What is the next step in managing a 32-year-old female patient with Attention Deficit Hyperactivity Disorder (ADHD) who is currently taking Adderall (amphetamine and dextroamphetamine) ER 10mg in the morning and an additional 5mg of Adderall (amphetamine and dextroamphetamine) IR in the afternoon?

Next Step: Optimize Current Stimulant Dose Before Considering Alternatives

For this 32-year-old female on Adderall ER 10mg morning and IR 5mg afternoon (total 15mg/day), the next step is to increase the total daily amphetamine dose, as she remains well below the maximum recommended range of 40mg/day for adults with ADHD. 1

Rationale for Dose Optimization

• The American Academy of Child and Adolescent Psychiatry emphasizes that if the top recommended dose does not help, more is not necessarily better—but this patient has not yet reached the top recommended dose 1
• Current total daily dose of 15mg is at the very low end of the therapeutic range for adults, where typical maintenance doses reach 20mg BID (40mg total daily) 1
• Stimulants achieve 70-80% response rates when properly titrated, and systematic titration to optimal effect is more important than strict mg/kg calculations 1, 2
• Maximum daily doses for adults generally reach 40mg for amphetamine salts, though some patients may require up to 0.9mg/kg or 65mg total daily dose with clear documentation that lower doses were insufficient 1

Specific Titration Protocol

Increase the Adderall IR component by 5mg increments weekly until reaching 40mg total daily amphetamine or achieving symptom control: 1

• Week 1: Increase afternoon IR dose from 5mg to 10mg (total daily: 20mg)
• Week 2: If inadequate response, increase morning ER to 15mg, keep afternoon IR at 10mg (total daily: 25mg)
• Week 3: If inadequate response, increase morning ER to 20mg, keep afternoon IR at 10mg (total daily: 30mg)
• Week 4: If inadequate response, consider adding a third afternoon dose of 5mg or increasing the existing afternoon dose to 15mg 1

The FDA label supports doses up to 40mg/day for adults with ADHD, with titration in 5-10mg increments at weekly intervals 3

Monitoring Requirements During Titration

At each weekly contact, systematically assess: 1

• Target symptoms: Use standardized ADHD rating scales to objectively measure improvement in executive function and task initiation 1
• Vital signs: Blood pressure and pulse at each in-person visit 1
• Side effects: Systematically query decreased appetite, insomnia, headaches, irritability, and social withdrawal 1
• Weight: Track at each visit 1

Alternative Strategies If Maximum Dose Fails

If 40mg/day amphetamine does not adequately control symptoms: 1

• First alternative: Switch to methylphenidate class (different mechanism of action, may be effective when amphetamines fail) 1
• Second alternative: Add atomoxetine (60-100mg/day) or guanfacine ER (1-4mg/day) as adjunctive therapy if stimulant optimization alone proves insufficient 1
• Atomoxetine provides "around-the-clock" norepinephrine reuptake inhibition that may complement stimulant effects 1
• Guanfacine enhances prefrontal cortex function through alpha-2A adrenergic agonism and may specifically improve working memory and impulse control 1

Critical Pitfalls to Avoid

• Do not prematurely switch medication classes—the patient has not yet reached the maximum recommended amphetamine dose 1
• Do not add non-stimulants before maximizing stimulant dose—guidelines emphasize that stimulants have the largest effect sizes for ADHD core symptoms 1
• Do not assume the current 15mg dose is adequate—54-70% of adults with ADHD respond to stimulants when properly titrated, and this patient is receiving a subtherapeutic dose 1, 4

Timeline for Reassessment

• Schedule follow-up at 4 weeks to comprehensively evaluate response using standardized measures 1
• If executive function and task initiation improve substantially, continue current regimen with monthly monitoring 1
• If partial response at maximum dose, consider adjunctive non-stimulant 1
• If no response at maximum dose, switch to methylphenidate class 1