Practical considerations in stimulant drug selection for the attention-deficit/hyperactivity disorder patient - Efficacy, potency and titration

Stimulant agents, most notably methylphenidate and dextroamphetamine, have proven highly effective and safe in controlling the inattention, hyperactivity and impulsiveness associated with attention deficit/hyperactivity disorder (ADHD) in affected children between 6 and 12 years of age. As the many varying formulations of stimulant medications appear to be generally equivalent in terms of both efficacy and tolerability, the principal feature that differentiates these agents is their duration of action. Of the four rapid-acting, long-duration stimulant compounds currently available, Concerta® (methylphenidate) and Adderall® XR (D,L-amphetamine) have been demonstrated to have a duration of effect of 10-12 hours. Therefore, the therapeutic activity of a morning dose of these formulations would be expected to be maintained throughout the school or work day, and into the early evening hours. Clinical opinion suggests that, assuming the stimulant is well tolerated, the starting dose of methylphenidate or D,L-amphetamine should be progressively increased at intervals ≥1 week until a therapeutic response is achieved. A favorable effect on ADHD symptoms should be attained within a dosage range of 1-2 mg/kg/day of methylphenidate, or 0.5-1 mg/kg/day of D,L-amphetamine. The use of stimulant therapy in treating ADHD in other patient populations-preschool children, adolescents and adults-requires particular care to ensure that the appropriate diagnosis is made in younger children, and that the risk of under-dosing is avoided in older children or adults.