Drug Duration of Action Starting Dose Max Daily Dose

Immediate Release Ritalin/methylphenidate 3-5h Kids- <8y/o-5mg BID 60mg

– (Methylphenidate) >8y/o- 10mg BID Off label: 100mg if over 50kg
Adults – 5-10mg BID

Methylin (oral solution) 3-5h Same as Ritalin Same as Ritalin

Extended Release – Concerta/methylphenidate 12h 6y/o and older – Kids – 54mg Adults – 72mg
(Methylphenidate) 18mg Off label: kids up to 40kg – 72mg; adolescents over
40kg – 90mg; Adults over 90kg – 108mg

Ritalin LA and SR LA – 6-9h LA - 6y/o and older – Same as Ritalin

**Ins does not like to pay for SR – 2-8h 10-20mg
these** SR - 6y/o and older –
20mg

Immediate Release Adderall/dextroamphetmaine 5-8h, (duration 3-5y/o – 2.5mg QD 40mg

– (Amphetamines) / increases with higher 6y/o and older – 5mg Off label: over 50kg – 60mg
amphetamine doses) QD-BID
Adult – 10mg BID

Extended Release – Adderall XR 10-12h 6-17y/o – 10mg 30mg

(Amphetamines) Adults – 20mg Off label: over 50kg – 60mg

Vyvanse/lisdexamfetamine 10-12h 6y/o and older – 70mg

30mg

Non - Stimulants Strattera/atomoxetine 10-12h or longer Pts up to 70kg – Children up to 70kg – 1.4mg/kg/day
0.5mg/kg/day Over 70kg – 100mg
Over 70kg – 40mg

Wellbutrin/bupropion (IR, 6-8h/12h/24h 75mg 400-450mg/day

SR, XL)*usually adults only*

Intuniv/guanfacine – long Intuniv – 8-12h Intuniv – 1mg Intuniv – 4mg

acting Tenex – 4-6h Tenex – 0.5-1mg (see Tenex – 1mg TID
Tenex/guanfacine – short notes below for
 acting titration)

Methylphenidate conversion of short acting to long acting: Amphetamine conversion of short acting to long acting:

Ritalin to Concerta: Adderall to Vyvanse:

5mg BID – TID = 18mg 10mg = 30mg
10mg BID – TID = 36mg 20mg = 50mg
15mg BID - TID = 54mg 30mg = 70mg
20mg BID – TID = 72mg

Methylphenidate to Amphetamines: start with ½ the dose and titrate up as needed due to mixed amphetamine salts have 75% amphetamine & 25% l-
amphetamine). Amphetamines to Methylphenidates: same dose
 Usually don’t start treatment before age 6y/o
 Always start with short acting stimulant to ensure the pt tolerates the med and then transition over to long acting. In adults, I
always switch to long acting to help decrease the abuse potential.
 If not sure if kids behavior is due to ADHD, then I start with tenex to see how they respond and then decide if a stimulant is
needed. Tenex can cause sedation, so the typical titration is ½ pill at bedtime for 3-4 days, then ½ pill in the morning and ½ pill in
the evening for 3-4 days. If no improvement, then increase to 1 pill BID. If sxs are better in the morning and evening, but worse
during the day, then I add mid-day dosing of ½ or 1 pill.
 If the long acting stimulant doesn’t last all day, then try a higher dose. If the higher dose causes side effects or is not more
beneficial, then give the long-acting stimulant in the morning and add a SHORT-acting stimulant in the afternoon.
 Guanfacine and clonidine have more data in children than adults. The extended-release products Kapvay (clonidine) and Intuniv
(guanfacine) are FDA-approved for ADHD as monotherapy or add-ons. These are not first-line treatments in adults. It’s common
to use stimulants with tenex for treatment of ADHD because each med works on different symptoms. The stimulant will help with
hyperactivity/focus/concentration and the tenex will help with impulsivity.
 Treatment of ADHD in kids can lead to better school performance which can decrease the likelihood of dropping out of school and
potentially the use of illicit drugs.
 Avoid any and all stimulants in pt’s with mood disorders and psychosis due to risk of causing manic episode or psychotic break.
 If side effects occur: Anxiety or tics are common with ADHD and stimulants may improve or worsen both. If anxiety or tics
worsen on a stimulant, try lowering the dose or switch to Strattera or guanfacine. If anxiety persists, suggest behavior therapy or
 add a SSRI (prozac works well with obsessive behaviors). Also consider suggesting a drug holiday, such as no stimulant on
weekends or long breaks from school. This may help lessen insomnia and appetite problems.
 Recent evidence suggests stimulants do not cause serious cardiovascular events, but they can increase blood pressure and heart rate
which can increase risk of cardiovascular events. So, the data is contradictory. Some experts feel the use of stimulants and Strattera
are acceptable options for pts with HTN as long as their blood pressure is controlled. Most don’t need an ECG unless there have
congenital heart defects, arrhythmias, seizures, or syncope, but you still should monitor BP and pulse.
 I refuse to give stimulants WITH benzos WITH sleep aids. Having that many addicting meds are not beneficial for the pt. If they
are experiencing anxiety or difficulty with sleep, then the stimulant needs to be decreased or stopped to ensure the symptoms are
not related to side effects of the stimulant.
 When a pt is demanding and pushing for a stimulant, I remind them that you can not die from untreated ADHD. If I refused the pt
meds for HTN or DM then there can be negative sequelae, but ADHD does not have to be treated with meds. I will usually discuss
behavioral modifications that can be just as helpful as meds especially in adults. The info below was copied from Up To Date.
 Behavior modifications for kids that can be used by parents or teachers to shape the behavior of children with ADHD include:
Maintaining a daily schedule; Keeping distractions to a minimum; Providing specific and logical places for the child to keep his
schoolwork, toys, and clothes; Setting small reachable goals; Rewarding positive behavior; Identifying unintentional reinforcement
of negative behaviors; Using charts and checklists to help the child stay "on task"; Limiting choices; Finding activities in which the
child can be successful (eg, hobbies, sports); Using calm discipline (eg, time out, distraction, removing the child from the
situation); Resources for parents and also has Vanderbilt survey for diagnosis can be found at http://www.nichq.org/childrens-
health/adhd/resources
 Behavioral modification in adults: CBT (cognitive behavioral therapy) targeting executive function has been shown to be
efficacious. CBT programs address deficit areas in executive function commonly seen in adult ADHD, including: Difficulty
keeping track of tasks and activities, Procrastination, Difficulty prioritizing, Disorganization, Poor short and long-term planning,
Therapeutic strategies used in these CBT programs to address these deficits include: Training in specific skills; Systematic use of
tools such as a planner, timer, and task list; Breaking down difficult tasks into manageable parts; Prioritizing tasks; Developing an
enhanced awareness of time — eg, how long things take; how much time remains before a deadline — can be facilitated through
activities such as self-timing exercises and daily time-logging; Setting up and maintaining organizational systems.

 Stimulants can help with hyperactivity, inattentiveness, impulsivity, and concentration.

 Stimulants do not help with forgetfulness, disorganization, or distractibility.

o Continues to work hard and participate in treatment including in individual therapy where "I even cried". Requesting increase of
Ativan but accepted continued limits regarding. Chart reviewed in response to patient's continued concern about focus and inattention
potentially put employment at jeopardy. Diagnosed as a child with ADHD and was treated for teen years and early 20s with Adderall. After
much discussion and consultation with therapist. Will resume that medication with caution (see below).

Readily endorses symptoms of ADHD now and, retrospectively, in childhood that included experiences related to inattention such as often
failing to give close attention to details and would make careless mistakes, difficulty sustaining attention in accomplishing tasks, times of not
listening to what others have said, not following through on instructions or plans to complete routine responsibilities or chores, has difficulty
organizing tasks, avoids, dislikes or reluctant to engage in tasks that require sustained concentration or loses tools or materials to complete such
tasks, easily distracted by extraneous issues or conversations, forgetful. Also present is hyperactivity and impulsivity in that the patient reports
being or demonstrates fidgeting, unable to sit still, running about when anxious, difficulty engaging in leisure activities, always on the go, and
talks excessively

Patient advised and appeared to understand the need to protect all medications but especially stimulants and pending written prescriptions for
stimulants from inadvertent destruction or loss or inappropriate use. The patient advised and appeared to understand that refills of these
medications would not be processed earlier than scheduled.