Welcome to this ADHD Medications Guide Part II. Part I of this ADHD Medications Guide focused on common questions and answers, provided by longtime ADHD specialist Ted Mandelkorn, MD, of Puget Sound Behavioral Health.
Here in Part II, Dr. Mandelkorn details the categories of medications along with dosing, pros, cons, and potential side effects.
I will continue to note updates to this information [in brackets.]
The more you know about your choices, the better you can choose a knowledgeable prescribing physician. Then you can pro-actively work with that physician for the best possible treatment outcome.
This is a major mission for me. I am so tired, over 20 years, of hearing medication-gone-wrong stories. So much promise for the future—dashed by ignorance, arrogance, and recklessness.
PLEASE NOTE (March 2021): My online training will cover medications in depth. Be sure to subscribe to this blog to be notified when it’s online!
This Post Covers
We can break down ADHD medications into two general categories:
- Non-stimulant medications
- Stimulant medications
1. Non-Stimulant Medications
ATOMOXETINE, 24 HOURS (Strattera)
CLONIDINE, TABLETS: 4-5HOURS, PATCH: 5-6 DAYS (Catapres)
GUANFACINE LONG ACTING (Intuniv)
2. Stimulant Medications:
METHYLPHENIDATE TABLETS, 2-4 HOURS (Ritalin)
DEXTRO-METHYLPHENIDATE, 4-6 HOURS (Focalin)
METHYLPHENIDATE SUSTAINED RELEASE, 6 HOURS (Ritalin SR20)
METHYLPHENIDATE LONG ACTING, 8 HOURS (Ritalin LA)
METHYLPHENIDATE CONTROLLED DISPENSE, 8 HOURS (Metadate CD)
METHYLPHENIDATE EXTENDED RELEASE, 12 HOURS (Concerta)
METHYLPHENIDATE TRANSDERMAL SYSTEM, 12 HOURS (Daytrana)
QUILLIVANT LIQUID METHYLPHENIDATE [GINA UPDATE]
DEXTROAMPHETAMINE TABLETS, 4 HOURS (Dexedrine, Dextrostat)
DEXTROAMPHETAMINE SPANSULES 6 HOURS (Dexedrine)
AMPHETAMINE SALTS TABLETS, 6 HOURS (Adderall tablets)
AMPHETAMINE SALTS EXTENDED RELEASE, 12 HOURS (Adderall XR and generic)
LISDEXAMFETAMINE, 12-14 HOURS (VYVANSE)
- Medical treatment for ADHD should always cover 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 12-16 hours daily.
Thee are at least three commonly used non-stimulant medications, though only one (Strattera/Atomoxetine) is considered a first-line medication.
1. ATOMOXETINE 24 hours (Strattera)
Released by the FDA in December 2002.
It is a non-stimulant medication that is not abusable and can be written without Schedule II restrictions. This is the first medication for ADHD that lasts 24 hours and therefore gives full therapeutic effect throughout the day and night.
Unfortunately, since its introduction, 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. To prevent nausea, take this medication with food.
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 Strattera for the first 4-6 weeks, then tapering the stimulant slowly until discontinued.
[Gina Notes: Many people with ADHD and their physicians report them doing very well on a low dose of Strattera—25-40 mg—combined with a stimulant. Published literature supports this.]
Possible Side Effects: No long-term safety information is available. Primary side effects in children include daytime sleepiness, appetite changes, and mood or personality changes. If these occur, give the dose at night or lower the dose until they improve. Then raise the 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. 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 stimulants. Has not been a very satisfactory treatment for many with ADHD.
2. CLONIDINE tablets 4-5 hours, patches 5-6 days (Catapres)
Form: Patches applied to the back or shoulder. Catapres TTS-1, TTS-2, TTS-3. Tablets. Clonidine tablets 0.1mg, 0.2mg, and 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. It 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 sleep.
Possible Side Effects: The major side effect is tiredness, particularly if the dose is raised too quickly. This disappears with time. Dizziness, dry mouth. Some will notice increased activity, irritability.
Pros: Excellent delivery system if the patch is used. No pills required
Cons: Does not usually work as well as stimulants. The patch can cause skin irritation in many individuals and may not be tolerated. It can affect cardiac conduction (heart rate and rhythm) in high doses and must not be left around for animals or small children to accidentally ingest.
3. GUANFACINE, Extended Release (Intuniv)
Intuniv is a new formulation of an existing medication, guanfacine.
It is an alpha 2 agonist, which will have a 24-hour effect on ADHD symptoms and may be beneficial for individuals with ADHD, particularly those with significant mood, anger, oppositional symptoms.
Preliminary results show that it is clearly beneficial for some patients without the adverse side effects often seen with other ADHD medications.
Form: Pills. 1mg, 2mg, 3mg, 4mg. Pills must be swallowed.
They must not be crushed, chewed or broken or they will lose the 24hr effect.
Dosage: It has a very slow rate of onset and will take 3-4 weeks to assess effectiveness. The primary side effect is tiredness, lethargy, and it must be started slowly. Suggest starting dose of 1 mg for one week, and raise by 1 mg each week to reach good therapeutic effect. The effects do last 24 hours.
Side Effects: Lethargy, tiredness, dry mouth, constipation, dizziness, decreased blood pressure.
Pros: A non-stimulant medication that appears to have a good, positive effect on ADHD and oppositional symptoms that lasts 24hours with reduced side effect profile, compared to the traditional treatments.
Cons: A new formulation with minimal time on the market to truly assess effectiveness. [This needs to be updated.]
2. Stimulant Medications: Safety and Common Side Effects
We can make a few general comments 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 the 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 12-16 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.
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 the 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
In general, the side effects with the short-acting stimulant 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.
We can group potential side effects into three major categories: 1) Appetite suppression, 2) Sleep disturbance, 3) Mood changes
Most patients taking stimulants 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 milkshake after school helps.
Many find their appetite returns late in the evening (around 8-9 pm) 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 Benadryl, 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.
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 sometimes have no problem with sleeping through the night but often do have problems with starting the sleep. A clear-cut bedtime routine helps (bath or shower and then read in bed). So does eliminating caffeine, computers, computer games, and television at least one hour before bedtime.
Interestingly, adding stimulant medication actually allows a percentage of patients to sleep better at night. This technique should be tried. It only takes one night to see if a dose of a 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 nonaddictive. 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: Five Types
One of the biggest complaints about stimulants is that they can cause mood changes. These come in various forms.
1. Rollercoaster effect
Short-acting medications have 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 can be greatly diminished by using eight-hour and twelve-hour medications.
2. Rebound effect
Stimulants can often wear off very rapidly. Some individuals will experience a rebound—that is, 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. The rebound effect is markedly reduced in frequency and severity in the long-acting stimulants.
3. Irritability and anxiety
All of the stimulants have the possibility of causing 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; it is worth trying different stimulants to identify the best one for each patient.
4. 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. There is no evidence 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.
5. 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 a 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 for ADHD symptoms but tics are worse, a medication to help control the tics is usually added to the treatment.
List of Stimulant Medications
Here is a list of the most common stimulant medications. New options have come onto the market since this writing but for the most part, they are not as well known or used.
METHYLPHENIDATE TABLETS 2-4 hours (Ritalin IR)
Form: Short-acting tablets. Methylphenidate (MPH) 5mg, 10mg, 20mg.
Dosage: Very individual. Average 5-20mg tablets every 2-4 hours.
Action: Immediate release (IR) MPH starts to take effect in 15 minutes, which is extremely helpful for some individuals. Some children need an early morning dose 20 minutes BEFORE arising in the am, followed by a long-acting medication 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 and work. Often causes rebound and rollercoaster 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.
Action: Same as methylphenidate, but eliminates the noontime dose.
Possible Side Effects: See above.
Pros: Eliminates midday dosing. Works more smoothly than IR methylphenidate and is more effective than methylphenidate SR.
Cons: Only works for eight hours and therefore subjects the patient to losing focus and control in mid-afternoon. This requires an afternoon booster.
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)
[Gina Notes: There are generic medications for Concerta. Two of them have been downgraded by the FDA as not being bioequivalent. But there remains an authorized generic.
An authorized-generic is the brand, marketed as a generic. It is worth learning about the differences and how to be a smart consumer. I detail everything you need to know on the always shifting situation: Authorized Generic Concerta Update.]
Form: 12-hour long-acting tablet…uses a unique delivery system that delivers a constant therapeutic level of methylphenidate for twelve full hours. Concerta 18mg, 27mg, 36mg, 54mg.
Dosage: Dosage will vary as with all methylphenidate products.
Here are some approximations comparing Concerta dosage to Ritalin dosage:
- 18mg = Ritalin 5mg three times a day
- 27mg = Ritalin 7.5mg three times a day
- 36mg = Ritalin 10mg three times a day
- 54mg = Ritalin 15mg three times a day
Action: 12 hours of consistent therapy with no highs or lows throughout the day. A few individuals will only get 8-9 hours of effective therapy and will need either a higher dose or a second dose.
Possible Side Effects: See above.
Pros: Unique delivery system avoids multiple dosing throughout the day. No dosage at school. No rebounding with missed doses. Fewer side effects, fewer mood swings, better therapeutic response for many individuals. No 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)
No generic available
The medication in the patch is methylphenidate, and thus all of the above information regarding this medication applies.
The trans-dermal patch arrived on the market in 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. That is, it allows the medication to gradually diffuse through the skin into the bloodstream directly. That means it avoids the intestinal tract.
The Daytrana patch is designed to be worn for nine hours and then removed. It will last longer, however, if needed for evening activities. After removal, it will gradually lose effectiveness over the next three hours, thus giving extended and controlled hours of therapy as the day dictate.
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.
[GINA UPDATES here with information on the patch causing inflammation or allergic reactions]
Some people will develop a reaction to the adhesive used in the patch. This is a common occurrence with all adhesive-patch medications, not just Daytrana.
To cope with this, it is recommended to vary the physical spot on which the patch is applied.
If the irritation is mild, you can try something like this “calming” lotion after removing the patch: Calmoseptine.
If the irritation is severe, talk with the prescribing physician about an alternate medication.
METHYLPHENIDATE LIQUID (QUILLIVANT XR)
[GINA UPDATES this list with a new entry, for Quillivant XR]
With the recent introduction of Quillivant XR, we now have a liquid, extended-release formulation designed to last 12 hours (as always, your mileage may vary, given your unique neurochemistry).
Basically, it comes as a powder that your pharmacist will mix for you into a liquid. You will receive:
- 1 bottle (containing the liquid)
- 1 oral dosing dispenser, and
- 1 bottle adapter
To learn more about this new option, please read this post: A New “Ritalin”: Extended-Release Liquid Quillivant XR.
DEXTROAMPHETAMINE TABLETS 4 hours (Dexedrine, Dextrostat)
Form: Short-acting tablets 5mg, 10mg.
Dosage: Very individual. Average 1-3 tablets each dose every 4-5 hours.
Action: Rapid onset of action, approx. 20 min. Lasts 4-5 hours.
Possible Side Effects: See above.
Pros: Excellent safety record. Rapid-acting. Some patients who do well on dextroamphetamine prefer the tablets to 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, 15mg.
Dosage: Very individual. The average is 5-20 mg.
Action: Very individual. May take up to one hour to be effective. Usually lasts 6-8 hours. In some individuals, it may last all day. In others, it may only last 4 hours. Most will take twice a day, six-hour intervals
Possible Side Effects: See above
Pros: Excellent safety record. Maybe the best drug for some individuals. Long-acting, smooth course of action. May avoid lunchtime dose at school.
Cons: Slow onset of action. May require a short-acting medication at the start of the day. Very abusable.
AMPHETAMINE SALTS TABLETS 6 hours (Adderall)
Form: Long acting tablets: 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg.
Dosage: Very individual, usually between 5mg and 20mg, once or twice each day.
Action: Usually lasts 6 hours. May be given once or twice a day depending on the 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 the short-acting medications.
Cons: Can cause irritability in a small percentage of patients. Very abusable.
[GINA NOTES: I’ve been warning for years about the many, serious potential problems with Adderall. Poor prescribing patterns risked—and still risk—de-legitimizing the ADHD diagnosis. Please read my blog’s most popular post: The Tragic Truth about Adderall, or Madderall.
There is some wisdom to considering Adderall only as a last resort—definitely NOT before trying other stimulants first. Unfortunately, many MDs seem to push Adderall. The reason remains mysterious. Who knows why? It seems related to an over-interpretation of a meta-analysis. More in a future post.]
AMPHETAMINE SALTS EXTENDED RELEASE 12 hours (Adderall XR)
Generic available April 1, 2009
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.
LISDEXAMFETAMINE 12-14 hours (Vyvanse)
No generic available
Form: A Pro-drug, which renders this delivery system minimally abusable. A new and novel delivery system that delivers dextro-amphetamine smoothly over a 12-14 hour period.
Dosage: Capsules: 30mg, 50mg, 70mg
Action: The same as Dextroamphetamine
Side Effects: Same as Dextroamphetamine
Pros: Only long-acting Dextroamphetamine on the market; unlikely to be abused.
Cons: Same as stimulants
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Although the author and the publisher did our best to provide sound and useful information in this article, we cannot and do not promise beneficial results to anyone who may use that information; nor does the author or the publisher accept liability to anyone who may use the information. Because we cannot respond to individual needs and circumstances, anyone who has a known or suspected medical condition, or is taking medication of any kind, or has health concerns, should consult a qualified health care provider before following any of the suggestions in this article.