for OROS-MPH 1, 2

Critical monitoring during titration: Obtain weekly symptom ratings using standardized scales to assess ADHD response, monitor blood pressure and pulse at each visit, and track height and weight at every appointment as stimulants can affect growth 3

Adults

Starting dose: 5 mg twice or three times daily (immediate-release) or 10-18 mg once daily (extended-release), administered 30-45 minutes before meals 2

Titration schedule:

• Increase by 5-10 mg weekly based on response 2
• Average therapeutic dose: 20-30 mg daily 2
• Maximum daily dose: 60 mg 2

Timing consideration: For adults with insomnia, administer the last dose before 6 PM to minimize sleep disruption 2

Formulation-Specific Considerations

Extended-Release Formulations Provide Superior Coverage

Long-acting methylphenidate formulations (8-12 hour duration) offer once-daily dosing that improves medication adherence compared to multiple daily doses of immediate-release formulations. 3, 4

• 8-hour preparations (Metadate CD, Ritalin LA): Use microbead technology for biphasic release 4
• 12-hour preparation (Concerta/OROS-MPH): Uses osmotic pump system for continuous delivery 4
• Extended-release formulations reduce rebound symptoms and provide "around-the-clock" symptom control 3

Immediate-Release Formulations

• Duration of action: approximately 4 hours 4, 5
• Requires 2-3 times daily dosing 2
• Useful for fine-tuning coverage or adding afternoon doses to extended-release regimens 1

Special Population Considerations

Preschool-Aged Children (4-5 years)

Methylphenidate should only be prescribed to preschool-aged children with moderate-to-severe ADHD dysfunction after behavioral therapy has proven inadequate. 1

• Start with lower doses due to slower metabolism in this age group 1
• Increase in smaller increments than used in older children 1
• Maximum doses have not been adequately studied in preschoolers 1
• Severity criteria requiring medication: symptoms persisting ≥9 months, dysfunction in both home and school settings, inadequate response to parent training in behavior management 1

Important caveat: Methylphenidate use in children 4-5 years remains off-label despite moderate evidence for safety and efficacy, as FDA approval was based on insufficient data 1

Adolescents (12-18 years)

Before initiating methylphenidate in adolescents, screen for substance use and assess diversion risk, as stimulant misuse is a particular concern in this age group. 1

• Consider extended-release formulations with lower abuse potential (OROS-MPH, dermal methylphenidate) to minimize diversion risk 1
• Provide medication coverage for driving hours, as adolescents with ADHD have increased crash risk 1
• Use longer-acting or late-afternoon short-acting medications to ensure symptom control during evening driving 1
• Monitor prescription refill requests for signs of misuse or diversion 1

Patients with Intellectual Disability/Developmental Disorder

Methylphenidate remains first-line treatment for ADHD in children with intellectual disability, though effect sizes are lower (0.39-0.52) compared to typically developing children (0.8-0.9). 1

• Approximately 40% of children with intellectual disability respond to methylphenidate 1
• Adverse effects are similar to those in typically developing children (appetite suppression, sleep problems) 1
• Efficacy is not moderated by severity of intellectual disability, presence of autism, or severity of ADHD symptoms 1
• Start with conservative dosing due to potential increased sensitivity to side effects 1

Patients with Substance Use History

Exercise extreme caution when prescribing methylphenidate to patients with comorbid substance abuse disorders, and strongly favor long-acting formulations with lower abuse potential. 1, 6

• OROS-MPH (Concerta) is resistant to diversion and has lower abuse potential 3
• Consider atomoxetine as first-line alternative in active substance use disorder 3
• Implement urine drug screening to ensure compliance and detect substance use 3
• Schedule monthly follow-up visits to monitor for relapse 3

Critical safety note: Sustained-release methylphenidate formulations should be favored over immediate-release due to slower rate of input, which reduces subjective euphoric effects and abuse potential 6

Discontinuation and Dose Reduction

If paradoxical aggravation of symptoms or adverse reactions occur, reduce the dose or discontinue methylphenidate. 2

• If no improvement occurs after appropriate dosage adjustment over one month, discontinue treatment 2
• Reassess the need for continued treatment periodically, as some patients may not require long-term medication 1

Common Pitfalls to Avoid

Do not assume the same dose will work indefinitely—systematic titration to optimal effect is more important than strict mg/kg calculations, with 70% of patients responding optimally when proper titration protocols are followed. 3

Do not underdose: Many patients, particularly adults, require doses at the higher end of the therapeutic range (40-60 mg daily) for optimal symptom control 2, 7

Do not prescribe immediate-release formulations when extended-release options are available: Once-daily dosing improves adherence and reduces stigma associated with school-day dosing 3, 4

Do not use methylphenidate in patients taking MAOIs or within 14 days of MAOI discontinuation due to risk of hypertensive crisis. 2

Do not ignore cardiovascular screening: Assess for cardiac disease, family history of sudden death, and perform physical examination before initiating treatment 2