Adderall (Mixed Amphetamine Salts) Clinical Guide
Dosing Guidelines
Start Adderall at 2.5 mg daily in children 3-5 years old, 5 mg once or twice daily in children ≥6 years, and 5 mg twice daily in adults, with weekly dose titration based on response. 1
Pediatric Dosing (ADHD)
- Ages 3-5 years: Start 2.5 mg daily; increase by 2.5 mg weekly until optimal response 1
- Ages ≥6 years: Start 5 mg once or twice daily; increase by 5 mg weekly until optimal response 1
- Maximum dose: 40 mg/day total (rarely necessary to exceed this) 2, 1
- Single dose limits: Children <25 kg should not receive single doses >10 mg 2
- Timing: Give first dose upon awakening; additional doses at 4-6 hour intervals 1
Adult Dosing (ADHD)
- Starting dose: 5 mg twice daily 2
- Titration: Increase by 5-10 mg per dose weekly 2
- Typical effective dose: Mean of 10.77 mg/day (0.14 mg/kg/day) in responders 3
- Maximum dose: 40 mg/day per FDA label, though expert consensus may occasionally exceed this 2, 1
Extended-Release Formulation (Adderall XR)
- Adults: Start 20 mg once daily; can titrate to 40-60 mg/day 4
- Adolescents (13-17 years): Start 10 mg daily; forced titration up to 40 mg/day showed efficacy 5
- Children (6-12 years): Start 10 mg daily; titrate by 10 mg weekly to maximum 30 mg/day 6
- Duration of effect: 12 hours documented in adults 4
Contraindications
Do not prescribe Adderall to patients with symptomatic cardiovascular disease, hyperthyroidism, glaucoma, active stimulant abuse, concurrent MAO inhibitor use, or active psychosis. 2
Absolute Contraindications
- Previous hypersensitivity to amphetamines 2
- Symptomatic cardiovascular disease 2
- Hyperthyroidism 2
- Glaucoma 2
- Hypertension (uncontrolled) 2
- Current or recent MAO inhibitor use (within 14 days) 2
- Active psychotic disorder 2
- History of illicit stimulant abuse (unless in controlled/supervised setting) 2
Relative Contraindications (Use with Caution)
- Controlled hypertension: Can be used safely with monitoring in adults whose hypertension is well-controlled on antihypertensives 7
- Anxiety disorders: May precipitate acute anxiety symptoms (occurred in 4/7 patients with comorbid anxiety in one study) 3
- Tics/Tourette's: FDA package insert lists as contraindication, but recent literature suggests these may not worsen with treatment 2
- Seizure disorders: Best to initiate after seizures are controlled with anticonvulsants 2
Pre-Treatment Assessment
Obtain baseline blood pressure, pulse, height, weight, and perform cardiac screening before initiating Adderall. 8, 2
Required Baseline Evaluation
- Cardiac history: Detailed personal and family history of sudden death, ventricular arrhythmia, or cardiac disease 8
- Physical examination: Including vital signs (blood pressure, pulse, height, weight) 2
- Tic assessment: Evaluate for motor/verbal tics or Tourette's syndrome 8, 1
- ECG: Consider if cardiac risk factors present 8
- Prior treatment documentation: Previous medications, doses, duration, response, side effects, and compliance 2
Common Side Effects
The most common adverse effects are decreased appetite (35.6%), insomnia (12%), headache (16.3%), and abdominal pain (10.7%). 5
Frequent Side Effects
- Appetite suppression/anorexia: 35.6% in adolescents 5; most common across all ages 6
- Insomnia: 12% in adolescents 5; more problematic with amphetamines than methylphenidate due to longer half-life 2
- Headache: 16.3% 5
- Abdominal pain: 10.7% 5
- Weight loss: 9.4% 5
- Anxiety: Can precipitate acute anxiety, especially in those with comorbid anxiety disorders 3
Cardiovascular Effects
- Blood pressure/pulse: Modest changes, not clinically meaningful in most patients 6
- In controlled hypertension: No sustained elevation or group mean increase in BP observed in adults with treated hypertension 7
Growth Effects
- Growth delays: Can occur in first 1-2 years of treatment, with return to expected measurements after 2-3 years on average 8
Monitoring Recommendations
Check blood pressure and pulse quarterly in adults, annually in children during routine physical exams, and monitor weight at each visit during titration. 2
During Initial Titration
- Visit frequency: Weekly during dose adjustments 2
- Symptom assessment: Evaluate target ADHD symptoms from parent and teacher regularly 2
- Side effect monitoring: Systematically ask about insomnia, anorexia, headaches, social withdrawal, tics, and weight loss 2
- Weight measurement: At each visit to objectively assess appetite effects 2
Long-Term Maintenance
- Adults: Blood pressure and pulse checked quarterly by treating or primary care physician 2
- Children: Vital signs checked annually during routine physical examination 2
- Rating scales: Use parent and teacher rating scales to supplement clinical assessment 2
- Adolescents/Adults: Obtain self-ratings 2
Cardiovascular Monitoring
- No routine ECG changes: No clinically significant ECG changes observed in studies 4, 7
- Vital signs: Monitor at all study visits and 30 days after discontinuation 5
Special Populations
Preschool Children (Ages 3-5)
- FDA approval: Amphetamines approved for age 3+, though approval criteria were less stringent historically 8
- Preferred agent: Methylphenidate recommended over amphetamines as first-line due to stronger evidence in this age group 8
- Severity threshold: Only use in moderate-to-severe ADHD with dysfunction in multiple settings after inadequate response to behavioral therapy 8
Females
- Menstrual cycle effects: ADHD symptoms may worsen during menstruation phase and improve during mid-follicular phase in females treated with amphetamine salts 9
- Clinical implication: Consider cycle-related symptom fluctuations when assessing treatment response 9
Clinical Pearls
- Onset of effect: Symptom improvement occurs within the first treatment week 5
- Response rate: 54% positive response rate in adults at low doses 3
- Effect size: Mean effect size of 0.8 in adults 4
- Dose-response: Patients with severe symptoms (ADHD Rating Scale >32) may benefit from higher doses (60 mg/day) 4
- Most adverse events: 97.5% are mild or moderate in intensity 5
- Late dosing: Avoid late evening doses due to insomnia 1