Increase the Concerta Dose to 72 mg
In a healthy 24-year-old female on Concerta 54 mg with persistent poor concentration, you should increase the dose to 72 mg rather than switching medications. 1
Rationale for Dose Escalation
Over 70% of patients require dose optimization beyond starting doses to achieve maximum benefit, and the goal of titration is reducing core symptoms to or close to the levels of individuals without ADHD, which typically requires higher doses 1
54 mg is not the maximum dose—the proper titration protocol calls for increases in 9-18 mg increments weekly until maximum benefit is achieved, intolerable side effects emerge, or maximum dose is reached 1
Switching medications prematurely is a common pitfall—before considering a medication switch, ensure adequate titration to higher Concerta doses (up to 72 mg, which is the maximum for adults) has been attempted 1
Why Not Switch Yet?
Stimulants remain first-line therapy with the largest effect sizes for ADHD core symptoms, and switching stimulant classes should only occur after adequate trials at optimal doses 1
Dose response is highly variable and unpredictable between individuals—the fact that she has some response at 54 mg suggests methylphenidate is working, just not optimally dosed yet 1
The landmark MTA study demonstrated that systematic titration across multiple dose levels resulted in over 70% of children and adolescents responding optimally to methylphenidate, whereas patients receiving "community treatment as usual" (often under-dosed) showed significantly less beneficial results 1
Implementation Strategy
Increase to Concerta 72 mg once daily in the morning (can be taken with or without food, as Concerta's osmotic pump delivery is unaffected by meals) 1, 2
Assess response after 1 week at 72 mg—if inadequate response persists at maximum dose, then consider switching to an amphetamine-based stimulant 1
Monitor during the first week for common adverse effects including agitation, insomnia, reduced appetite, and headache 3
Evaluate symptom control throughout the day—morning, midday, and evening—since Concerta provides 10-12 hours of coverage 1, 4
Common Pitfalls to Avoid
Do not assume 54 mg is "high enough" simply because it's a commonly prescribed dose—adult therapeutic dosing averages 20-30 mg daily of immediate-release methylphenidate (roughly equivalent to Concerta 36-54 mg), but many adults require higher doses up to the maximum of 72 mg 1
Do not switch medications without completing proper titration first—this leads to cycling through multiple medications unnecessarily when the first medication would have worked at the correct dose 1
Do not calculate dose based on body weight (mg/kg)—this has not been shown to be helpful, and systematic titration based on clinical response is the only reliable method 1