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ADHD Medications: Adderall, Concerta, Daytrana, Dexedrine, Focalin, Metadate, Ritalin, Strattera and More

by Theodore Mandelkorn, M.D.
Mercer Island, WA—July, 2003

Terms of Use: This educational material is made available courtesy of the author and Attention Deficit Disorder Resources. You may reprint this article for personal use only.

PART ONE:TAKING MEDICINE

PART TWO: OVERVIEW OF MEDICATIONS

NON-STIMULANT MEDICATIONS

STIMULANT MEDICATIONS: OVERVIEW, SAFETY PROFILE, SIDE EFFECTS

INTRODUCTION

Human beings are rarely created in perfect form, so the great majority of us arrive in this world with unique differences. Some differences are blessings; others are handicaps. Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world. I consider poor vision a condition of "human–ness." People can also have other conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.—all well recognized differences that can impair the pursuit of a normal life if not dealt with in some manner.

ADHD is characterized by a prolonged history of inattention, impulsiveness, and variable amounts of hyperactivity. It is important to emphasize that all of these symptoms are normal human characteristics. All of us are forgetful and inattentive at times. We all at times become nervous and fidgety, and we certainly are impulsive to some degree. It's part of our "human–ness." ADHD, then, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but from the DEGREE to which we manifest these symptoms. ADHD people have an overabundance of these normal human characteristics.

WHO SHOULD TAKE MEDICATION, AND WHY?

Returning to the vision analogy, there are a number of options open to an individual who has bad eyesight. One option is to attempt to correct the problem. This could involve wearing glasses to correct the visual deficiency. Perhaps glasses can totally correct the problem, or perhaps they can only partially help. After the glasses are in place, we are in a position to assess
what further problems are interfering with success. Then we can address these issues as well.

ADHD is a medical condition. Dr. Alan Zametkin has clearly demonstrated that there is something uniquely different about the metabolism of the brain affected by ADHD. If a person meets the criteria for a diagnosis of ADHD and is not succeeding academically or socially up to expectations, medication should be a PRIMARY OPTION of therapeutic intervention. The opportunity to eliminate the symptomss of a medical condition partially or completely should be available to all. Many children benefit enormously from the use of medication. Many families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan. As many as 80% of individuals will show a positive response to one of the medical treatments.

Since it is impossible to determine who will respond favorably to medication, I always offer a trial of medication to each diagnosed patient. If medication will help alleviate the symptoms and does not elicit any unfavorable effects, then
the patient may choose to utilize medication as one part of therapy for ADHD.

WHAT IMPROVEMENT SHOULD BE SEEN?

In the early 1930's, Dr. Charles Bradley noted some dramatic effects of stimulant medications on patients with behavior and learning disorders. He
found that the use of stimulants "normalized" many of the systems that we use for successful living. People on medication IMPROVED their attention span, concentration, memory, motor coordination, mood, and on–task behavior. At the same time they DECREASED daydreaming, hyper–activity, anger, immature behavior, defiance, oppositional behavior. It was evident that medical treatment allowed intellectual capabilities that were already present to function more appropriately.

When medication is used appropriately, patients notice a significant improvement in control. Objective observers should notice better control of focus, concentration, attending skills, and task completion. Many children are able to cope with stress more appropriately, with fewer temper outbursts, less anger, and better compliance. They relate and interact better with siblings and friends. Less restlessness, motor activity and impulsiveness are noted.

It is very important to remember what medicine does and does not do. Using medication is like putting on glasses. It enables the system to function more appropriately. Glasses do not make you behave, write a term paper, or even get up in the morning. They allow your eyes to function more normally IF YOU CHOOSE to open them. YOU are still in charge of your vision. Whether you open your eyes or not, and what you choose to lookat, are controlled by you. Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally. Medication does not provide skills or motivation to perform. ADHD individuals often complain of forgotten appointments, incomplete homework, miscopied assignments, frequent arguments with siblings and parents, excessive activity, and impulsive behaviors. With medication, many of these problems dramatically improve. Patients successfully treated with medication typically can go to bed
at night and find that most of the day went the way they had planned.

WHO SHOULD PRESCRIBE MEDICATIONS?

Medications can be prescribed by a licensed physician, physician's assistant or nurse practitioner only. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training, and social skill assistance. Parents and adults should look for a physician, physician assistant or nurse practitioner who has a special interest and knowledge in dealing with ADHD individuals.

MEDICAL TRIALS

It is necessary to establish a team for an appropriate evaluation of the medication trial.I gather information from sources who spend time with my patients. This might include parents, teachers, spouses, friends, co–workers, grandparents, tutors, piano teachers, coaches, etc. As gradually increasing dosages are administered, input is gathered from these observers. Various rating scales are available to assist in gathering factual data. However, the true assessment is whether the ADHD patient's quality of success in life has improved. For this information, I find no scale takes the place of conversations with observers.

When evaluating patients during a trial of medication, I will treat them throughout the day, seven days a week. Treating them only at school or only at work is totally inadequate. I need all involved observers, assisting in the evaluation process. Furthermore, I want to know if treatment has an effect on non–academic issues. After the trial of medication, if positive results are evident, then the family and/orthe patient can make informed decisions as to when the medication is helpful. Many patients find the medication is helpful throughout all waking hours. Others may need it only during certain times of the day.

WHAT IS THE CORRECT MEDICATION?

At the present stage of medical knowledge, there is not a method of predicting which medication will be most helpful for any individual. At best, physicians can make educated decisions based on information about success rates with individual medications. In general, a large percentage of patients will respond favorably to Ritalin or Dexedrine, and one of these is usually my first choice. If one stimulant does not work effectively, the others should be tried, for experience has proven that individuals may respond quite differently to each one. Many patients respond remarkably well to imipramine or desipramine, and some physicians feel this group of medications is under used. Each family and physician must be willing to try different medications in order to determine the best and most effective therapy. This is the only way to find the appropriate treatment modality.

In some patients who have multiple diagnoses such as ADHD and depression, or ADHD and oppositional–defiant disorder, or ADHD and Tourette Syndrome, combinations of drugs are being successfully utilized for treatment.

WHAT IS THE CORRECT DOSE?

If medications work, there is a best dose for each individual. Unfortunately, medical knowledge is not at a point where it can predict what the correct dose will be. This isnot an unusual circumstance in medicine, however. For a person with diabetes, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is needed to determine the best treatment. For ADHD medications, there is no magic formula. The dose cannot be detemined by age, body weight, or severity of symptoms.

In fact, it appears that the correct dose is extremely individual and is not really predictable. Again, similar to people who need glasses, the kind of prescription and the thickness of the lenses is not dependent on any measurable parameter other than what you say enables you to see well. The dose of medication is determined solely by what ADHD patients need to improve their symptoms.

You must be willing to experiment with carefully observed dosage changes to determine your child's correct dosage. Once the correct dosage is determined, it does not seem to change significantly with age or growth. Medication continues to work effectively through the teenage years and into adulthood if needed.

For atomoxetine, the dosage at the present time is calculated according to weight. This is the only medication for ADHD for which this is true.

WHAT ABOUT "NATURAL" THERAPIES?

At this time, there is no evidence that natural therapies are therapeutic. There are many anecdotes about various "magical" cures for ADHD, but none have been found to be valid. Remember: multiple anecdotes do not mean proof. Natural therapies such as grape seed extract, blue algae, biofeedback, magnets, megavitamins, diet, and other "natural products" have not yet shown any lasting therapeutic benefit. At this time traditional medical therapy is the most effective treatment for ADHD. This is quite similar to other medical treatments such as insulin, THE best form of treatment for Type 1 diabetes, or thyroid pills THE best therapy for inactive thyroid gland. Furthermore, natural health food treatments are not regulated by the government and are therefore highly suspect for contamination. Please be cautious when experimenting with alternative therapies on your family members.

SUMMARY

Individuals with ADHD will present with a variety of well–defined symptoms and behaviors. Medication may be extremely helpful in alleviating some of these symptoms and will make the other forms of accompanying therapies much more meaningful and effective. Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.

References:

  1. Dougherty, D.D. Dopamine transporter density in patients with ADHD. Lancet 1999; 354: 2132.
  2. Bradley, C. The behavior of children receiving Benzedrine. Am J Psychiatry 1939; 99: 577-585.
  3. Bradley, C. Benzedrine and Dexedrine in treatment of children's behavior disorders. Pediatrics 1950; 5: 24-37.

MEDICATIONS: OVERVIEW

It is important to note that medical treatment should always be given for the entire waking day, seven days a week. There are few medical conditions that we do not elect to treat in the evenings, on weekends or holidays. No one chooses to turn down their brain chemistry during his or her wakeful hours. Therefore, all medical treatment for ADHD should last for at least 12 hours daily and 24 hours when possible. With this in mind, I have highlighted (***) the medications that should be preferred treatments for ADHD.

NON-STIMULANT MEDICATIONS

***ATOMOXETINE 24 hours (Strattera)

This is a new medication for ADHD, which was released by the FDA in December 2002. It is a non-stimulant medication, which is not abusable and can be written without Schedule II restrictions. This is the first medication that lasts 24 hours and therefore gives full therapeutic effect throughout the day and night. It has great implications for homework, driving, and social relations in the evening. Unfortunately, over the past few years it has not performed as well as expected. It tends to often have side effect and does not deliver as robust a response as the stimulants.

Form:
Capsules: 10mg, 18mg, 25mg, 40mg, 60mg.
Dosage:
Weight based dose: first four days=0.5mg/kg; target dose (day five and after)=1.2mg/kg. This medication must be taken with food to prevent nausea.
Action:
Very slow acting and will take 3–4 weeks (or more) to reach therapeutic effect. If the patient is already taking stimulant medications, suggest continuing them and adding the Strattera for the first 4-6 weeks, then tapering the stimulant slowly until discontinued.
Possible Side Effects:
No long term safety information is available for this medication. Primary side effects in children includes sleepiness during the day, appetite changes, mood or personality changes. If these occur, give the dose at night or lower the dose until they improve. Then raise dose if possible. Adults can experience more noted effects: transitory dry mouth and dizziness, insomnia, sleepiness and significant moodiness. Other effects in adults include possible bladder spasm, sexual dysfunction (uncommon but often result in discontinuation of medication). Occasionally a child or adult will get very agitated. If this occurs, discontinue the medication.Occasionally a child or adult will get very agitated. If this occurs, discontinue the medication.
Pros:
24 hour coverage. Less effect on appetite than stimulants.
Cons:
Many complaints about side effects, lack of efficacy compared to stimulanrts.

CLONIDINE (catapres)

Form:
Patches applied to back or shoulder. Catapres TTS–1, TTS–2, TTS–3. Tablets . Clonidine tablets 0.1mg, 0.2mg, 0.3mg.
Dosage:
Very individual, usually .1–.3mg.
Action:
Works quickly. Tablets work within 1 hour, patches within 1 day.
Effects:
Often will improve ADHD symptoms, particularly aggressive and hyperactive behaviors. Not too helpful for focus and attention. Decreases motor and vocal tics. Can have a dramatic effect on oppositional defiant behavior and anger management. Often used as one dose at night about 1½ hours before bedtime to assist with getting to asleep.
Possible Side Effects:
Major side effect is tiredness, particularly if dose is raised too quickly. This disappears with time. Dizziness, dry mouth. Some will notice increased activity, irritability.
Pros:
Excellent delivery system if patch is used. No pills required
Cons:
Does not usually work as well as stimulants. Patch can cause skin irritation in many individuals and may not be tolerated. Can effect cardiac conduction (heart rate and rhythm) in high doses and must not be left around for animals or small children to accidentally ingest.

STIMULANT MEDICATIONS: AN OVERVIEW

Some general comments can be made about stimulant medications as a class of medications. The longer acting medications have clear advantages over the short acting medications, not only in duration of therapeutic effect throughout the day, but also in smoothness of the therapeutic effect. It is very difficult for an individual with ADHD to remember to take multiple doses of medication during the day. Multiple dosing increases the risk of missing doses, which results in the return of symptoms at inopportune times. The afternoon dosing is frequently missed, causing significant difficulties. Furthermore, each additional dose serves as an unnecessary reminder that treatment for this condition is needed and "something is wrong."

The reason for medical treatment is to "normalize" the day. My general rule is to always use 12 hour medications unless they are not effective or have intolerable side effects. In such a case, the six or eight hour medications should be tried, because some individuals tolerate them better and find them more effective. However, if the six or eight hour medication is used, a second dose should be given to allow patients to have the therapeutic benefit for the full day.

SAFETY PROFILE

The stimulant medications are one of the most studied treatments in the history of medicine. The medications have been used extensively in children and adults over the past 50 years with no evidence to date of long term concerning side effects. At this time there is no conclusive evidence that use of stimulants causes any long term lasting effects on growth, although there may be some delay in height and weight gain in some individuals.

The short acting stimulants are extremely abusable and are valued highly on the street. It is best to always use the long acting preparations which are not abusable to avoid the temptation of misuse and abuse.

There have been recent concerns expressed by the FDA and the press with regard to the use of stimulant medications and the risk of sudden unexpected death. This concern was a consequence of a study done in 1999-2003 in which they looked at a large number of individuals taking stimulants and felt that there may be a slight risk. As reported in an excellent article in the New York Times Feb 14, 2006 the apparent calculated risk of sudden unexpected death in those using amphetamines was 0.35/million (1 in 3 million) prescriptions and the risk for those on stimulants was 0.18/million (1 in 5 million) prescriptions. There is no real evidence that this is any different from that which occurs in the normal population. These extraordinary events of unexpected death tended to occur in individuals with congenital cardiac defects. For this reason the FDA issued a BLACK BOX warning to all physicians that stimulants should be used very cautiously or not at all in individuals with congenital cardiac defects.

COMMON SIDE EFFECTS:

The following side effects are often noted with the use of stimulants. In general, the side effects with the short acting medications are more pronounced and bothersome than with the long acting medications. Thus, long acting meds are somewhat more tolerable for long term treatment and are certainly a marked improvement for long term therapeutic effect.

Appetite suppression:
Most will note decreased appetite during the effective hours of the medication. This often means minimal lunch intake. I suggest a small protein lunch such as milk, peanut butter crackers, beef or turkey jerky to get through the day. A milk shake after school helps. Many find their appetite returns late in the evening (around 8-9pm) when their medication wears off, and they need to be allowed to eat at that time. If weight gain is a continued concern, I often add cyproheptadine (Periactin) 4mg, ½ tablet at breakfast and dinner. Periactin is an antihistamine similar to Benedryl which enhances appetite and often results in 1-2lbs weight gain per month. Remember that good nutrition is helpful for all, and these individuals should emphasize protein intake in their diet.
Sleep disturbance:
Many ADHD individuals will have sleep difficulties before they begin their medical treatment. At night, their brain continues its activity and starts thinking of the day. Using stimulant medications may either improve or worsen this problem. In those with no prior sleep difficulty, stimulants can create significant sleep issues. ADHD individuals do not usually have a problem with sleeping through the night (sleep disorder) but often do have problems with starting the sleep. A clear-cut bedtime routine helps (bath or shower and then read in bed) with the elimination of caffeine, computers, computer games and television at least one hour before bedtime. Interestingly, adding stimulant medication actually allows a percentage to sleep better at night, and this technique should be tried. It only takes one night to see if a dose of short acting stimulant will enable sleep initiation. Some patients, however, require more assistance. Many patients will use a small dose of Clonidine tablets given one hour before bedtime to help with sleep initiation. Clonidine is a mild sedative, not a sleeping pill, and it is non addictive. Approximately 60-90 minutes after taking the medication, a brief sleepy phase will occur that lasts about 20 minutes. If the patient is in bed and trying to go to sleep, it is very effective. It will NOT make someone stop playing computer games and go to bed.
Mood changes:
One of the biggest complaints about stimulants is that they can cause mood changes. These come in a number of different forms.
Rollercoaster effect:
Short acting medications have a continuous cycling of the blood level, either rising or falling throughout the day. This can lead to significant mood changes, particularly at the end of the four hour cycle when the medication is wearing off. This problem with cycling is greatly diminished with the use of eight hour and twelve hour medications.
Rebound effect:
Stimulants can often wear off very rapidly, and in some individuals this can cause a rebound, a marked change in demeanor often characterized by irritability, loss of patience, and a worsening of the ADHD core symptoms. Rebound can occur in the evening when the medication wears off and can also be evident in the morning on first arising. The morning rebound may require an early dose of immediate release methylphenidate (MPH) prior to the administration of the long acting dose at breakfast. Rebound effect is markedly reduced in frequency and severity in the long acting stimulants.
Irritability and anxiety:
All of the stimulants have the possibility of causing a generalized irritability, and sometimes even anger, which is not tolerable over a long period of time. They can cause anxiety and panic disorder and may aggravate existing anxiety. Often, changing from one stimulant to another will reduce this side effect, so it is worth trying different stimulants to identify the best one for each patient.
Overdose effect:
When using the stimulants it is necessary to gradually raise the dose to find the most effective therapeutic level. Sometimes in doing this, one gets an overdose effect. The stimulants are incredibly safe. They have been studied for over 50 years, and there is no evidence at this time of any long term serious complications when used appropriately for ADHD. However, if ADHD individuals take too high a dose, they will experience an overdose effect which appears as a dulling of the personality: They complain of being somewhat physically lethargic, subdued, dull, less conversational, less apt to laugh and be social. By simply lowering the dose for one day, these symptoms will disappear.
Tic Formation:
All of the stimulants have the possibility of temporarily causing a tic disorder or aggravating an existing one. There is no evidence that the use of stimulant medications will cause permanent formation of tic disorder or Tourette syndrome. Children who already have tics (10% of children have mild tics at some point in childhood) and individuals with Tourette syndrome will find a number of different scenarios with the use of medication. Approximately 1/3 will actually notice that the tics improve (lessen) with the use of stimulants, 1/3 will see no change at all, and 1/3 will find the tics worsen with use of stimulants. If the stimulants are effective and tics are worse, a medication to help control the tics is usually added to the treatment.

METHYLPHENIDATE TABLETS 2-4 hours (Ritalin IR)

Form:
Short acting tablets administered by mouth. Methylphenidate (MPH)5 mg, 10 mg, 20 mg
Dosage:
Very individual. Average 5 mg – 20 mg every 4 hours. I prescribe 5 mg to start and raise by 5 mg every 4–5 days with close observation until correct dose is achieved.
Duration of Action:
Rapid acting Ritalin starts to work in 15–20 minutes, which is extremely helpful for some individuals who has trouble starting their day, Some children will need medication 20 minutes BEFORE time to get up, followed by a long–acting medicaiton at breakfast. Often used as a booster for evening coverage.
Possible Side Effects:
See above
Pros:
Very easy to use for short periods of coverage, such as early morning and evening.
Cons:
Must be administered frequently during the day (3-5 times/day). Inconvenient to use at school. Often causes rebound and roller coaster effect. Very abusable.

DEXTRO-METHYLPHENIDATE 4-6 hours (Focalin) 8-12 hours (Focalin XR)

Focalin is an isomer product of methylphenidate. Methylphenidate is composed of two mirror image molecules, and it has been determined that the right-hand side of the molecule contains most of the therapeutic activity. Therefore the left–hand side has been eliminated, giving a cleaner formulation of methylphenidate.

Form:
Tablets: 2.5mg, 5mg, and 10mg. (Focalin)
Capsules: 5mg, 10mg, 20mg
Dosage:
The same as methylphenidate, but divide the dose by half.
Action:
The same as methylphenidate, but in some individuals up to 6 hours duration.
Possible Side Effects:
Same as MPH but possibly to a slightly less degree.
Pros:
A cleaned up version of MPH that may last a bit longer with slightly decreased side effects.
Cons:
Same as MPH. Very abusable.

METHYLPHENIDATE SUSTAINED RELEASE 6 hours (Ritalin SR20)

Replaced by Ritalin LA

METHYLPHENIDATE LONG ACTING 8 hours (Ritalin LA

Form:
Capsules: 20mg, 30mg and 40mg
Dosage:
Very individual. Average 20-40 mg daily or twice a day, every 8 hours.
Duration of Action:
Same as methylphenidate SR, but eliminates the noontime dose
Possible Side Effects:
See above
Pros:
Eliminates midday dosing. Works more smoothly the IR methylphenidatee and is more effective than methylphenidate SR
Cons:
Only works for eight hours and therefore subjects the patient to loss of focus and control in mid-afternoon. This requires an afternoon booster to be administered.

METHYLPHENIDATE CONTROLLED DISPENSE 8 hours (Metadate CD)

Form:
Capsules: 20mg (10mg and 30mg to be available in 2003)
Dosage:
Very individual. Average: 2-3 capsules in the am.
Action:
Same as methylphenidate.
Possible Side Effects:
See above.
Pros:
Works more smoothly than IR methylphenidate. Sometimes is effective when Concerta and Ritalin LA are not effective. Not abusable.
Cons:
Works for only eight hours. (See Ritalin LA)

METHYLPHENIDATE EXTENDED RELEASE 12 HOURS (Concerta)

Form:
12–hour long–acting tablet—unique delivery system that delivers a constant therapeutic level of methlyphenidate for twelve full hours. Concerta 18 mg, 27mg, 36 mg and 54 mg.
Dosage:
Dosage will vasy as with all methylphenidate products.
  • Concerta 18mg = Ritalin 5mg three times a day
  • Concerta 27mg = Ritalin 7.5mg three times a day
  • Concerta 36mg = Ritalin 10mg three times a day.
  • Concerta 54mg = Ritalin 15mg three times a day
Duration of Action:
12 hours of consistent therapy with no highs or lows throughout the day.
Effects:
Same as Ritalin
Pros:
Unique delivery system avoids multiple dosing though the day. No dosage at school. No rebounding with missed doses. Fewer side effects, less mood swings, better therapeutic response for many individuals. No need for daytime dosing. Less anxiety and worry. Not abusable.
Cons:
Does not work for all individuals who use methylphenidate. If ineffective, should try Ritalin LA and/or Metadate CD. May need a short–acting booster to cover the evening hours.

METHYLPHENIDATE TRANSDERMAL SYSTEM 12-15 HOUR (Daytrana)

The trans–dermal patch arrived on the market July, 2006 as a new and novel delivery system for methylphenidate. The patch has the medication within the adhesive layer and is thus very thin. It works by diffusion, allowing the medication to gradually diffuse through the skin into the blood stream directly, thus avoiding the intestinal tract. It is designed to be worn for nine hours and then removed, but will last longer if needed for evening activities. After removal it will gradually loose effect over the next three hours, thus giving extended and controlled hours of therapy as the day dictates. The unique attribute of the patch is that the patient has complete control of when to start the patch and when to discontinue the patch. For the first time the patient can regulate the treatment for part or all of the day. The medication in the patch is methylphenidate, and thus all of the above information regarding this medication applies.

DEXTROAMPHETAMINE TABLETS 4 hours (Dexedrine, Destrostat)

Form:
Short–acting tablets 5mg, 10 mg
Dosage:
Very individual: Average 1–3 tablets each dose every 4-5 hours.
Duration of Action:
Rapid onset of action 20–30 minutes. Lasts 4-5 hours.
Possible Side Effects:
See above
Pros:
Excellent safety record. Rapid acting. Some patients who do well on dextroamphetamin prefer the tablets over the spansules. The rapid onset in tablet form is apparently more effective for these individuals.
Cons:
Same as MPH. Very abusable.

DEXTROAMPHETAMINE SPANSULES>6 hours (Dexedrine)

Form:
Long acting. Dexedrine Spansules 5mg, 10mg, 15 mg.
Dosage:
Very individual: Average is 5–20 mg.
Duration of Action:
Very individual. May take up to one hour to be effective. Usually lasts6–8 hours. In some individuals it may be effective all day. In others it may last only four hours. Most will take twice a day, six hour intervals.
Possible Side Effects:
See above
Pros:
Excellent safety record. May be the best drug for some individuals: longer acting, smooth course of action. May avoid lunch time dose at school.
Cons:
Slow onset of action. May require a short–acting medication at the start of the day.

AMPHETAMINE SALTS TABLETS 6 hours (ADDerall)

Form:
Long–acting tablets: 5 mg, 7.5 mg. 10 mg. 12.5 mg, 15 mg. 20 mg, 30 mg
Dosage:
Very individual, usually between 5 mg and 20 mg, once or twice a day
Duration of Action:
Usually last 6 hours. May be given once or twice a day, depending on length of therapeutic effect. Duration of effect varies from person to person.
Possible Side Effects:
See above
Pros:
Only needs to be given once or twice a day, often fewer side effects than short acting medications. Cons:
Cons:
Can cause irritability in a small percentage of patients. Very abusable.

***AMPHETAMINE SALTS EXTENDED RELEASE 12 hours (Adderall XR)

Form:
Uses a unique delivery system that delivers a constant therapeutic level of amphetamine salts for twelve full hours. Capsules: 5mg, 10mg, 15mg, 20mg, 25mg, 30mg.
Dosage:
Very individual. Average 15-30mg daily.
Action:
Long acting 12–hour control of ADHD symptoms for coverage during most of the day.
Possible Side Effects:
See above.
Pros:
Very effective. Same as Adderall with longer duration of action. Cannot be abused.
Cons:
May need a booster to cover the evening hours.

PEMOLINE 24 hours (Cylert)

Form:
18.75mg, 37.5mg , 75mg tablets. 37.5 mg chewable tablets.
Dosage:
Very individual.
Action:
Good medication for ADHD symptom relief, similar to other stimulants.
Possible Side Effects:
Cylert has a BLACK BOX warning from the FDA. This medication is associated with risk of liver failure leading to death, and its use requires blood tests every two weeks. It should be used as a last resort with very careful and continuous supervision.
Pros:
Not abusable.
Cons:
Significant risk.

For an excellent reference book regarding all of the medications that might be used for ADHD individuals, including not only medications for ADHD but also medications for all of the associated co–morbid conditions, please refer to the following book: STRAIGHT TALK ABOUT PSYCHIATRIC MEDICATIONS FOR KIDS , Revised Edition 2004 by Timothy Wilens M.D.

Theodore Mandelkorn, MD, is a physician with Puget Sound Behavioral Medicine, a clinic that treats teens, children and adults with attention deficit disorder and related conditions. For further information visit the website at http://www.psbmed.com, send email to info@psbmed.com, or call 206/275-0702.

Dr. Mandelkorn trained in pediatrics and adolescent medicine and was a mental health fellow under Dr. Michael Rothenberg. An adult with ADHD who has a son with ADHD, Dr. Mandelkorn specializes in the diagnosis and treatment of ADHD in children and adolescents. He maintains a private practice in Mercer Island, Washington. His ADHD clinic presently follows over 600 children with ADHD. Dr.Mandelkorn lectures nationwide about management







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