Concerta 36mg Not Working: Next Steps
Increase the Concerta dose to 54mg once daily in the morning, as the current 36mg dose is likely subtherapeutic and proper dose titration achieves 70-80% response rates in adults with ADHD. 1
Why Dose Optimization Should Be Your First Step
The current 36mg dose represents a starting dose, not a therapeutic endpoint. Adults with ADHD typically require higher doses for optimal symptom control:
- Maximum daily dose of methylphenidate for adults is 60mg, with average effective doses ranging from 20-30mg of immediate-release methylphenidate three times daily (equivalent to 54-72mg of Concerta) 1
- Response rates reach 78% when methylphenidate is dosed at approximately 1 mg/kg total daily dose, compared to only 4% placebo response 1
- Concerta provides 10-12 hours of symptom control through its OROS delivery system, but only if dosed adequately 2, 3
Specific Titration Protocol
Increase to 54mg Concerta once daily in the morning immediately. 1 This represents the next standard titration step and remains within the FDA-approved maximum of 72mg daily for adults.
- Monitor response after 1 week at 54mg 1
- If symptoms persist, increase to 72mg once daily (maximum dose) 1
- Assess ADHD symptom control across multiple settings: work, home, and social environments 1
Critical Monitoring Parameters
Track these specific outcomes weekly during dose adjustment 1:
- Blood pressure and pulse at each visit (methylphenidate causes average increases of 1-4 mm Hg blood pressure and 1-2 beats per minute heart rate) 1
- Sleep quality and timing (avoid dosing after 2 PM if insomnia develops) 2
- Appetite and weight changes 1
- Functional improvement in work performance, task completion, and organization 1
If Adequate Dose Titration Fails
Only after reaching 72mg daily without adequate response should you consider these alternatives 1:
Switch Stimulant Classes
Trial an amphetamine-based stimulant (lisdexamfetamine 30-70mg daily or mixed amphetamine salts 10-40mg daily), as approximately 40% of patients respond to only one stimulant class 1, 4
Add Afternoon Coverage
Add immediate-release methylphenidate 5-10mg in late afternoon (around 3-4 PM) if symptoms return before bedtime despite optimized morning Concerta dose 1, 2
Consider Non-Stimulants (Second-Line)
Only if both methylphenidate and amphetamines fail or cause intolerable side effects 1:
- Atomoxetine 60-100mg daily (requires 6-12 weeks for full effect; effect size 0.7 vs 1.0 for stimulants) 1, 4
- Extended-release guanfacine 1-4mg daily (effect size 0.7; particularly useful if sleep disturbances or anxiety present) 1
Common Pitfalls to Avoid
- Don't assume 36mg is adequate without systematic titration to higher doses—this is the most common error leading to perceived "treatment failure" 1
- Don't switch medications prematurely before optimizing the current stimulant dose to maximum recommended levels 1
- Don't use immediate-release methylphenidate "as needed"—ADHD requires consistent daily treatment for optimal functional outcomes 1
- Don't ignore timing of symptom assessment—evaluate whether symptoms occur throughout the day or only in late afternoon/evening, as this determines whether dose increase versus additional afternoon dose is needed 2
Why This Approach Is Evidence-Based
The OROS delivery system in Concerta provides ascending plasma levels over 12 hours, making it superior to older sustained-release formulations that only provide 4-6 hours of coverage 2, 3. However, this advantage only materializes at therapeutic doses. The evidence shows that proper dose titration, not medication switching, resolves most cases of apparent "treatment failure" in adults with ADHD 1, 5.