What are the guidelines for prescribing stimulants, such as Ritalin (methylphenidate) or Adderall (amphetamine), to a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Guidelines for Prescribing Stimulants to Patients with ADHD

Stimulant medications (methylphenidate or amphetamines) are the first-line pharmacological treatment for ADHD in children aged 6 years and older, adolescents, and adults, with effect sizes of approximately 1.0 and response rates of 70-80% when properly titrated. 1

Pre-Prescribing Assessment and Screening

Cardiac Evaluation

Before initiating stimulant therapy, expand the history to specifically assess for cardiac symptoms, Wolf-Parkinson-White syndrome, sudden death in family members, hypertrophic cardiomyopathy, and long QT syndrome. 1

• Avoid stimulants entirely in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmias, coronary artery disease, or other serious cardiac disease. 2
• Measure baseline blood pressure and pulse before starting treatment. 1

Psychiatric Screening

Screen patients for risk factors for developing manic episodes prior to initiating stimulants, including personal or family history of bipolar disorder, as stimulants can precipitate manic or hypomanic episodes. 3

• Assess for active psychosis or mania, which are contraindications to stimulant use. 3
• Evaluate for comorbid substance use disorders, as this requires modified treatment approaches. 1, 3

Abuse Risk Assessment

Before prescribing, assess each patient's risk for abuse, misuse, and addiction, particularly noting factors such as comorbid antisocial personality disorder, treatment initiation during adolescence/young adulthood, and personal or family history of substance use disorders. 2, 4

Medication Selection Algorithm

First-Line Stimulant Choice

Both methylphenidate and amphetamine-based stimulants are equally appropriate first-line options, as approximately 40% of patients respond to both, 40% respond to only methylphenidate, and 40% respond to only amphetamines—making individual response idiosyncratic. 1

• For elementary school-aged children and adolescents, the evidence is particularly strong for stimulant medications with effect sizes of 1.0. 1
• The ADHD subtype does not predict response to a specific stimulant agent. 1

Formulation Selection

Prefer long-acting stimulant formulations over immediate-release preparations because they provide around-the-clock coverage, improve medication adherence, reduce rebound symptoms, and eliminate compliance problems with in-school dosing. 3, 5

• OROS-methylphenidate (Concerta) provides 12 hours of coverage. 5
• Lisdexamfetamine (Vyvanse) provides 13-14 hours of coverage with once-daily dosing. 5
• Extended-release mixed amphetamine salts (Adderall XR) provide approximately 8-9 hours of coverage. 5

Special Population Considerations

For preschool-aged children (ages 4-5 years), initiate behavioral therapy alone first before considering stimulant medication. 1 If medication becomes necessary, preschool-aged children may experience increased mood lability and dysphoria with stimulants. 1

For patients with substance use disorders or abuse concerns, consider long-acting stimulant formulations with lower abuse potential (such as OROS-methylphenidate or lisdexamfetamine) or non-stimulant alternatives like atomoxetine as first-line treatment. 3, 4

Dosing Protocols

Methylphenidate Dosing

For pediatric patients 6 years and older, start with 5 mg twice daily (before breakfast and lunch), increase by 5-10 mg weekly based on response, with a maximum daily dose of 60 mg. 2

For adults, administer methylphenidate in divided doses 2-3 times daily, preferably 30-45 minutes before meals, with an average dosage of 20-30 mg daily and maximum of 60 mg daily. 2

Amphetamine Dosing

For adults, start dextroamphetamine/mixed amphetamine salts at 5-10 mg in the morning, titrating upward by 5-10 mg weekly until symptoms are controlled, with typical maintenance doses of 20-40 mg daily and maximum doses of 40-60 mg daily. 3

Lisdexamfetamine dosing for adults ranges from 20-70 mg once daily in the morning. 3

Monitoring Requirements

Ongoing Monitoring Parameters

Monitor blood pressure and pulse at baseline and regularly during treatment. 1, 3

Track height and weight in pediatric patients at each visit, as stimulants can cause growth suppression of 1-2 cm, though effects diminish by the third year of treatment. 1

Assess for common adverse effects including appetite loss, abdominal pain, headaches, and sleep disturbance. 1

Psychiatric Monitoring

Throughout treatment, reassess each patient's risk and frequently monitor for signs and symptoms of abuse, misuse, and addiction. 2

If new psychotic or manic symptoms occur, consider discontinuing stimulant medication. 2

Monitor for emergence or worsening of tics or Tourette's syndrome, particularly in patients with family history or clinical evidence of these conditions. 2

Combination and Adjunctive Therapy

Behavioral Therapy Integration

Combine stimulant medication with behavioral therapy (preferably both) for optimal outcomes, as both have demonstrated efficacy in reducing ADHD-associated behaviors and improving function. 1

• The evidence quality for medications is Grade A; for behavioral therapy is Grade C. 1
• Family preference is essential in determining the treatment plan. 1

Managing Comorbid Conditions

If ADHD symptoms improve with stimulants but depressive or anxiety symptoms persist, add an SSRI to the stimulant regimen, as there are no significant drug-drug interactions between stimulants and SSRIs. 3

For patients with residual ADHD symptoms despite optimized stimulant therapy, extended-release guanfacine or extended-release clonidine are the only FDA-approved adjunctive medications with sufficient evidence for combination use. 1

Critical Safety Warnings

Absolute Contraindications

Never use stimulants concurrently with MAO inhibitors or within 14 days of MAOI discontinuation due to risk of severe hypertension and potential cerebrovascular accidents. 3

Do not prescribe stimulants to patients with known hypersensitivity to methylphenidate or amphetamines. 2

Serious Adverse Events to Monitor

Be aware that hallucinations and other psychotic symptoms can occur as uncommon but significant adverse effects. 1

Priapism can occur; instruct patients to seek immediate medical attention for abnormally sustained or frequent painful erections. 2

Monitor for peripheral vasculopathy including Raynaud's phenomenon, with careful observation for digital changes and consideration of rheumatology referral if signs develop. 2

Screen for acute angle closure glaucoma risk in patients with significant hyperopia, and prescribe cautiously to patients with open-angle glaucoma or abnormally increased intraocular pressure. 2

Non-Stimulant Alternatives

When stimulants are contraindicated, not tolerated, or ineffective after adequate trials of both methylphenidate and amphetamines, consider non-stimulant medications including atomoxetine (effect size ~0.7), extended-release guanfacine (effect size ~0.7), or extended-release clonidine (effect size ~0.7). 1

• None of the non-stimulants have FDA approval for preschool-aged children. 1
• The evidence base for non-stimulants is considerably smaller than for stimulants, though adequate for FDA approval. 1

Common Pitfalls to Avoid

Do not assume pharmacogenetic testing will improve outcomes, as current tools lack sufficient evidence for clinical utility, are not covered by insurance, and may cost thousands of dollars. 1

Do not underdose stimulants—systematic titration to optimal effect using weekly symptom ratings is more important than strict mg/kg calculations, with 70% of patients responding optimally when proper titration protocols are followed. 3

Do not switch medication classes prematurely—if inadequate response occurs after adequate treatment with one stimulant class, trial the other class before considering non-stimulants, as individual response patterns are idiosyncratic. 3

Do not use off-label medication combinations without evidence, as only extended-release guanfacine and extended-release clonidine have sufficient evidence for FDA approval as adjunctive therapy with stimulants. 1