Medication by Form

• Age:
  • ADHD: >= 6y
  • Narcolepsy: no age floor
• Onset: ~ 1 hour
• Duration: 3 to 4 hours
• Initial Dose:
  • >= 6 y/o and older: 5 mg twice daily, before breakfast and before lunch
  • Adults: 20 to 30 mg daily in 2 or 3 divided doses, 30 to 45 minutes before meals.
• Titration: 5 - 10 mg every 7 days
• Max Dose: 60 mg/day
• Considerations: The chewable tablet must be taken with at least 8 ounces of fluid because it swells and can cause choking, and it contains phenylalanine.

• Age:
  • ADHD: 3-16 y/o, the range this label's indication is written for
  • Narcolepsy: ≥ 6 y/o, no upper bound
• Onset: 30 to 60 min
• Duration: 4 to 6 hours
• Initial Dose:
  • ADHD, 3-5 y/o: 2.5 mg daily, that is 2.5 mL
  • ADHD, 6-16 y/o: 5 mg once or twice daily
  • Narcolepsy, 6-11 y/o: 5 mg daily
  • Narcolepsy, ≥ 12 y/o: 10 mg daily
• Titration:
  • ADHD, 3-5 y/o: 2.5 mg every 7 days
  • ADHD, 6-16 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; the label says only in rare cases will it be necessary to exceed this
  • Narcolepsy: usual range 5-60 mg/day in divided doses
• Considerations: The maximum is set by indication, not by age or weight. First dose on awakening, then one or two more at 4-6 hour intervals. This is a solution, not a suspension; it does not need shaking.

• Age: >= 6y; no upper limit
• Onset: ~ 45 minutes
• Duration: up to 12 hours
• Release Profile: 20% IR / 80% ER via drug ion-bound to suspended resin
• Initial Dose: 20 mg, which is 4 mL, once daily in the morning
• Titration: 10 - 20 mg every 7 days
• Max Dose: 60 mg/day, which is 12 mL
• Considerations: Shake vigorously at least 10 seconds before every dose or the dose drawn will be wrong. The reconstituted suspension is stable 4 months at room temperature.

• Age: ≥ 6 y/o
• Onset: ~ 1 hour
• Duration: up to 13 hours
• Release Profile: combined immediate-release and extended-release components; this label publishes no percentage split
• Initial Dose: 2.5 mg or 5 mg once daily in the morning, all patients ≥ 6
• Titration: 2.5 mg to 10 mg per day every 4 to 7 days
• Max Dose: 20 mg once daily
• Considerations: Suspension and tablet substitute milligram for milligram; no other amphetamine does, because these strengths are base rather than salt. Titrate from scratch when switching in.

Vyvanse (Lisdexamfetamine dimesylate); capsule; Brand/Generic

• Age:
  • ADHD: ≥ 6 y/o; not recommended below 6 years
  • Binge eating disorder: ≥ 18 y/o only; not established under 18
• Onset: 1.5-2 hours
• Duration: 13-14 hours
• Release Profile: None. Inactive prodrug hydrolysed by red blood cells; Tmax about 3.5 h from the capsule, 4.4 h from the chewable
• Initial Dose:
  • ADHD, ≥ 6 y/o and adults: 30 mg once daily in the morning
  • BED, adults: 30 mg once daily in the morning
• Titration:
  • ADHD: 10 mg or 20 mg at approximately weekly intervals
  • BED: 20 mg at approximately weekly intervals, to a target of 50 to 70 mg/day
• Max Dose:
  • ADHD and BED: 70 mg/day
  • Severe renal impairment (GFR 15 to < 30): 50 mg/day
  • End stage renal disease (GFR < 15): 30 mg/day
• Considerations: Give in the morning; avoid afternoon doses. Capsule and chewable substitute milligram for milligram, but there is no 70 mg chewable.

• Age:
  • ADHD: >= 6y
  • Narcolepsy: no age floor
• Onset: ~ 1 hour
• Duration: 3 to 4 hours
• Initial Dose:
  • >= 6 y/o and older: 5 mg twice daily, before breakfast and before lunch
  • Adults: 20 to 30 mg daily in 2 or 3 divided doses, 30 to 45 minutes before meals.
• Titration: 5 - 10 mg every 7 days
• Max Dose: 60 mg/day
• Considerations: The chewable tablet must be taken with at least 8 ounces of fluid because it swells and can cause choking, and it contains phenylalanine.

• Age: >= 6y; no upper limit
• Onset: ~ 45 minutes
• Duration: up to 8 hours
• Release Profile: 30% IR / 70% ER via drug ion-bound to resin
• Initial Dose: 20 mg once daily in the morning
• Titration: 10, 15 or 20 mg every 7 days, up or down
• Max Dose: 60 mg/day
• Considerations: The 20 mg and 30 mg tablets are halved to give the 10 mg and 15 mg steps; the 40 mg is not scored. It contains aspartame, giving 3 to 6 mg of phenylalanine per tablet.

• Age: ≥ 6 y/o
• Onset: ~ 1 hour
• Duration: up to 13 hours
• Release Profile: combined immediate-release and extended-release components; this label publishes no percentage split
• Initial Dose: 2.5 mg or 5 mg once daily in the morning, all patients ≥ 6
• Titration: 2.5 mg to 10 mg per day every 4 to 7 days
• Max Dose: 20 mg once daily
• Considerations: Suspension and tablet substitute milligram for milligram; no other amphetamine does, because these strengths are base rather than salt. Titrate from scratch when switching in.

• Age:
  • ADHD: ≥ 6 y/o; not recommended below 6 years
  • Binge eating disorder: ≥ 18 y/o only; not established under 18
• Onset: 1.5-2 hours
• Duration: 13-14 hours
• Release Profile: None. Inactive prodrug hydrolysed by red blood cells; Tmax about 3.5 h from the capsule, 4.4 h from the chewable
• Initial Dose:
  • ADHD, ≥ 6 y/o and adults: 30 mg once daily in the morning
  • BED, adults: 30 mg once daily in the morning
• Titration:
  • ADHD: 10 mg or 20 mg at approximately weekly intervals
  • BED: 20 mg at approximately weekly intervals, to a target of 50 to 70 mg/day
• Max Dose:
  • ADHD and BED: 70 mg/day
  • Severe renal impairment (GFR 15 to < 30): 50 mg/day
  • End stage renal disease (GFR < 15): 30 mg/day
• Considerations: Give in the morning; avoid afternoon doses. Capsule and chewable substitute milligram for milligram, but there is no 70 mg chewable.

• Age: 6-17 y/o; pediatric only
• Onset: ~ 1 hour
• Duration: up to 12 hours
• Release Profile: 25% IR / 75% ER, methylphenidate ion-bound to polystyrene sulfonate resin
• Initial Dose: 17.3 mg once daily in the morning
• Titration: 8.6 mg to 17.3 mg every 7 days
• Max Dose: 51.8 mg/day
• Considerations: Strengths are methylphenidate base, so 17.3 mg equals 20 mg of a hydrochloride product. Do not co-prescribe an H2-blocker or PPI; they alter the release profile.

• Age: ≥ 6 y/o
• Onset: 30 to 60 min
• Duration: ~ 12 hours
• Release Profile: 50% immediate-release / 50% delayed-release amphetamine in one tablet. Delayed, not extended
• Initial Dose:
  • 6-17 y/o: 6.3 mg once daily in the morning
  • ≥ 18 y/o: 12.5 mg once daily, the recommended adult dose rather than a starting dose
• Titration: 3.1 mg or 6.3 mg every 7 days, patients 6-17
• Max Dose:
  • 6-12 y/o: 18.8 mg/day
  • 13-17 y/o: 12.5 mg/day
  • ≥ 18 y/o: 12.5 mg/day recommended; no separate adult maximum is stated
• Considerations: The adolescent ceiling is LOWER than the child ceiling, and is not a typo: a 13 year old cannot exceed 12.5 mg/day. Strengths are amphetamine base; never convert milligram for milligram.

• Age:
  • 6-17 y/o: safety and effectiveness established
  • 18 y/o and older: efficacy established at 20, 30 and 40 mg/day
  • Under 6 y/o: not recommended; higher plasma exposure and more adverse reactions, including weight loss, at the same dosage
• Onset: ~ 30 min
• Duration: up to 12 hours
• Release Profile: 50% IR / 50% delayed-release via enteric-coated beads, giving two plasma peaks about 4 hours apart, the second at about 6.5 hours
• Initial Dose:
  • New to methylphenidate, 6-17 y/o: 5 mg once daily in the morning
  • New to methylphenidate, 18 y/o and older: 10 mg once daily in the morning
  • Currently on racemic methylphenidate: half the current total daily dose
  • Currently on Focalin immediate-release tablets: the same total daily dose
• Titration: 5 mg every 7 days (6-17 y/o); 10 mg every 7 days (18 y/o and older)
• Max Dose: 30 mg/day (6-17 y/o); 40 mg/day (18 y/o and older)
• Considerations: Once daily in the morning, with or without food. Swallow whole or open onto applesauce and take immediately without chewing. A capsule must never be divided.

• Age: 6 to 15 y/o only; no indication at 16, 17 or in adults
• Onset: ~ 1 hour
• Duration: about 8 hours
• Release Profile: 30% IR / 70% ER via biphasic beads
• Initial Dose: 20 mg once daily in the morning, before breakfast
• Titration: 10 - 20 mg every 7 days
• Max Dose: 60 mg/day
• Considerations: Give before breakfast; a high-fat meal raises Cmax ~30% and delays the peak an hour. Alcohol releases 84% of the dose in the first hour, so counsel adolescents. May be opened onto applesauce.

• Age: 6 to 12 y/o only; no adolescent and no adult indication
• Onset: ~ 1 hour
• Duration: about 8 hours
• Release Profile: 50% IR / 50% DR via bimodal beads
• Initial Dose:
  • New to methylphenidate: 20 mg once daily in the morning; 10 mg where a lower start is appropriate
  • From Ritalin twice daily, per dose: 5 mg to 10 mg; 10 mg to 20 mg; 15 mg to 30 mg; 20 mg to 40 mg; 30 mg to 60 mg once daily
• Titration: 10 mg every 7 days
• Max Dose: 60 mg/day
• Considerations: Switching from any methylphenidate other than Ritalin means titrating from the start, not converting milligram-for-milligram. Capsules may be opened onto cool applesauce.

• Age: >= 6y; no upper limit
• Onset: ~ 1 hour
• Duration: up to 12 hours
• Release Profile: 40% IR / 60% ER via multilayer beads
• Initial Dose: 10 mg once daily in the morning
• Titration: 10 mg every 7 days
• Max Dose: 60 mg/day
• Considerations: May be swallowed whole or opened onto applesauce, but never divided, so the ladder moves in whole capsules only.

• Age: 6 y/o and older
• Onset: delayed until the following morning (~10 hours after an evening dose)
• Duration: through the day after dosing
• Release Profile: delayed-release outer coat holds absorption overnight; an extended-release inner coat meters release next day
• Initial Dose: 20 mg once daily in the evening, started at 8:00 p.m.
• Titration: 20 mg every 7 days
• Max Dose: 100 mg/day
• Considerations: Dose in the evening only, never in the morning. Start at 8:00 p.m., shift within 6:30 to 9:30 p.m. to tune next-morning onset, then hold that time.

• Age:
  • 6-12 y/o: established by a controlled trial and a 12-month open-label safety study
  • 13-17 y/o and adults: established by pharmacokinetic bridging
  • Under 6 y/o: not recommended; higher plasma exposure and more adverse reactions, including weight loss
• Onset: ~ 2 hours fasted, later with food
• Duration: up to 13 hours
• Release Profile: fixed molar ratio, 30% dexmethylphenidate to 70% serdexmethylphenidate. This is capsule composition, not a bead-release split: the long tail comes from prodrug conversion in the lower gut
• Initial Dose: 39.2 mg / 7.8 mg once daily in the morning, in every age band
• Titration:
  • 6-12 y/o: after 7 days, increase to 52.3 mg / 10.4 mg or decrease to 26.1 mg / 5.2 mg
  • 13-17 y/o and adults: after 7 days, increase to 52.3 mg / 10.4 mg; no labelled down-titration step
• Max Dose: 52.3 mg / 10.4 mg once daily, in every age band
• Considerations: Once daily in the morning; food delays the peak about 2 hours without changing exposure. Never substitute for another methylphenidate milligram for milligram; stop it and titrate from the standard start.

• Age: ≥ 6 y/o; not recommended below 6 years
• Onset: 30-60 min, from the immediate-release bead fraction
• Duration: 10-12 hours
• Release Profile: Biphasic; immediate-release plus delayed-release beads in one capsule, Tmax about 7 hours
• Initial Dose:
  • 6-12 y/o: 10 mg once daily in the morning; 5 mg where a lower start is judged appropriate
  • 13-17 y/o: 10 mg once daily in the morning
  • ≥ 18 y/o: 20 mg once daily in the morning
  • Severe renal impairment (GFR 15 to < 30): 5 mg, 6-17 y/o; 15 mg, adults. ESRD not recommended
• Titration:
  • 6-12 y/o: increase by 5 mg or 10 mg at weekly intervals
  • 13-17 y/o: a single increase to 20 mg after one week if control is inadequate
• Max Dose:
  • 6-12 y/o: 30 mg/day; doses above 30 mg/day have not been studied in children. Severe renal impairment: 20 mg/day
  • 13-17 y/o: no numeric maximum in the label; no added benefit above 20 mg/day in the adolescent trial
  • ≥ 18 y/o: no numeric maximum; same finding above 20 mg/day
• Considerations: Give on awakening and avoid afternoon doses; a capsule may not be divided, and the patient must not take less than one whole capsule per day.

• Age:
  • ADHD: ≥ 6 y/o; not recommended below 6 years
  • Binge eating disorder: ≥ 18 y/o only; not established under 18
• Onset: 1.5-2 hours
• Duration: 13-14 hours
• Release Profile: None. Inactive prodrug hydrolysed by red blood cells; Tmax about 3.5 h from the capsule, 4.4 h from the chewable
• Initial Dose:
  • ADHD, ≥ 6 y/o and adults: 30 mg once daily in the morning
  • BED, adults: 30 mg once daily in the morning
• Titration:
  • ADHD: 10 mg or 20 mg at approximately weekly intervals
  • BED: 20 mg at approximately weekly intervals, to a target of 50 to 70 mg/day
• Max Dose:
  • ADHD and BED: 70 mg/day
  • Severe renal impairment (GFR 15 to < 30): 50 mg/day
  • End stage renal disease (GFR < 15): 30 mg/day
• Considerations: Give in the morning; avoid afternoon doses. Capsule and chewable substitute milligram for milligram, but there is no 70 mg chewable.

• Age: ≥ 13 y/o; not established at 12 years and younger
• Onset: 2-4 hours to measurable effect
• Duration: up to 16 hours
• Release Profile: Triple bead; one immediate-release plus two delayed-release beads releasing at pH 5.5 and pH 7.0. Tmax 7-10 hours pediatric, about 8 hours adult
• Initial Dose:
  • 13-17 y/o: 12.5 mg once daily on awakening
  • 18-55 y/o: 12.5 mg once daily on awakening; 25 mg may be considered
  • Severe renal impairment (GFR 15 to < 30), adults: 12.5 mg once daily. ESRD not recommended at any age
• Titration: 12.5 mg no sooner than weekly, at any age
• Max Dose:
  • 13-17 y/o: 25 mg/day; above 25 mg not evaluated in pediatric trials. Severe renal impairment: 12.5 mg/day
  • 18-55 y/o: 50 mg/day; no additional benefit above 50 mg. Severe renal impairment: 25 mg/day
  • No dosing recommendation above age 55
• Considerations: Give on awakening; effect may last 16 hours. Take consistently with or without food, since a high-fat meal delays Tmax 4.5 to 5 hours. A missed dose is skipped.

Qelbree (viloxazine); capsule; Brand

• Age: 6 y/o and older, and adults; not established below 6 y/o
• Onset: weeks to clinical effect; not a rescue or as-needed medication
• Duration: continuous with once-daily dosing; steady state in 2 days, no accumulation
• Release Profile: extended-release beaded capsule, about 88% relative bioavailability against an immediate-release reference, median Tmax 5 hours (range 3 to 9)
• Initial Dose:
  • 6 to 11 y/o: 100 mg once daily
  • 12 to 17 y/o: 200 mg once daily
  • 18 y/o and over: 200 mg once daily
• Titration:
  • 6 to 11 y/o: 100 mg every 7 days
  • 12 to 17 y/o: a single 200 mg increment after 1 week
  • 18 y/o and over: 200 mg every 7 days
• Max Dose:
  • 6 to 11 y/o: 400 mg/day
  • 12 to 17 y/o: 400 mg/day
  • 18 y/o and over: 600 mg/day
• Considerations: In severe renal impairment (eGFR under 30 mL/min/1.73 m2) start at 100 mg once daily, titrate by 50 to 100 mg weekly, and cap at 200 mg/day at any age. No adjustment for mild or moderate impairment.

• Age: 6-17 y/o; pediatric only
• Onset: ~ 2 hours after application
• Duration: through 12 hours after application, on a 9-hour wear time
• Release Profile: continuous transdermal delivery from an adhesive matrix; no IR fraction and no bead or coat split
• Initial Dose: 10 mg/9 h patch (12.5 cm2) once daily, including when converting from an oral methylphenidate
• Titration: one patch size every 7 days, in the order 10, 15, 20, 30 mg/9 h
• Max Dose: 30 mg/9 h
• Considerations: Wear time is a second dosing variable: remove at 9 hours, or earlier for a shorter day. Never cut a patch. Heat or inflamed skin under the patch can double or triple absorption.

• Age: ≥ 6 y/o
• Onset: ~ 2 hours
• Duration: up to 12 hours
• Release Profile: continuous transdermal delivery, about 90% of content over 9 hours; peak plasma at 6 to 9 hours, ~6 hours on repeat
• Initial Dose:
  • 6-17 y/o: 4.5 mg/9 h daily
  • ≥ 18 y/o: 9 mg/9 h daily
• Titration: 4.5 mg/9 h every 7 days, patients 6-17
• Max Dose:
  • All ages: 18 mg/9 h, one system per 24 hours
  • Severe renal impairment, GFR 15 to under 30 mL/min/1.73 m²: 13.5 mg/9 h
  • End-stage renal disease, GFR under 15 mL/min/1.73 m²: 9 mg/9 h
• Considerations: Apply 2 hours before effect is needed, remove within 9 hours, and use a shorter wear to shorten the day. Rotate sites daily, never cut a patch, and keep external heat off it.

• Age:
  • ADHD: >= 6y, and adults
  • Narcolepsy: no age floor
• Onset: ~ 1 hour
• Duration: 3 to 4 hours
• Initial Dose:
  • >= 6 y/o and older: 5 mg twice daily, before breakfast and before lunch
  • Adults: 20 to 30 mg daily in 2 or 3 divided doses, 30 to 45 minutes before meals.
• Titration: 5 - 10 mg every 7 days
• Max Dose: 60 mg/day
• Considerations: Give 30 to 45 minutes before meals, and the last dose before 6 p.m. The offset is abrupt and visible, which is the trade-off against every long-acting product.

• Age:
  • 6-17 y/o: established in two controlled trials
  • Under 6 y/o: not established
  • 18 y/o and older: no adult dose ladder on this label; adult data sit on the Focalin XR label
• Onset: ~ 30 min
• Duration: 5 to 6 hours
• Initial Dose:
  • New to methylphenidate: 5 mg daily, given as 2.5 mg twice daily
  • Currently on racemic methylphenidate: half the current total daily dose
• Titration: 2.5 mg to 5 mg every 7 days
• Max Dose: 20 mg/day, given as 10 mg twice daily
• Considerations: Give twice daily at least 4 hours apart, with or without food. Converting from racemic methylphenidate is half the total daily dose, never milligram for milligram.

• Age:
  • ADHD: >= 6y
  • Narcolepsy: no age floor
• Onset: ~ 1 hour
• Duration: 3 to 4 hours
• Initial Dose:
  • >= 6 y/o and older: 5 mg twice daily, before breakfast and before lunch
  • Adults: 20 to 30 mg daily in 2 or 3 divided doses, 30 to 45 minutes before meals.
• Titration: 5 - 10 mg every 7 days
• Max Dose: 60 mg/day
• Considerations: The chewable tablet must be taken with at least 8 ounces of fluid because it swells and can cause choking, and it contains phenylalanine.

• Age:
  • ADHD: ≥ 3 y/o
  • Narcolepsy: ≥ 6 y/o
• Onset: 30-60 min
• Duration: 4-6 hours
• Initial Dose:
  • 3-5 y/o: 2.5 mg daily
  • ≥ 6 y/o: 5 mg once or twice daily
• Titration:
  • 3-5 y/o: increase by 2.5 mg at weekly intervals
  • ≥ 6 y/o: increase by 5 mg at weekly intervals
• Max Dose:
  • ADHD: 40 mg/day; the label states only in rare cases will it be necessary to exceed this
  • Narcolepsy: usual range 5-60 mg/day
• Considerations: Give the first dose on waking, with further doses at 4-6 hour intervals. May be taken with or without food; a high-fat meal may delay absorption. Avoid late-afternoon dosing.

• Age:
  • ADHD: 3-16 y/o, the lowest approved age here. Not recommended under 3
  • Narcolepsy: no age bound stated; dose ladder given from age 6
• Onset: 30-60 min
• Duration: 4-6 hours, the label's own redosing interval
• Initial Dose:
  • ADHD, 3-5 y/o: 2.5 mg daily
  • ADHD, 6-16 y/o: 5 mg once or twice daily
  • Narcolepsy, 6-11 y/o: 5 mg daily
  • Narcolepsy, ≥ 12 y/o: 10 mg daily
• Titration:
  • ADHD, 3-5 y/o: 2.5 mg at weekly intervals until optimal response
  • ADHD, 6-16 y/o: 5 mg at weekly intervals until optimal response
  • Narcolepsy, 6-11 y/o: 5 mg at weekly intervals
  • Narcolepsy, ≥ 12 y/o: 10 mg at weekly intervals
• Max Dose:
  • ADHD, 6-16 y/o: 40 mg/day; only in rare cases will it be necessary to exceed this
  • ADHD, 3-5 y/o: no maximum stated in this label. Titrate to optimal response; 40 mg/day is not transferable downward to a preschooler
  • Narcolepsy: usual range 5-60 mg/day in divided doses
• Considerations: First dose on waking, one or two further doses at 4 to 6 hour intervals; avoid late evening doses. The label directs interrupting treatment occasionally to test continued need.

• 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.

• Age: >= 6y; no upper limit
• Onset: ~ 45 minutes
• Duration: up to 8 hours
• Release Profile: 30% IR / 70% ER via drug ion-bound to resin
• Initial Dose: 20 mg once daily in the morning
• Titration: 10, 15 or 20 mg every 7 days, up or down
• Max Dose: 60 mg/day
• Considerations: The 20 mg and 30 mg tablets are halved to give the 10 mg and 15 mg steps; the 40 mg is not scored. It contains aspartame, giving 3 to 6 mg of phenylalanine per tablet.

• Age: ≥ 6 y/o
• Onset: ~ 1 hour
• Duration: up to 13 hours
• Release Profile: combined immediate-release and extended-release components; this label publishes no percentage split
• Initial Dose: 2.5 mg or 5 mg once daily in the morning, all patients ≥ 6
• Titration: 2.5 mg to 10 mg per day every 4 to 7 days
• Max Dose: 20 mg once daily
• Considerations: Suspension and tablet substitute milligram for milligram; no other amphetamine does, because these strengths are base rather than salt. Titrate from scratch when switching in.

• Age:
  • ADHD: ≥ 6 y/o; not recommended below 6 years
  • Binge eating disorder: ≥ 18 y/o only; not established under 18
• Onset: 1.5-2 hours
• Duration: 13-14 hours
• Release Profile: None. Inactive prodrug hydrolysed by red blood cells; Tmax about 3.5 h from the capsule, 4.4 h from the chewable
• Initial Dose:
  • ADHD, ≥ 6 y/o and adults: 30 mg once daily in the morning
  • BED, adults: 30 mg once daily in the morning
• Titration:
  • ADHD: 10 mg or 20 mg at approximately weekly intervals
  • BED: 20 mg at approximately weekly intervals, to a target of 50 to 70 mg/day
• Max Dose:
  • ADHD and BED: 70 mg/day
  • Severe renal impairment (GFR 15 to < 30): 50 mg/day
  • End stage renal disease (GFR < 15): 30 mg/day
• Considerations: Give in the morning; avoid afternoon doses. Capsule and chewable substitute milligram for milligram, but there is no 70 mg chewable.

Concerta (methylphenidate ER (OROS)); OSM tablets; Brand/Generic

• Age: 6 to 65 y/o
• Onset: ~ 1 hour
• Duration: up to 12 hours
• Release Profile: 22% IR / 78% ER via OROS osmotic delivery
• Initial Dose:
  • 6 to 17 y/o, new to methylphenidate: 18 mg once daily in the morning
  • 18 to 65 y/o, new to methylphenidate: 18 mg or 36 mg once daily
  • From IR methylphenidate, per dose given 2-3 times daily: 5 mg to 18 mg; 10 mg to 36 mg; 15 mg to 54 mg; 20 mg to 72 mg (13 y/o and older only)
• Titration: 18 mg every 7 days; use 27 mg for a smaller step
• Max Dose:
  • 6 to 12 y/o: 54 mg/day
  • 13 to 17 y/o: 72 mg/day, not to exceed 2 mg/kg/day
  • 18 to 65 y/o: 72 mg/day
• Considerations: Swallow whole; splitting or chewing destroys the extended release. The nondeformable tablet is unsuitable in severe GI narrowing, and the empty shell passing in stool is not a failed dose.

Relexxii (Methylphenidate ER (OROS) Tablets); Brand

Relexxii is a tablet-shaped version of Concerta, offering the same OROS delivery system and bioequivalence. It also comes in additional dosage strengths.

• Age: 6 to 65 y/o
• Onset: ~ 1 hour
• Duration: up to 12 hours
• Release Profile: 18% IR / 82% ER via OROS osmotic delivery
• Initial Dose:
  • 6 to 17 y/o, new to methylphenidate: 18 mg once daily in the morning
  • 18 to 65 y/o, new to methylphenidate: 18 mg or 36 mg once daily in the morning
  • From methylphenidate 2-3 times daily, per dose: 5 mg to 18 mg; 10 mg to 36 mg; 15 mg to 54 mg; 20 mg to 72 mg
• Titration: 18 mg every 7 days; 27, 45 and 63 mg give intermediate steps
• Max Dose:
  • 6 to 12 y/o: 54 mg/day
  • 13 to 17 y/o: 72 mg/day, not to exceed 2 mg/kg/day
  • 18 to 65 y/o: 72 mg/day
• Considerations: Swallow whole; chewing or dividing destroys the osmotic pump. The 45, 63 and 72 mg strengths avoid two-tablet regimens above 54 mg. Do not substitute milligram-for-milligram with another methylphenidate.

Intuniv (guanfacine ER); capsule; Brand/Generic

• Age: 6-17 y/o; not established below 6 years
• Onset: sedation same day; ADHD benefit over weeks, trial endpoints at 5 to 8 weeks
• Duration: once daily, morning or evening, same time each day; half-life about 18 hours
• Release Profile: extended release from a matrix tablet; Cmax about 60% lower and AUC about 43% lower than immediate-release guanfacine, Tmax about 3 hours later, relative bioavailability 58%
• Initial Dose: 1 mg once daily
• Titration: no more than 1 mg every 7 days
• Max Dose: target 0.05 to 0.12 mg/kg/day, total 1 mg to 7 mg/day. Two age ceilings sit above the weight bands and both apply:
  • 6-12 y/o: do not exceed 4 mg/day
  • 13-17 y/o: do not exceed 7 mg/day
  • As adjunct to a stimulant: do not exceed 4 mg/day at any age
  • Under 25 kg: no weight band; dose from 0.05 to 0.12 mg/kg/day, starting at 1 mg
  • 25 to 33.9 kg: 2 to 3 mg/day
  • 34 to 41.4 kg: 2 to 4 mg/day
  • 41.5 to 49.4 kg: 3 to 5 mg/day
  • 49.5 to 58.4 kg: 3 to 6 mg/day
  • 58.5 to 91 kg: 4 to 7 mg/day
  • Over 91 kg: 5 to 7 mg/day
• Considerations: Swallow whole and do not give with a high-fat meal, which raises Cmax about 75%. Halve the dose with strong or moderate CYP3A4 inhibitors, and re-check the weight band as the child grows.

 Strattera (atomoxetine); capsule; Brand/Generic

• Age: 6 y/o and older, and adults; not established below 6 y/o
• Onset: weeks to clinical effect, not minutes; not a rescue or as-needed medication
• Duration: continuous with daily dosing; no afternoon wear-off
• Initial Dose:
  • Under 70 kg: 0.5 mg/kg/day
  • 70 kg and over, and adults: 40 mg/day
• Titration:
  • Under 70 kg: after at least 3 days, to a target of 1.2 mg/kg/day; no added benefit above that
  • 70 kg and over, and adults: after at least 3 days, to 80 mg/day; if response is not optimal after 2 to 4 further weeks, may increase to 100 mg/day
  • CYP2D6 poor metabolizers and patients on a strong CYP2D6 inhibitor: titration interval of 4 weeks, not 3 days. Starting, target and maximum doses unchanged
• Max Dose:
  • Under 70 kg: the lesser of 1.4 mg/kg/day or 100 mg/day
  • 70 kg and over, and adults: 100 mg/day
• Considerations: Give once daily in the morning, or as two evenly divided doses morning and late afternoon; never more. Reduce to 50% of the usual dose in moderate hepatic impairment and 25% in severe.