What is the generic name of Adderall, its typical dosing for children and adults, contraindications, common adverse effects, and alternative treatments?

What is Generic Adderall?

Generic Adderall is mixed amphetamine salts—a combination of dextroamphetamine sulfate, dextroamphetamine saccharate, amphetamine aspartate monohydrate, and amphetamine sulfate—used primarily to treat attention-deficit/hyperactivity disorder (ADHD) and narcolepsy. 1

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Composition and Mechanism

Generic Adderall contains four amphetamine salts that stimulate the release of norepinephrine, affecting both α- and β-adrenergic receptor sites. 2 α-Adrenergic stimulation causes vasoconstriction and increases total peripheral resistance, while β-adrenergic receptor stimulation increases heart rate, stroke volume, and skeletal muscle blood flow. 2 The medication enhances dopamine and norepinephrine in prefrontal cortex networks, directly improving executive function deficits characteristic of ADHD. 3

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Typical Dosing

Children (6–17 years)

• Start at 5 mg once or twice daily in the morning. 1
• Titrate by 5–10 mg weekly based on response and tolerability. 1
• Maximum dose is typically 40 mg daily, though some children may require higher doses with clear documentation that lower doses were insufficient. 1

Adults

• Initiate at 10 mg once daily in the morning (for extended-release formulations). 1
• Increase by 5 mg weekly until optimal symptom control is achieved. 1
• Typical therapeutic range is 10–50 mg daily, with maximum doses reaching 60 mg daily in some cases. 1, 4
• Average effective dose in clinical trials is approximately 54 mg daily (administered in two divided doses). 4

Extended-Release vs. Immediate-Release

• Extended-release (Adderall XR) provides 8–12 hours of coverage with once-daily dosing, improving adherence and reducing rebound effects. 1, 5
• Immediate-release formulations require multiple daily doses (typically 2–3 times daily) and have a shorter duration of action. 6

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Contraindications

Absolute Contraindications

• Concurrent use with MAO inhibitors or within 14 days of stopping an MAOI—risk of hypertensive crisis. 1
• Active psychotic disorder—stimulants can precipitate or worsen psychosis. 1
• Symptomatic cardiovascular disease or uncontrolled hypertension. 1, 3
• Hyperthyroidism—amphetamines can exacerbate symptoms. 1
• Glaucoma—risk of increased intraocular pressure. 1
• Known hypersensitivity to amphetamines. 1

Relative Contraindications (Use with Caution)

• History of substance use disorder—consider long-acting formulations with lower abuse potential. 1, 5
• Seizure disorder—ensure patient is stable on anticonvulsant therapy before initiating. 1
• Unstable mood disorder—stabilize mood first, though some patients with secondary depression improve once ADHD is treated. 1
• Marked anxiety—recent data suggest stimulants may not worsen anxiety and can improve comorbid anxiety symptoms in many cases. 1, 3

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Common Adverse Effects

Most Frequent Side Effects

• Decreased appetite and weight loss—occurs in >10% of patients. 1, 3
• Insomnia—can be managed by adjusting dose timing or reducing evening doses. 1, 3
• Headache—common but often transient. 1
• Cardiovascular effects—modest increases in blood pressure (1–4 mm Hg) and heart rate (1–2 beats per minute). 1, 3

Serious Adverse Effects

• Hyperthermia, tachycardia, tachypnea, mydriasis, tremors, and seizures in overdose situations. 2
• Psychotic symptoms (hallucinations, delusions)—rare but require immediate discontinuation. 1
• Sudden cardiac death—extremely rare, but baseline cardiovascular screening is recommended. 1, 3

Monitoring Requirements

• Baseline assessment: Blood pressure, pulse, height, weight, and comprehensive cardiac history (including family history of sudden cardiac death, arrhythmias, or structural heart disease). 1
• During titration: Weekly blood pressure and pulse checks, ADHD symptom ratings, and assessment of sleep quality and appetite. 1
• Maintenance phase: Quarterly vital signs in adults; more frequent monitoring in children with height and weight tracking at every visit. 1

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Alternative Treatments

First-Line Alternatives (Stimulants)

• Methylphenidate (Ritalin, Concerta)—equally effective first-line option with 70–80% response rates when properly titrated. 1, 3 Approximately 40% of patients respond to both methylphenidate and amphetamines, while another 40% respond to only one class. 1, 3
• Lisdexamfetamine (Vyvanse)—a prodrug of dextroamphetamine with once-daily dosing and reduced abuse potential due to its unique metabolic pathway. 1, 7

Second-Line Non-Stimulant Options

• Atomoxetine (Strattera)—the only FDA-approved non-stimulant for adult ADHD, with a target dose of 60–100 mg daily. 1, 3, 8 Requires 6–12 weeks to achieve full therapeutic effect and has a medium-range effect size of approximately 0.7 compared to stimulants (effect size 1.0). 1, 3, 8 Carries an FDA black-box warning for increased suicidal ideation in children and adolescents. 1
• Extended-release guanfacine (Intuniv) and extended-release clonidine (Kapvay)—alpha-2 adrenergic agonists with effect sizes around 0.7, particularly useful when comorbid sleep disturbances, tics, or anxiety are present. 1, 3 Require 2–4 weeks for full effect. 1
• Viloxazine extended-release (Qelbree)—a serotonin-norepinephrine modulating agent with favorable efficacy and tolerability in pediatric and adult ADHD trials. 1, 3
• Bupropion (Wellbutrin)—considered a second-line agent for ADHD with an effect size of approximately 0.7, particularly useful when comorbid depression is present. 1, 3

Non-Pharmacological Interventions

• Cognitive Behavioral Therapy (CBT)—the most extensively studied psychotherapy for adult ADHD, focusing on time management, organization, and adaptive behavioral skills. 3 Most effective when combined with medication rather than as monotherapy. 3
• Mindfulness-Based Interventions—show increasing evidence for managing ADHD in adults, helping with inattention symptoms, emotion regulation, executive function, and quality of life. 3
• Parent training in behavior management and behavioral classroom interventions—essential components for children and adolescents with ADHD. 1, 3

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Special Considerations

Abuse Potential and Diversion Risk

• Amphetamines are DEA Schedule II controlled substances with high potential for abuse. 2 Long-acting formulations (e.g., Adderall XR, lisdexamfetamine) are associated with lower abuse potential due to steady medication levels that reduce reinforcing "peaks." 5
• Lisdexamfetamine is a prodrug that requires enzymatic conversion to active dextroamphetamine, making it resistant to tampering and reducing diversion risk. 1, 7

Pregnancy and Lactation

• Current evidence does not link amphetamines to major congenital malformations, though a modest increase in preterm birth risk has been reported. 1 Continuing stimulant therapy during pregnancy may be advised when ADHD symptoms cause significant functional impairment, as untreated ADHD carries documented risks including spontaneous abortion and preterm birth. 1

Substance Use Disorders

• Exercise particular caution when prescribing amphetamines to patients with comorbid substance abuse disorders. 1, 3 Consider long-acting formulations or non-stimulant alternatives (atomoxetine, guanfacine, clonidine) in this population. 1, 5

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Clinical Pearls

• Do not rely solely on weight-adjusted (mg/kg) dosing—systematic titration to the lowest effective dose that yields clinical benefit is preferred. 1
• Stimulants work rapidly (within days), allowing quick assessment of ADHD symptom response, unlike non-stimulants which require weeks to months. 1, 3
• If one stimulant class fails, trial the other class before considering non-stimulants, as approximately 40% of patients respond preferentially to one class. 1, 3
• Avoid abrupt discontinuation—patients who stop stimulants after long-term use may experience significant symptom worsening and increased depressive symptoms. 1