First line stimulant

[peony]

I know that there’s a lot of controversy in diagnosing ADHD, but once you’re confident that a patient meets criteria, what would be your first line medication? I was taught that methylphenidate is first line, but then I couldn’t get a clear answer as to why you wouldn’t try an amphetamine compound first. Is it because there is more potential for misuse and diversion? Would your first line med change depending on whether it was a child or adult patient? Thanks so much!

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[wolfvgang22]

It's due to mechanism of action of these drugs. Methylphenidate is mainly a NDRI whereas amphetamine can also cause more release of norepinephrine and dopamine in addition to it's own re-uptake actions, and therefore amphetamines may cause more side effects. Also methylphenidate reduces neuronal firing rate while amphetamine may increase it. Basically amphetamines are a little "dirtier" drug. So a lot of child psychiatrists prefer to use methylphenidate first just like we prefer SSRIs for depression over the more complex TCA molecules. There really isn't a lot of clinical difference regarding tolerability and effectiveness per the literature overall, though. So in the end it's more of an "art of medicine" thing we do. Amphetamine racemic salts have been more affordable and available in the past.

Edit: Don't be an ignorant NP/PA and prescribe both amphetamine and methylphenidate. Methylphenidate will inhibit amphetamines effects on mononoamine transporters.

 

[randomdoc1]

Adderall IR, 60mg day one baby.

 

[wolfvgang22]

Adderall IR, 60mg day one baby.

This is a joke, don't do this. Little Johnny's mom may not appreciate it. Also, it's probably better to be conservative with stimulant medications. I have a 250lb not obese adult male who was diagnosed with ADHD as a child on Adderall 10mg daily. His job performance, family relationships, and school performance all improved, but it's probably mainly placebo effect. I don't care and don't tell him, it's working.

 

[TexasPhysician]

Personal preference is going to determine what you use. I prefer Amphetamines to Methylphenidates. Amphetamines are FDA approved at a lower age and better tolerated in my population. I don’t doubt the reverse to be true elsewhere.

 

[hamstergang]

Edit: Don't be an ignorant NP/PA and prescribe both amphetamine and methylphenidate. Methylphenidate will inhibit amphetamines effects on mononoamine transporters.

Are you saying that a methylphenidate-based stimulant will prevent an amphetamine-based stimulant from having any action?

 

[wolfvgang22]

Are you saying that a methylphenidate-based stimulant will prevent an amphetamine-based stimulant from having any action?

No. I'm saying it will inhibit the release of monoamines from the presynaptic neuron by the action of amphetamine on the monoamine transporter system, so it will reduce the effectiveness of the amphetamine.

 

[thoffen]

No. I'm saying it will inhibit the release of monoamines from the presynaptic neuron by the action of amphetamine on the monoamine transporter system, so it will reduce the effectiveness of the amphetamine.

Thanks for this. I'm happy to say I was an ignorant MD to this one.

 

[PistolPete]

Personal preference is going to determine what you use. I prefer Amphetamines to Methylphenidates. Amphetamines are FDA approved at a lower age and better tolerated in my population. I don’t doubt the reverse to be true elsewhere.

The FDA bit is precisely why I start Adderall on 5 year olds, for example, when the ADHD diagnosis is clear, instead of Ritalin, even if I have to fill out prior auth paperwork

 

[Blitz2006]

Any evidence on the different formulations of methylphenidate (concerta vs. focalin vs. ritalin)? Or do they all work the same?

Also, I come across patients that have been prescribed Adderal IR AND XR...is this needed or just one formulation is appropriate?

 

[Amygdarya]

Also, I come across patients that have been prescribed Adderal IR AND XR...is this needed or just one formulation is appropriate?

I've heard that it's not uncommon, the reason being that there are quite a few patients who take XR in the morning and crush in the afternoon, so they take IR in the afternoon, especially if their job/school requires some work in the evenings.

 

[Blitz2006]

I've heard that it's not uncommon, the reason being that there are quite a few patients who take XR in the morning and crush in the afternoon, so they take IR in the afternoon, especially if their job/school requires some work in the evenings.

So if I were to use both, what is the maximum, a combined of 60 mg?

I know for IR, maximum daily total dose is 40 mg
For XR, maximum daily total dose is 60 mg.

But if I prescribed both? Its obviously not 100 mg/day...

 

[randomdoc1]

So if I were to use both, what is the maximum, a combined of 60 mg?

I know for IR, maximum daily total dose is 40 mg
For XR, maximum daily total dose is 60 mg.

But if I prescribed both? Its obviously not 100 mg/day...

Or is it....?
jk

 

[Merovinge]

So if I were to use both, what is the maximum, a combined of 60 mg?

I know for IR, maximum daily total dose is 40 mg
For XR, maximum daily total dose is 60 mg.

But if I prescribed both? Its obviously not 100 mg/day...

FDA max dosages are garbage for many things, particularly stimulants. AACAPs guidelines are much more reasonable. I have gone up to 60mg total daily dose and while its fine, I would say rarely do patients require that much.

 

[whopper]

Thanks for this. I'm happy to say I was an ignorant MD to this one.

I say this not with criticism. I find it fascinating how so many things in medicine fly without us MDs knowing WTF we're doing with it.
E.g. I know so many PCPs that prescribe SSRIs and don't know how they work, don't know that higher dosages work better, nor know that they got to give it a month at a high dose before they can rule out if it worked or not. PCPs are the largest demographic of physicians that prescribe SSRIs!!! And Goddammit antidepressant treatment is one of the things they get trained in residency. Yeah not as much as we do but they get it too.

While I was a professor I always told the medstudents and residents not going to psychiatry that I expected them to at least know the 1 month at a high dosage rule. That's freaking it. Just freaking know that if you are going to keep one thing in your brain and you're already going to be a light-year ahead of the other PCPs prescribing antidepressants who don't know what they're doing.

And this Methylphenidate/Adderall is one of those things too where for several months I was like "WTF!!!" nothing conventional is explaining WTF the differences are.

Sorry for the hyperbole but this is one of those problems that is so simple yet continues to go on with no one really addressing it in formal training or the conventional textbooks.

 

[hamstergang]

Thanks for this. I'm happy to say I was an ignorant MD to this one.

I also did not know this. Never really thought to use these meds in combination, so never even crossed my mind.