ADHD Stimulants: Methylphenidate and Amphetamine Formularies

00:00 As a provider. When you're considering prescribing methylphenidate, you want to think about the formularies and the availability of methylphenidate.

00:08 Now, three major categories.

00:09 You'll have immediate release.

00:11 You'll have extended intermediate duration, and you'll have extended duration.

00:16 Now there's a couple of words that I want to go over just in case they're unfamiliar to you. The first one is enantiomers and the second one is a racemic mixture.

00:27 Okay. So you see that on the screen.

00:29 Take a look at that drawing of the molecule.

00:32 Now you'll see that with the enantiomers there's a pair of molecules.

00:36 And they exist in two forms.

00:37 But they're mirror images of one another.

00:39 But you can't put them on top of each other.

00:42 Now think about right hand left hand right.

00:44 If I put them on top of each other, they don't match up.

00:48 But they are mirror images of one another.

00:52 So these types of enantiomers cannot be superimposed on top of each other, but they have the same chemical makeup.

00:59 So if you look at the image there you can see how you have the molecule.

01:02 They are just mirror images of the other.

01:05 It's like having a pair of gloves, right? The thumb is in an opposite place, just like it would be on your hand.

01:12 Now, the other Word terminology is a racemic mixture.

01:15 Now that's a mixture of two chiral molecules that are the enantiomers.

01:19 Good job. Where half of the molecules are dextrorotatory, that means they're kind of right handed. And the other half of the molecules are levorotary or left handed, and they're in a 50 over 50 ratio.

01:32 You're welcome. There's some fun words you can try out with your friends and family later on. So there's methylphenidate, HCL, and Dexmethylphenidate.

01:41 Now you've got the names there.

01:43 Under methylphenidate you have Ritalin, methylene solution and chewable versions.

01:47 Now adults you're going to start at five milligrams twice a day with a max dose of 60mg a day.

01:52 Obviously you would work up to that slowly.

01:55 And for younger children, you want to start them at 2.5mg bid with a maximum dose of 1mg/kg per day.

02:03 Now you look at the dexmethylphenidate you've got by the trademark name of Focalin.

02:08 Now, this roughly has double the potency as methylphenidate, and you would start them at a lower dose. So you start with 2.5mg twice a day with a maximum dose of 20mg daily.

02:20 Methylphenidate and dexmethylphenidate are immediate release, so they're going to kick in within 3 to 6 hours.

02:27 The next category is the extended intermediate duration, which is 6 to 8 hours.

02:33 Now the examples of that would be Metadate er standing for extended release Metadate CD or Ritalin LA.

02:41 Now for adults with these medications, you would start at ten milligrams every morning with a maximum dose of 60mg daily.

02:48 For younger children, obviously much lower.

02:50 Max is 1.5mg/kg every day.

02:54 The third category is the extended duration.

02:56 Now, when the immediate kicks in right away at 3 to 6, the intermediate was 6 to 8.

03:02 This is up to 12 hours.

03:04 On the left hand side.

03:06 You've got four examples there.

03:07 And I left you a little note on the third one on the right though.

03:11 This is what I what I wanted to focus on is Concerta.

03:14 It has some unique things, particularly in how it's delivered.

03:17 Now Concerta is methylphenidate with an extended release system.

03:22 Now it uses osmotic release oral system.

03:25 That's how this drug gets into the body in a very slow way.

03:29 An osmotic release oral system is this advanced, sustained release of the medication, the methylphenidate, because it uses this semi-permeable outer membrane that has small laser drilled holes in it.

03:41 So the osmotic pressure in the patient's body is going to push the active drug ingredient into the GI system very slowly.

03:48 That's why this medication has to be swallowed whole.

03:51 You're going to start around 18mg with a maximum dose being 72mg.

03:57 Now here's additional ones that are the extended long duration.

04:00 You've got daytrana which the helpful thing about that is it's a patch.

04:04 So the patient can use a transdermal patch, particularly if they have a difficult time swallowing pills. You've got Focalin XR, you've got journey.

04:11 You can start at 20mg.

04:13 The max dose is up to up to 100 and then you've got coolavin, so you've got 20mg in the morning. The maximum dose is again, that's 60mg, which you've seen repeated for other medications.

04:23 And when you titrate this medication, you're going to want to titrate it by increments of ten milligrams.

04:29 The amphetamine formularies are also divided or categorized by how long they act.

04:34 You have the short acting, which is 3 to 6 hours.

04:37 The extended release 10 to 12 hours, and the extra long duration, which is up to 16 hours, which you'll notice is longer than the longest duration we talked about with methylphenidate. So when you're looking at the formularies, let's go back and take a look at the short acting.

04:53 You'll see first on the left.

04:54 Let's start with the mixed amphetamine salts or what you may know as Adderall.

04:59 Now it's called mixed amphetamine salts because it's equal parts of dextroamphetamin and racemic amphetamine.

05:06 You have both the D and the L for adults.

05:09 The dosage would be to start at five milligrams daily with a maximum dose of 40mg.

05:13 Now, for younger kids, you're going to want to start at 2.5mg daily.

05:17 And a max is 0.5mg/kg per day.

05:22 Now the other two options be dextroamphetamin or amphetamine.

05:26 That's racemic amphetamine.

05:28 Now remember these agents can be used initially in children less than 16kg at 2.5mg daily. Adderall XR is an example of an extended release amphetamine formulary.

05:41 Now this should last around the 10 to 12 hour time range.

05:45 Now you have both the D and L amphetamine oral suspension, and it's 1.25mg amphetamine per milliliter. So you would start your client at 6.3mg every morning by mouth.

05:57 Now you can increase this by 3.1mg or 6.3mg per week to a maximum dose of 18.8mg per day.

06:06 Now, children that are greater than or equal to 6 to 12 years of age, that will work.

06:11 But if the child is greater than 13 years of age, 12.5mg per day is the maximum.

06:17 Lisdexamfetamine is another example of the extended release the 10 to 12 hour range amphetamine formulary.

06:24 Now, lisdexamfetamine is a prodrug of dextroamphetamin.

06:28 It's known as vyvanse.

06:31 Now, lisdexamfetamine gets hydrolyzed to l-lysine and the active ingredient d-amphetamine. You'll want to start with 20mg daily, with a maximum of 70mg a day.

06:42 Now the capsule can be opened and mixed with food if the patient has difficulty with swallowing. The last category of amphetamine formularies is pretty impressive.

06:50 Remember, it's got an extra long duration of up to 16 hours, which makes the timing of the medication a little tricky.

06:58 Now an example is my dais.

06:59 This is a mixed amphetamine salt.

07:02 It's a triple bead preparation and you use it with clients only 13 years and older.

07:07 You're going to want to start with a 12.5mg dosage, with a maximum of 25mg dosage per day. That wraps up our discussion on the use of stimulants, both methylphenidate and amphetamines, in the treatment of ADHD.