What is the equivalent long‑acting methylphenidate dose for a patient stable on immediate‑release methylphenidate 5 mg twice daily?

Equivalent Long-Acting Methylphenidate Dose for 5 mg BID

For a patient stable on immediate-release methylphenidate 5 mg twice daily (total 10 mg/day), start with long-acting methylphenidate 18 mg once daily in the morning. 1

Rationale for Dose Conversion

• The American Academy of Child and Adolescent Psychiatry recommends that when converting from immediate-release to extended-release formulations, the total daily dose should be matched or slightly increased to account for the different pharmacokinetic profiles 2, 1
• Your current total daily dose is 10 mg (5 mg × 2 doses), so the closest long-acting equivalent is 18 mg once daily 1
• This represents a conservative starting point that can be titrated upward by 18 mg increments weekly if symptom control is inadequate 1

Formulation Selection

OROS-methylphenidate (Concerta) 18 mg once daily is the preferred long-acting option because:

• It provides 12 hours of continuous coverage compared to 8 hours with bimodal delivery capsules (Ritalin LA, Metadate CD) 2, 3
• The osmotic pump delivery system creates steady plasma concentrations throughout the day, minimizing rebound effects 2
• Once-daily dosing eliminates compliance issues with in-school dosing 2

Alternative: Ritalin LA or Metadate CD 10 mg once daily if 8-hour coverage is sufficient:

• These bimodal capsules release 50% immediately and 50% after 4 hours, providing approximately 8 hours of action 2
• They can be opened and sprinkled on food if swallowing is difficult 2, 4
• The 10 mg dose more closely matches your current total daily exposure 2

Titration Strategy After Conversion

Week 1: Start with the chosen long-acting formulation at the equivalent dose 1

Weekly assessment: Collect standardized rating scales (parent/teacher reports) before each potential dose increase 1

If inadequate response: Increase by one dose increment (18 mg for Concerta, 10 mg for Ritalin LA/Metadate CD) weekly until optimal symptom control is achieved, not exceeding 60 mg/day total 1

If partial morning coverage: The bimodal capsules (Ritalin LA/Metadate CD) provide stronger early morning effects at equivalent total daily doses compared to OROS-methylphenidate 5

Administration and Monitoring

• Administer in the morning before mid-morning to minimize insomnia risk 2, 1
• Take with or without food; taking with meals may reduce gastrointestinal discomfort 2
• Monitor during the first week for agitation, insomnia, decreased appetite, headache, tachycardia, and palpitations 1
• Check blood pressure, pulse, height, and weight at baseline and regularly during titration 1

Common Pitfalls to Avoid

• Do not assume bioequivalence across formulations: While total daily doses may be similar, the pharmacokinetic profiles differ significantly, affecting symptom control timing 3, 6
• Do not use older sustained-release formulations: These provide only 4-6 hours of action and have delayed onset with lower peaks, making them clinically inferior 2
• Do not schedule doses after 2:00 PM if insomnia becomes problematic 2
• Do not titrate too rapidly: Weekly increases allow adequate assessment of response and side effects 1