What is the recommended approach when starting stimulant medication for an adult ADHD patient?

Starting Stimulant Medication for Adult ADHD: Required Steps

Before prescribing any stimulant medication for adult ADHD, you must obtain baseline vital signs (blood pressure and pulse), conduct a detailed cardiac history including family history of sudden death or arrhythmias, perform a physical examination, and screen for substance abuse risk. 1, 2, 3

Pre-Treatment Evaluation Requirements

Mandatory Baseline Assessments

• Cardiovascular screening is essential before initiating stimulants, including blood pressure, pulse, height, and weight measurements 1, 2
• Detailed cardiac history must assess for syncope, chest pain, palpitations, exercise intolerance, and prior cardiac diagnoses 2
• Family history focusing on sudden unexplained death before age 50, early cardiovascular disease, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, long QT syndrome, and arrhythmias 2
• Physical examination should be completed to identify any contraindications 1

Critical Contraindications to Screen For

• Active stimulant abuse or uncontrolled substance use disorder (though stimulants can be used cautiously with close supervision in patients with comorbid substance dependence) 1, 4
• Symptomatic cardiovascular disease, including uncontrolled hypertension, coronary artery disease, serious cardiac arrhythmias, or structural cardiac abnormalities 2, 3
• Active psychotic disorder or untreated bipolar disorder (requires screening for bipolar risk before initiating stimulants) 2
• Concurrent MAOI use or use within the preceding 14 days 3
• Uncontrolled hyperthyroidism or glaucoma 1

Psychiatric Screening

• Screen for bipolar disorder risk before starting stimulants, including detailed psychiatric history and family history of suicide, bipolar disorder, and depression, as stimulants may induce manic/mixed episodes 2
• Document prior ADHD treatments, including previous medications, dosages, duration, response, side effects, and compliance 1

Laboratory and Cardiac Testing

• No routine blood work is required unless clinically indicated by history or physical examination 4
• Routine EKG is NOT recommended by the American Academy of Pediatrics for adults without cardiac risk factors 4
• EKG should be obtained only if cardiac risk factors are identified during history or physical examination 2
• Urine drug screen may be considered in adults with suspected substance abuse before starting stimulants 4

Initial Dosing and Titration Protocol

Starting Doses for Adults

• Methylphenidate: Start at 5 mg twice daily (after breakfast and lunch), or use long-acting formulations at equivalent doses 1
• Amphetamine/dextroamphetamine: Start at 2.5 mg once or twice daily 1
• Long-acting formulations are strongly preferred for adults due to better adherence, lower rebound effects, more consistent symptom control, and reduced diversion potential 4

Titration Schedule

• Increase doses weekly by 5-10 mg for methylphenidate or 2.5-5 mg for amphetamines based on symptom response and tolerability 1
• Maximum recommended daily doses: 60 mg for methylphenidate, 40-50 mg for amphetamines 1, 4
• Average effective adult doses: 20-30 mg daily for methylphenidate, with response rates of 70-80% when properly titrated 4, 5

Monitoring During Titration

At each dose adjustment or weekly during titration:

• Blood pressure and pulse measurement 1
• ADHD symptom rating scales from patient and significant other 1
• Side effect assessment (appetite, sleep, anxiety, cardiovascular symptoms) 1

Contact mode can be office visits or phone calls for dose adjustments after the initial visit 1

Ongoing Monitoring Requirements

Regular Follow-Up Schedule

• Blood pressure and pulse should be checked quarterly in adults during stable treatment 4
• Weight monitoring to assess for appetite suppression effects 1
• Symptom and functional improvement across multiple domains (work, home, social) 1
• Side effect surveillance for cardiovascular symptoms, sleep disturbances, appetite changes, anxiety, or emergence of psychotic/manic symptoms 2, 3

Warning Signs Requiring Immediate Evaluation

• Exertional chest pain, unexplained syncope, or palpitations require prompt cardiac evaluation 2
• New psychotic or manic symptoms (hallucinations, delusions, mania) may require discontinuation 2
• Blood pressure elevation above 130/80 mmHg requires dose reduction or antihypertensive therapy 6
• Sustained or painful erections (priapism) require immediate medical attention 3

Common Pitfalls to Avoid

• Do not skip baseline vital signs and cardiac history—this is the most critical safety step and identifies patients at risk for serious cardiovascular events 2, 3
• Do not prescribe immediate-release formulations for "as-needed" use—ADHD requires consistent daily treatment for optimal functional outcomes 4
• Do not assume all patients will respond to the first stimulant tried—approximately 40% respond to both methylphenidate and amphetamines, while 40% respond to only one class, requiring cross-titration 4
• Do not obtain routine EKGs in low-risk adults—this is not supported by guidelines and increases unnecessary costs 4
• Do not ignore collateral information—adults with ADHD are unreliable reporters of their own behaviors; obtain information from family members or close contacts when possible 4