# Evekeo ### (amphetamine sulfate) **[Evekeo](https://wiki.joshnp.com/books/drug-library/page/evekeo)** (amphetamine sulfate); CII
[**Full Prescribing Information**](https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=f469fb38-0380-4621-9db3-a4f429126156&type=display)[**DailyMed Drug Information**](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f469fb38-0380-4621-9db3-a4f429126156)
--- ### **Summary** Evekeo is an immediate-release, short-acting tablet of racemic amphetamine sulfate, approved for ADHD from age 3, narcolepsy from age 6, and short-term use in exogenous obesity from age 12. Unlike Adderall it is a single-entity salt rather than a mixed-salt blend, and unlike Zenzedi it carries the l-isomer too; that racemic composition is why you would reach for it. Schedule II; brand and generic. --- ### **Forms & Strengths** - **Tablets** (5 mg single-scored, 10 mg double-scored): 5 mg, 10 mg --- ### **Dosing** - **Age:** - ADHD: ≥ 3 y/o - Narcolepsy: ≥ 6 y/o - Exogenous obesity: ≥ 12 y/o - **Onset:** 30 to 60 min - **Duration:** 4 to 6 hours - **Initial Dose:** - ADHD, 3-5 y/o: 2.5 mg daily - ADHD, ≥ 6 y/o: 5 mg once or twice daily - Narcolepsy, 6-11 y/o: 5 mg daily - Narcolepsy, ≥ 12 y/o: 10 mg daily - Exogenous obesity, ≥ 12 y/o: 5-10 mg per dose, 30-60 min before meals - **Titration:** - ADHD, 3-5 y/o: 2.5 mg every 7 days - ADHD, ≥ 6 y/o: 5 mg every 7 days - Narcolepsy, 6-11 y/o: 5 mg every 7 days - Narcolepsy, ≥ 12 y/o: 10 mg every 7 days - **Max Dose:** - ADHD: 40 mg/day, at any age - Narcolepsy: usual range 5-60 mg/day in divided doses - Exogenous obesity: up to 30 mg/day in divided doses of 5-10 mg - **Considerations:** First dose on awakening, then one or two further doses at 4-6 hour intervals; the maximum is set by indication, not by weight, and late evening doses cause insomnia. --- ### **Pharmacology** - **Mechanism:** Blocks reuptake at DAT and NET and promotes presynaptic catecholamine release via VMAT2 and TAAR1; the release component distinguishes amphetamines from methylphenidate - **Delivery / Release:** Plain immediate-release tablet; single early peak, one block of coverage per dose - **Formulation:** Racemic amphetamine sulfate, equal d- and l-isomer. Per the label the l-isomer is more potent in cardiovascular activity and much less potent in CNS excitatory effects - **Metabolism:** CYP2D6 forms active 4-hydroxyamphetamine; urinary excretion is pH dependent; this label publishes no half-life - **Class Positioning:** A single salt, not the 3:1 d:l blend of [Adderall](https://wiki.joshnp.com/link/8), so relatively more peripheral effect per unit of CNS effect; unlike pure-dextroamphetamine [Zenzedi](https://wiki.joshnp.com/link/34) and [ProCentra](https://wiki.joshnp.com/link/26) it adds the l-isomer back - **Interchange:** not milligram-for-milligram equivalent to any other amphetamine moiety --- ### **Indications** - **ADHD** (ICD-10: F90.0, F90.1, F90.2, F90.8, F90.9): patients ≥ 3 y/o, within a total treatment program - **Narcolepsy** (ICD-10: G47.419): patients ≥ 6 y/o - **Exogenous obesity** (ICD-10: E66.9): patients ≥ 12 y/o, short-term adjunct of a few weeks, second-line only; the label puts the gain over placebo at a fraction of a pound per week --- ### **Off-Label Uses** - **None established** for this moiety outside its labelled indications. - **Where the evidence does not support use:** - **Non-ADHD indications in youth:** AHRQ CER 267 graded none; insufficient (AHRQ 2024). - **Weight management under 12, first-line, or beyond a few weeks:** not supported. - **Cognitive enhancement without ADHD:** not supported. --- ### **Contraindications & Warnings** - **Boxed Warning:** Abuse, misuse, and addiction. High potential for abuse, leading to substance use disorder; overdose and death, more so at higher doses or by snorting or injection. Assess risk before prescribing; reassess throughout. - **Contraindicated:** - Known hypersensitivity to amphetamine products - MAOI use, current or within 14 days; hypertensive crisis - **Use with caution** (Warnings in this label, not contraindications): - Structural cardiac abnormality, cardiomyopathy, serious arrhythmia or coronary disease; label says avoid, for sudden death - Hypertension, including mild, which the label names explicitly - Pre-existing psychosis; bipolar disorder, for treatment-emergent mania - Prior seizure or prior EEG abnormality; this label carries an explicit Seizures warning and directs discontinuation if a seizure occurs - Motor or verbal tics, or Tourette syndrome - Peripheral vasculopathy including Raynaud phenomenon - Substance use disorder in the patient or the household - **Screen before starting:** - Cardiac history, family history of sudden death or arrhythmia, and exam - Personal and family history of tics or Tourette syndrome - Mania risk: personal or family depression, bipolar disorder, suicide - Abuse and diversion risk; baseline height, weight, BP and HR --- ### **Drug Interactions** - **MAOIs** (also linezolid, IV methylene blue): hypertensive crisis, malignant hyperpyrexia, sometimes fatal. Do not co-prescribe; confirm a 14 day washout. - **Serotonergic agents** (SSRIs, SNRIs, TCAs, triptans, lithium, fentanyl, tramadol, buspirone, St John's Wort): serotonin syndrome. Start lower; stop both drugs if symptoms appear. - **CYP2D6 inhibitors** (paroxetine, fluoxetine, quinidine, ritonavir): raise exposure and serotonin syndrome risk. Prefer an alternative; else start lower. - **Urinary pH agents:** acidifiers (ascorbic acid, fruit juice, ammonium chloride, methenamine) lower levels and efficacy; alkalinizers (bicarbonate, antacids, acetazolamide, thiazides) raise them. Check both before changing the dose. - **Tricyclic antidepressants** (desipramine, protriptyline): sustained rise in brain d-amphetamine, potentiated cardiovascular effect. Monitor BP and HR; titrate slowly. - **Sympathomimetics and antihypertensives:** additive cardiovascular effect; hypotensive effect antagonized. Avoid OTC decongestants; recheck blood pressure. --- ### **Administration** - First dose on awakening; one or two further doses at 4-6 hour intervals. - Split the scored 5 mg tablet for the 2.5 mg preschool starting dose. - Exogenous obesity only: dose 30 to 60 minutes before a meal; that timing does not apply to ADHD or narcolepsy. - Avoid late evening doses; the label names resulting insomnia. - No suspension, chewable or sprinkle form exists; any instruction to shake or open belongs to another product. - Interrupt occasionally to see whether symptoms recur at a level requiring continued therapy; this is a label instruction. - Store securely, preferably locked. --- ### **Side Effects** - **Common:** decreased appetite and weight loss, insomnia, overstimulation, irritability and dysphoria, headache, dizziness, dry mouth, unpleasant taste, bowel change, palpitations, tachycardia, elevated blood pressure. - **Serious:** - Sudden death with structural cardiac abnormality or serious cardiac disease; avoid rather than monitor through it. - Psychosis or mania at recommended doses, roughly 0.1% in pooled stimulant trials; consider discontinuing. - Serotonin syndrome; stop both drugs and treat supportively. - Seizure; discontinue. - Peripheral vasculopathy including Raynaud phenomenon, rarely digital ulceration; reduce or stop, refer if persistent. - Growth suppression; interrupt in a child not growing or gaining as expected. - New or worsening tics and Tourette syndrome; discontinue if clinically appropriate. - Rhabdomyolysis, intestinal ischemia; priapism, a surgical emergency. --- ### **Monitoring & Labs** - **Cardiovascular:** HR and BP at baseline, each dose change, and every 6 months; mean rise 2-4 mm Hg and 3-6 bpm, investigate beyond that. - **Growth:** height, weight and BMI charted at baseline and every 6 months; interrupt if crossing two major percentile lines. - **Appetite and sleep:** every visit; usually fixed by timing rather than dose. - **Psychiatric:** psychosis, mania, aggression, dysphoria at each visit and 2 weeks after any increase. - **Tics and digits:** ask about tics and inspect fingers and toes for colour change, coolness or unexplained wounds at each visit. - **Abuse and diversion:** adherence, pill counts and PDMP check at each refill; reassess need for therapy at least annually. - **Laboratory:** none routinely; amphetamines interfere with urinary steroid determinations. --- ### **Discontinuation & Taper** - Can be stopped abruptly at therapeutic doses; no taper required. - Physical dependence is labelled; withdrawal is dysphoria, depression, fatigue, vivid dreams, sleep change, increased appetite. Warn the family in advance. - End-of-dose rebound irritability and hunger is pharmacodynamic offset, not withdrawal. - Planned interruptions are asked for by this label; drug holidays suit appetite or growth as the limiting problem. --- ### **Pregnancy & Lactation** - **Pregnancy:** No adequate controlled studies. Embryotoxic and teratogenic in two mouse strains at about 41 times the maximum human dose; not in rabbits at 7 or rats at 12.5 times. - **Pregnancy, clinical:** increased premature delivery and low birth weight in dependent mothers; infants may withdraw. Weigh rather than abstain. - **Lactation:** the label says amphetamines enter milk and mothers should not nurse. LactMed: one narcolepsy case gave 1.9% to 2.1% of the maternal weight-adjusted dose. (LactMed 2025) - **Lactation, practical:** some experts accept therapeutic doses, monitoring the infant for irritability, insomnia and feeding difficulty. - **Lactation, milk supply:** prolactin suppressed 25% to 40% dose-dependently; large doses may impair milk production where lactation is not yet established. (LactMed 2025) --- ### **Counseling Points** - **Counsel the family on:** - The 4-6 hour window, and that a second or third dose usually covers the afternoon. - End-of-dose rebound irritability and hunger; not a signal to increase the dose. - Moving the last dose earlier rather than adding a sleep aid. - Appetite suppression peaking midday; largest meal at breakfast and in the evening. - Avoiding vitamin C loading and fruit juice around dosing, and asking before any antacid. - Secure, preferably locked storage; sharing a Schedule II medication is a felony. - Bringing a teacher rating scale to the next visit, and expecting a planned trial off medication. - **Advise them to call for:** - Chest pain on exertion, fainting, or a racing heart that does not settle. - Any seizure, or a new staring spell. - New hallucinations, or new suspicious or fearful thinking. - Numbness, coldness or colour change in the fingers or toes, or an unexplained sore on a digit. - A new or markedly worse tic; new throat clearing or blinking. - Weight loss, or clothes fitting more loosely over a few weeks. - A painful erection lasting more than a few hours. --- ### **References** 1. DailyMed. Evekeo (amphetamine sulfate) tablets, USP prescribing information. Azurity Pharmaceuticals. 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f469fb38-0380-4621-9db3-a4f429126156 2. FDA. openFDA National Drug Code Directory, generic\_name "amphetamine sulfate". 2026. https://api.fda.gov/drug/ndc.json?search=generic\_name:%22amphetamine%22&limit=1000 3. LactMed. Amphetamine. Drugs and Lactation Database, NICHD. 2025. https://www.ncbi.nlm.nih.gov/books/NBK501307/ 4. AHRQ. ADHD Diagnosis and Treatment in Children and Adolescents. Comparative Effectiveness Review No. 267. 2024. https://www.ncbi.nlm.nih.gov/books/NBK603001/