Attention-Deficit/Hyperactivity Disorder (ADHD) Clinical Pathway, Primary Care – Medications to Treat ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) Clinical Pathway — Primary Care

Medications to Treat ADHD

General Guidance for Medication Management

  • Stimulants are the first-line pharmacologic option for treatment of ADHD
    • If treatment failure occurs, trial a stimulant from a different class before considering non-stimulant options
    • Stimulants are highly effective: ~70% of school-age children and adolescents respond to the first trial and 90% respond after a second trial
  • After initial dosing, titrate up by next highest available dose up to maximum tolerated dose with a meaningful reduction of symptoms
  • Review PA Patient Drug Monitoring Program   requirements and diversion and abuse risk, especially with adolescents
  • In comorbid mood/anxiety disorders, consider “stepped care”: start treatment for the most impairing disorder first, followed by gradually expanding treatment to other comorbidities
Age First-Line Medication Class Second-Line Medication Class
< 6 yrs
  • Short-Acting
    • Methylphenidate
  • Short-Acting
    • Amphetamine-based
    • Dexmethylphenidate
≥ 6 yrs
  • Long-Acting
    • Methylphenidate
    • Dexmethylphenidate
  • Long-Acting
    • Alternative class
    • Amphetamine-based

Stimulant Options

Medication Class Brand Frequency Duration (hrs) Considerations
Short-Acting Methylphenidate Methylin 1-2 times daily 3-5 Solution or chewable tablet, may crush, grape flavored
Ritalin 1-2 times daily 3-5 Tablet, may crush
Long-Acting Methylphenidate Aptensio XR Daily 10-12 Capsule, may sprinkle beads onto spoonful of semi-solid food
for administration
Concerta Daily 10-12 Caplet, must swallow whole, ghost shell may be seen in stool
Not all generics are bioequivalent
Cotempla
XR-ODT
Brand only		 Daily 10-12 ODT, grape flavored, store in original blister pack
Doses > 25.9 mg require 2 tablets
Daytrana
Brand only		 Daily 11-12
If worn 9 hrs		 Patch, alternate application sites between hips
Medication absorption may continue for few hours after patch removal
Jornay PM
Brand only		 Nightly 10-12
After onset		 Capsule, may sprinkle beads onto spoonful of semi-solid food
for administration
Metadate CD Daily 10-12  
Quillivant XR
Brand only		 Daily 10-12 Suspension, banana flavored
Shake vigorously ≥ 10 secs before each dose
Requires pharmacy reconstitution
Quilichew ER
Brand only		 Daily 10-12 Chewable tablet, cherry flavored, contains aspartame
May crush tablet
Ritalin LA Daily 8-10 Capsule, may sprinkle beads onto spoonful of semi-solid food
for administration
Short-Acting Dexmethylphenidate Focalin 1-2 times daily 3-5 Tablet, may crush
Long-Acting Dexmethylphenidate Focalin XR Daily 9-12 Capsule, may sprinkle beads onto spoonful of semi-solid food
for administration
Long-Acting Serdexmethylphenidate/
Dexmethylphenidate		 Azstarys
Brand only		 Daily 10-12 Capsule, may sprinkle powder onto spoonful of food or water,
must consume within 10 mins
Short-Acting Mixed Amphetamine Salts Adderall 1-2 times daily 4-6 Tablet, may crush
Long-Acting Mixed Amphetamine Salts Adderall XR Daily 10-12 Capsule, may sprinkle beads onto spoonful of semi-solid food
for administration
Mydayis
Brand only		 Daily 12-16 Capsule, may sprinkle beads onto spoonful of semi-solid food
for administration
Administer consistently with or without food
Short-Acting Amphetamine Evekeo 1-2 times daily 4-6 Tablet
Long-Acting Amphetamine Adzenys XR
Brand only		 Daily 10-12 ODT, orange-flavored, do not chew or crush tablet
Store in original blister pack
Dynavel XR
Brand only		 Daily 10-12 Suspension, chewable tablet, bubblegum flavored
May crush tablet
Short-Acting Dextroamphetamine ProCentra 1-2 times daily 3-5 Solution, bubble gum flavored
Zenzedi 1-2 times daily 3-5 Tablet, may crush
Long-Acting Dextroamphetamine Dexedrine Spansule Daily 5-8
Highly variable		 Capsule, may sprinkle beads onto spoonful of semi-solid food
for administration
Xelstrym
Brand only		 Daily 11-12
If worn 9 hrs		 Patch, alternate application sites between hips, arm, chest, upper back, or flank
Medication absorption may continue for a few hours after patch removal
Long-Acting Lisdexamfetamine Vyvanse Daily 10-12 Capsule, may open and mix powder with semi-solid food, orange juice or water
Chewable tablet, strawberry flavored
Chew thoroughly

Strategies for Management of Common Stimulant Medication-Related Side Effects

Some side effects are more prominent at initiation and with dose changes.

Side Effect Management
Reduced Appetite
or Weight Loss
  • Optimize meals prior to giving stimulant and after medication has worn off
  • Add calorie-boosted snacks
  • Consider
    • Short-acting medications
    • Holding dose on weekends
    • Cyproheptadine
Decreased Growth Rate
  • Lower dose
  • Medication holiday
Upset Stomach
  • Administer stimulant with food
    • High-fat meals may delay absorption and time to therapeutic effect
  • Consider lower dose
Stimulant-Induced Rebound Symptoms
Behavioral deterioration that may occur as stimulant medications wear off
  • Consider longer-acting stimulant or non-stimulant options
  • Add "booster" immediate release dose in early afternoon
Headache
  • Lower dose or administer across divided doses
  • Short bridge with acetaminophen or ibuprofen at dose change
    • Caution: long-term use of analgesics may result in rebound headaches
  • Administer with food
Insomnia
  • Encourage good sleep hygiene
    • Limit naps
    • Limit use of screens and electronic devices near bedtime
  • Administer medication earlier in day if possible
  • Discontinue afternoon dose, or lower last dose of the day, if applicable
  • Change to shorter-acting formulation
    • Long-acting to intermediate-acting or intermediate-acting to short-acting
  • Consider melatonin or alpha agonist (clonidine, guanfacine) at bedtime
Irritability
Mood Lability
Dysphoria
  • Determine whether irritability is prevalent while medication is active or after it has worn off
  • If irritability most prominent within window of duration of action:
    • Consider different medication or formulation, or dose reduction
  • If irritability most prominent when medication wearing off:
    • Consider
      • Longer-acting formulation
      • Different medication
      • Addition of alpha agonist (clonidine, guanfacine)

Resources

References