Best Alternative to Jornay PM for Evening-Dosed ADHD Treatment
For children and adolescents who cannot take an evening dose, switch to Concerta (OROS-MPH) as the best alternative, given once in the morning to provide 12-hour symptom control extending into the evening. 1
Why Concerta is the Optimal Choice
Concerta uses an osmotic pump delivery system that provides up to 12 hours of symptom control with once-daily morning dosing, matching the extended coverage that Jornay PM provides but without requiring evening administration. 1 This formulation has been shown to be equally effective as methylphenidate immediate-release tablets given 3 times daily in double-blind, placebo-controlled trials. 2, 1
Key Advantages Over Other Options
Extended duration matches Jornay PM's coverage window: Concerta provides symptom control from morning through evening (up to 12 hours), addressing the same functional impairments in late afternoon and evening that Jornay PM targets. 1, 3
Morning dosing eliminates adherence concerns: Unlike Jornay PM's evening dose, morning administration fits naturally into daily routines and eliminates the risk of forgetting an evening dose. 2
Proven efficacy for after-school activities: The ascending plasma drug level pattern generated by Concerta's osmotic delivery system provides consistent coverage during unstructured times, homework, and evening activities. 2, 1
Alternative Stimulant Options (If Concerta Fails)
If Concerta does not provide adequate symptom control after proper titration, consider lisdexamfetamine (Vyvanse) as the next option, which provides extended duration through its prodrug mechanism requiring enzymatic conversion to active dextroamphetamine. 2, 1
When to Consider Lisdexamfetamine
If no desired benefit is observed after adequate treatment with methylphenidate formulations, lisdexamfetamine should be preferred as the next option over non-stimulants. 2
Provides 10-12 hours of coverage with once-daily morning dosing, though some patients may require an afternoon booster of immediate-release stimulant (5-10mg methylphenidate or 2.5-5mg mixed amphetamine salts) if evening coverage is insufficient. 4
Non-Stimulant Alternatives (Second-Line)
Atomoxetine (Strattera) should be considered only as a second-line option when stimulants are contraindicated or have failed, despite its "around-the-clock" effects. 2, 5
Critical Limitations of Atomoxetine
Smaller effect sizes compared to stimulants: Atomoxetine's effect sizes are in the medium range and consistently smaller than those of stimulants in head-to-head trials. 2
Delayed onset of therapeutic effect: Requires 6-12 weeks to reach full efficacy, unlike stimulants which work within 30 minutes. 2, 5
Morning dosing is standard: Administer as a single morning dose for 24-hour coverage, though the dose can be split morning and evening if adverse effects occur. 2, 5
When Atomoxetine May Be Preferred
Consider atomoxetine as first-line only in specific comorbid conditions: 2
- Substance use disorders (where stimulants may be contraindicated)
- Disruptive behavior disorders
- Tic disorder or Tourette's syndrome
- Comorbid sleep disturbances (though clonidine or guanfacine may be better options)
Practical Dosing Guidance
Starting Concerta
Begin with 18mg once daily in the morning, which is equivalent to methylphenidate 5mg three times daily. 2, 1
Titrate weekly by 18mg increments based on response and tolerability, up to a maximum of 54-72mg daily in children and adolescents. 6
Monitor blood pressure, pulse, height, and weight at each follow-up visit. 2, 6
Common Pitfalls to Avoid
Don't assume all long-acting methylphenidate formulations are equivalent: Pharmacokinetic profiles differ significantly between formulations, with Concerta's ascending pattern providing better evening coverage than older sustained-release preparations like Ritalin-SR. 2, 7
Don't switch to immediate-release multiple daily dosing: This defeats the purpose of avoiding evening doses and significantly reduces medication adherence. 2
Don't add an afternoon booster too early: First optimize the Concerta dose to maximum tolerated levels before considering additional doses. 4
Don't expect identical timing of effects: While Jornay PM is designed for effect upon awakening, Concerta begins working 30-60 minutes after morning administration, which may require adjustment of morning routines. 2
Monitoring and Adjustment Strategy
Reassess symptom control at 2-4 weeks after each dose adjustment, using standardized rating scales (ADHD-RS-IV) and functional impairment measures for early morning and evening periods. 8 If Concerta at optimal doses (54-72mg) fails to provide adequate evening coverage, consider either switching to lisdexamfetamine or adding a low-dose immediate-release methylphenidate booster (5-10mg) at 2-3 PM. 4