What is the appropriate starting dose of Adderall (amphetamine/dextroamphetamine) for an adult (18–65 years) without cardiovascular disease, hypertension, hyperthyroidism, glaucoma, monoamine‑oxidase inhibitor use, or substance‑abuse history, and how should it be titrated?

Starting Dose of Adderall for Adult Patients

Start with 5 mg of immediate-release mixed amphetamine salts (Adderall) once or twice daily in the morning, then titrate upward by 5 mg increments at weekly intervals until optimal symptom control is achieved, typically reaching a maintenance dose of 20 mg twice daily (40 mg total daily dose). 1, 2, 3

Initial Dosing Protocol

For adults with ADHD, begin with 5 mg of amphetamine/dextroamphetamine (Adderall) administered in the early morning. 1, 3 The FDA-approved labeling for amphetamine products specifies that adults should start at 5 mg once or twice daily, with the first dose given upon awakening. 3

• If using immediate-release formulation, administer the first dose upon awakening, with a second dose 4-6 hours later if twice-daily dosing is chosen. 3
• Avoid late evening doses to prevent insomnia. 3

Titration Schedule

Increase the dose by 5 mg increments at weekly intervals based on symptom response and tolerability. 1, 2, 3 The American Academy of Child and Adolescent Psychiatry recommends a structured titration protocol:

• Week 1: 5 mg (2.5 mg for dextroamphetamine alone) 1
• Week 2: 10 mg (5 mg for dextroamphetamine alone) 1
• Week 3: 15 mg (7.5 mg for dextroamphetamine alone) 1
• Week 4: 20 mg (10 mg for dextroamphetamine alone) 1

Continue titration beyond week 4 if symptoms are not adequately controlled and side effects are tolerable. 1, 2

Target Maintenance Dose

The typical maintenance dose for adults is 20 mg twice daily (40 mg total daily dose), though the range extends from 10-50 mg daily depending on individual response. 2 The American Academy of Child and Adolescent Psychiatry practice parameters identify 20 mg BID as the standard maximum in the initial titration phase, with this dose representing the most common maintenance regimen. 2

• Maximum daily doses generally reach 40 mg for amphetamine salts in standard practice. 2
• Some patients may require up to 0.9 mg/kg or 65 mg total daily dose with clear documentation that lower doses were insufficient. 2
• Only in rare cases will it be necessary to exceed 40 mg per day. 3

Monitoring During Titration

Obtain standardized ADHD rating scales from the patient (and significant other if available) before each dose increase to objectively guide titration decisions. 1, 2 The American Academy of Child and Adolescent Psychiatry recommends:

• Weekly contact during titration phase (can be by phone). 1
• Assessment of blood pressure and pulse at each visit. 1, 2
• Evaluation of side effects including appetite suppression, sleep disturbances, and cardiovascular parameters. 1, 2
• Height and weight monitoring at baseline and follow-up visits. 1

Amphetamines increase systolic blood pressure by approximately 1.93 mmHg and diastolic blood pressure by 1.84 mmHg, with heart rate increasing by 3.71 beats per minute. 4 These cardiovascular effects are sustained with long-term use and require ongoing monitoring. 4

Dosing Strategy: Standard vs. Forced Titration

You have two evidence-based approaches:

Standard Stepwise Titration (Recommended)

Increase the dose weekly until symptoms resolve or side effects become problematic, using clinical judgment and rating scales to guide decisions. 1 This reflects typical practice in the United States and allows for individualized optimization. 1

Forced Titration Alternative

Give the patient all four dosage levels (5,10,15,20 mg) with each dose condition lasting 1 week, collecting rating scales at each level, then select the optimal dose based on the data. 1 This systematic approach ensures you don't miss the optimal dose but may expose patients to subtherapeutic or excessive doses during the trial period. 1

Critical Timing Considerations

Administer immediate-release Adderall twice daily (morning and midday) to provide coverage through the school/work day and afternoon homework/activities period. 1 The American Academy of Child and Adolescent Psychiatry explicitly recommends adding a third dose after school/work to help with homework and social activities if needed. 2

• Adjust the timing and strength of the end-of-day dose to minimize side effects such as reduced appetite at dinner and delayed sleep onset. 1
• Consider switching to extended-release formulations for maintenance treatment to improve adherence and provide more consistent coverage. 2

When to Stop Titrating

Stop increasing the dose when ADHD symptoms are adequately controlled across multiple settings (work, home, social) without prohibitive side effects. 1, 2 There is no universally agreed-upon criterion for how much symptoms must change, but clinicians should base decisions on standardized rating scale scores rather than subjective impressions alone. 1

• Stimulants achieve 70-80% response rates when properly titrated. 2
• Different target symptoms may require different doses, so prioritize which symptoms are most impairing. 1
• If the top recommended dose (40 mg daily) does not help, more is not necessarily better—consider switching medications or adding psychosocial interventions. 2

Common Pitfalls to Avoid

Do not assume 5 mg is adequate without systematic titration. 2 The starting dose of 5 mg is at the very low end of the therapeutic range, and 54-70% of adults with ADHD respond optimally only when proper titration protocols are followed. 2

Do not use objective tools like continuous performance tests (CPTs) as the primary outcome measure for dose adjustment. 1 CPTs have 20% false-positive and false-negative rates for identifying ADHD, and their utility for adjusting medication dosages has never been validated against functional outcomes. 1

Do not titrate too rapidly in an attempt to achieve faster results. 5 Research on antidepressant titration demonstrates that slower titration with lower starting doses significantly reduces discontinuation due to adverse events (3.6% vs. 15.0% in duloxetine studies). 5 While this evidence comes from antidepressant trials, the principle applies to stimulant tolerability—gradual dose escalation allows the body to adapt to adverse effects. 6, 7

Monitor for withdrawal risk. 4 Participants taking amphetamines are 2.69 times more likely to withdraw from treatment due to adverse effects compared to placebo, with an absolute risk increase of 4.3%. 4