Adderall

The side effects and potential for abuse with Adderall are essentially the same as for dextroamphetamine. We recommend starting Adderall at 2.5 mg twice a day or 5 mg each morning and then adding the second dose after a week or so. Using the extended-release formulation allows for the titration of the single dose with weekly adjustments as needed. 

Pemoline (Cylert). Pemoline was introduced as an alternative stimulant. Its two key advantages are that it can be taken once a day, though with the extended-release versions of methylphenidate and Adderall this is less of an issue, and it may be less prone to abuse. It was generally believed that pemoline has a gradual onset of action, taking several weeks to reach full therapeutic benefit, but some researchers discount this assumption. 

First-line pharmacotherapy treatments include methylphenidate, dextroamphetamine, the mixed amphetamine salts (Adderall), and atomoxetine (see Table 8.3). When an early evening dose is indicated (e.g., completion of homework) it is typically at 25-50% of the doses prescribed earlier in the day. 

Close to 70% of children with ADHD will respond to a stimulant. When the child is not helped by the first stimulant that is prescribed, there is still a good chance of responding to a different one. If an initial trial of methylphenidate isn t successful, then switching to dextroamphetamine or Adderall is a reasonable strategy. If dextroamphetamine or Adderall was used first and did not work well, then we recommend switching to methylphenidate. Because dextroamphetamine and Adderall are more similar, it makes less sense to switch between these two. We do not recommend pemoline as a first-line treatment. 

Starting Treatment in Adults with ADHD. Beginning treatment of an adult is not significantly different from doing so in a child. The stimulants and atomoxetine remain the most effective medications. Methylphenidate, dextroamphetamine, and Adderall appear to be equally effective in group trials, but individuals may respond preferentially to one medication or the other. 

Dopamine activity can be enhanced in one of four main ways. Medications can stimulate dopaminergic nerve cells to release dopamine into the synapse. This is the way that stimulants such as methylphenidate (Ritalin), dextroamphetamine (Dexe-drine), and dextroamphetamine/amphetamine (Adderall) work. In addition, certain drugs of abuse, notably cocaine and methamphetamine, act in part in this way. Providing more of the raw material that nerve cells use to manufacture dopamine can also increase dopamine activity. This is the approach that neurologists use when they prescribe L-DOPA (Sinemet) to patients with Parkinson s disease. Nerve cells convert L-DOPA into dopamine. L-DOPA otherwise has little place in the treatment of psychiatric disorders. Dopamine activity can also be increased by medications that directly stimulate dopamine receptors. Bromocriptine, another medication used to... 

Tablets 5, 7.5, 10, 12.5, 15, 20, and 30 mg mixed salts of a single entity amphetamine product (c-ii) Adderall (Shire Richwood)...

Amphetamine mixture - Peak plasma concentrations occur in about 3 hours (Adderall) and 7 hours (Adderall XR). Elimination half-life is 10 to 13 hours in adults and 9 to 11 hours in children. Extended-release amphetamine mixture capsules demonstrate linear pharmacokinetics. There is no unexpected accumulation at steady state. Food does not affect the extent of absorption of extended-release amphetamine mixture capsules, but prolongs T ax by 2.5 hours. 

APPROVED TREATMENTS FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER AMPHETAMINE (ADDERALL ), METHYLPHENIDATE (RITALIN ), AND ATOMOXETINE (STRATERRA )... 

Many psychomotor stimulants possess activities similar to those of amphetamine and have been discussed previously (see Chapter 10). Of primary importance to our discussion of the psychomotor stimulants are amphetamine Adderall, Benzedrine, Dexedrine), methampheta-mine (Desoxyn), and methylphenidate (Concerta, Ritalin, Metadate, Methylin). 

The recently introduced product Concerta is a once-a-day administration MPH delivery system called OROS (osmotically released). This delivery system creates an ascending plasma level pattern instead of the peak-and-valley pharmacokinetic profile seen in the IR preparations. Similar extended-delivery bead-technology, double-pulse preparations have been introduced for Metadate-CD at 10, 20, and 30 mg (Green-hill et ah, 2002, in press) for the spheroidal technology of Ritalin-EA, and for Adderall-XR preparations (McGough et ah, 2002, in press). Beaded stimulant preparations mix IR and delayed-release beads in a capsule. The patient can swallow the capsule whole or sprinkle the contents in food if pill taking is difficult for the child. 

The IR version of Adderall, which has been on the market under that name since 1994, has a duration of action of 5 hours only (Swanson et al., 1998), so it required a double-pulse, bead-technology delivery system to enable one dosing administration to cover the entire day (Greenhill et al., 2001b). 

Children naive to stimulant treatment may be started directly on a sustained-release formulation. Starting doses could be any of the following 5 mg of Dexedrine spansules once in the morning, or 5 mg of Adderall bid, or 18 mg of Concerta, which is equivalent to MPH 5 mg tid. Before the availability of Concerta, it had become common practice to combine short-acting MPH with MPH-SR20 to increase efficacy and duration of effect and to allow for more flexible dosing. 

Greenhill, L., Swanson, J., Steinhoff K, Tullock S, Clausen S, Zhang Y (2002 b), A pharmacokinetic/pharmacodynamic study comparing a single morning dose of Adderall to twice daily dosing in children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc (in press). Psychiatry. 

Methylphenidate and D-amphetamine are both short-acting compounds, with an onset of action within 30 to 60 minutes and a peak clinical effect seen usually between 1 and 2 hours after administration, lasting 2 to 5 hours. Therefore, multiple daily administrations are required for a consistent daytime response. The amphetamine compound Adderall, the sustained-release preparations of methylphenidate and dextroamphetamine, and pemoline are all intermediate-acting compounds with an onset of action within 60 minutes and a peak clinical effect seen usually between 1 and 3 hours after administration and maintained for up to 8 hours (8 hours with metadate C.D. and Ritalin LA 12 hours with Concerta), allowing for a single dose for the entire school day. Adderall XR is a 12 hour preparation. 

More research has been done on pharmacotherapy of ADHD in children and adolescents with MR than for other disorders. Reviews by Aman (1996), Arnold et al. (1998), and Handen (1993) summarize the psychostimulant research (methylphenidate, amphetamine, and magnesium pemoline). Of the 10 or more group studies of methylphenidate or dextroamphetamine in children, adolescents, and adults with ADHD and MR/ DD since 1980, all but one were positive and statistically significant. They showed substantial benefit for motor overflow, attention span, and impulsiveness. Improvements were also seen in cognitive performance, some measures of social behavior, and independent play. The sole negative study was of adolescents and adults without ADHD, most of them with profound MR (see Aman, 1996). No studies of mixed amphetamine salts (Adderall) or magnesium pemoline (Cylert) were found for this population (Arnold et al., 1998). 

Swanson, J.M., Wigal, S., Greenhill, L.L., Browne, R., Waslik, B., Lerner, M., Williams, L., Flynn, D., Aglet, D., Crowley, K., Fi-neberg, E., Baren, M., and Cantwell, D.P. (1998) Analog classroom assessment of Adderall in children with ADHD. / Am Acad Child Adolesc Psychiatry 37 519-526. 

Metadate-CD, Ritalin-LA, Focalin, others Dexedrine 5 mg t 5, 10, 15 mg sustained-release spansules Adderall 5, 10, 20, 30 mg... 

Amphetamine/ Adderall dextroamphetamine Adderall XR 5-, 7.5-, 10-, 12.5-, 15-, 20-, 30-mg tablets 5-, 10-, 15-, 20-, 25-, 30-mg extended-release capsules (can be opened and sprinkled over applesauce before immediate consumption)... 

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