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ADHD - Pediatrics Medication Table

ADHD - Pediatrics Medication Table - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Psychiatry, Related


26
Appendix D
Medications for Treatment of Attention-Deficit/Hyperactivity Disorder (Pediatric)
GENERAL CONSIDERATIONS FOR STIMULANTS
ξ Despite lack of FDA approval for age <6 years, safety and effectiveness have
been demonstrated and off label use may be appropriate in selected children
under 6.1,3-5 Consultation with Pediatric Psychiatry is encouraged.
ξ Initiate therapy with a long acting stimulant to promote continuous, stable
therapy throughout the day.
ξ Consider duration of formulation with regard to interference with sleep
ξ Because of different stimulant combinations (methylphenidate or
amphetamine) and kinetic profiles, do not substitute on a mg-per-mg basis.
ξ Nonabsorbable tablet shell may be seen in stool (Concerta)
ξ Monitor patient weight and vital signs
ξ Swallow tablets whole with liquids. If patient is unable to swallow,
consider alternative formulations or capsules may be opened and
sprinkled on food. Beads inside capsules should NOT be chewed.
ξ Consider cardiac risk factors prior to initiating therapy (e.g., cardiac
hypertrophy, family history of ventricular arrhythmia, murmur,
palpitations, near syncope)
ξ Use cautiously if history of tics, seizures, anorexia nervosa, anxiety,
or history of substance misuse or diversion
ξ Most common side effects include appetite suppression, weight loss,
insomnia or headache
Methylphenidate Products
Product Names Strengths Available
Duration
of Action
Usual Dosing
Pediatric Titration Dose
(titrate every 7 days, unless
otherwise indicated)
Maximum Daily Dose
Short acting
methylphenidate tab^* (Ritalin) 5,10, 20 mg tabs ≤ 4 hours 5-20 mg given 2-3 times dailyTitrate by 5-10 mg every 7-14 days
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate tab ^* (Methylin)
(equivalent to Ritalin)
2.5, 5, 10, 20 mg tabs
5 mg/5mL, 10mg/5mL
solution
2.5, 5, 10 mg chew tabs
≤ 4 hours
5–20 mg given 2-3 times daily
Titrate by 5-10 mg every 7-14 days
FDA: 60 mg
Off label: 100 mg if over
50 kg
Intermediate
acting 4-6
hours
methylphenidate SR tab^*
(Ritalin SR) 20 mg tabs 4 – 6 hours
20–60 mg (divided in 1-2 doses/day)
(20-40 mg in morning, 20 mg in
early afternoon)
Titrate by 20 mg/day
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate^* (Methylin ER)
(equivalent to Ritalin SR) 10,20 mg tabs 4 – 6 hours 10-60 mg daily
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate ER tab^*
(Metadate ER) 20 mg tabs 4 – 6 hours
20-60 mg daily (divided in 1-2
doses/day)
FDA: 60 mg
Off label: 100 mg if over
50 kg
dexmethylphenidate^* (Focalin) tab 2.5, 5, 10 mg tabs 4 – 6 hours 2.5–10 mg given twice daily at least
twice daily at 4 hours apart
FDA: 20 mg
Off label: 50 mg
ADHD – Pediatric – Ambulatory Guideline
Copyright © 2016 University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2016CCKM@uwhealth.org

27

Intermediate
acting 6-8
hours
methylphenidate* ^ (Metadate CD)
cap (bimodal release with 30% rapid
onset and 70% delayed release)
10, 20, 30, 40, 50, 60
mg caps 6 – 8 hours
10-60 mg daily
Titration 10-20 mg
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate ER*^§ (Ritalin LA)
cap (bimodal release with 50% rapid
onset and 50% delayed release)
10, 20, 30, 40 mg caps 6 – 8 hours 20-60 mg daily
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate § (Aptensio XR)
cap (bimodal release with 40% rapid
onset and 60% delayed release)
10, 15, 20, 30, 40, 50,
60 mg caps 8 hours
10 mg daily
Titrate every week FDA: 60 mg
Long acting
dexmethylphenidate*^§ (Focalin XR)
cap (bimodal release with 50% rapid
onset and 50% delayed release)
5, 10, 15, 20, 25, 30,
35, 40 mg caps

(25 & 35 mg are not
available generic)
10 - 12
hours
5-20 mg
once daily
5–40 mg daily
(titrate by 5 mg for children)
FDA: 30 mg for children,
40 mg adults
Off label: 50 mg
methylphenidate ^ (Daytrana) patch
apply to hip for 9 hours
10, 15, 20, 30 mg patch
12 hours
(with 2 -3
hour delay)
10-30 mg patch daily
Titrate by next highest strength patch FDA: 30 mg
methylphenidate *^§ (Concerta) tabs
(bimodal release with 22% rapid
onset and 78% delayed release)
18, 27, 36, 54 mg tabs 10 hours 18-54 mg once daily
(titrate by 18 mg)
FDA: 54 mg for children,
72 mg for adolescents
and adults
Off label: 72 mg
(children ≤ 40 kg),
90 mg adolescents
(>40 kg)
methylphenidate chew tabs
(Quillichew ER chew tabs)
20, 30, 40 mg
chewable tabs 12 hours
20 mg once daily
(titrate by 10 mg/week) FDA: 60 mg
methylphenidate susp (Quillivant
XR)
5 mg/mL suspension
(fruit flavored)
12 hours
20 mg once daily
(titrate by 10 mg/week) FDA: 60 mg
^ FDA approved for treatment of ADHD, * Generic product, §Oral long acting methylphenidate products have immediate release and extended release
components. Vary by product
.
Medications which can be sprinkled on food
- methylphenidate (Ritalin LA)
- methylphenidate (Metadate CD)
- methylphenidate (Aptensio XR)
- dexmethylphenidate (Focalin)
- amphetamine (Adderall)
- dextroamphetamine (Dexedrine
spansules)

ADHD – Pediatric – Ambulatory Guideline
Copyright © 2016 University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org

28

Amphetamine Products
Product Names Strengths Available Duration of Action
Usual Dosing
(titrate every 7 days,
Unless otherwise noted)
Maximum Dose
Short acting
dextroamphetamine tabs* (Dexedrine)


dextroamphetamine tabs (Zenzedi)
5, 10 mg tabs
1 mg/mL solution

2.5, 5, 7.5, 15, 20, 30
mg tabs
4-6 hours
2.5 -15 mg two to three times
daily. Titration 2.5 mg/week
(3-5 years),
5 mg/week (≥ 6 years)
FDA: 40 mg
Off label: 60 mg
(>50 kg)
amphetamine sulfate* (Evekeo) tabs 5, 10 mg tabs 4-6 hours 2.5 mg Titrate by 2.5 mg weekly FDA: 40 mg
Intermediate
acting
dextroamphetamine SR caps*§
(Dexedrine spansules)
bimodal release with immediate and
delayed onset
5, 10, 15 mg caps 6-8 hours 5-15 mg 2 times twice daily Titration 5 mg
FDA: 40 mg
Off label: 60 mg
(>50 kg)
amphetamine mixed salts tab
^combo*§ (Adderall) *§
5, 7.5, 10, 12.5, 15, 20,
30 mg tabs 5-8 hours
52.5-30 mg
1-2 times once or twice daily
Titration 2.5-5 mg once
or twice daily
FDA: 40 mg
Off label: 40 mg
(≤ 50kg), 60 mg
(>50 kg)
Long acting
amphetamine mixed salts caps^*
combo (Adderall XR)*
5, 10, 15, 20, 25, 30
caps
10 hours
10-30 mg once daily
Titration 5-10 mg
FDA: 30 mg
Off-label: 30 mg
(≤ 50kg),
60 mg (>50 kg)
lisdexamfetamine (Vyvanse) caps^§ 20, 30, 40, 50, 60,
70 mg capsule
10-12
hours
20-70 mg once daily
Titration 10-20 mg daily FDA: 70 mg
dextroamphetamine/amphetamine
biphasic tab (Adzenys XR ODT)
3.1, 6.3, 9.4, 12.5,
15.7, 18.8 mg ODT 9-14 hours Titrate 3.1 mg weekly FDA: 18.8 mg
dextroamphetamine/amphetamine XR
oral suspension (Dyanavel) 2.5 mg/mL
10-12
hours
2.5-5 mg every am
Titrate every 4-7 days FDA: 20 mg
^ FDA approved for treatment of ADHD, * Generic product, §Oral long acting amphetamine products have immediate release and extended release
components. Vary by product





ADHD – Pediatric – Ambulatory Guideline
Copyright © 2016 University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org

29

GENERAL CONSIDERATIONS FOR NON-STIMULANTS
ξ Despite lack of FDA approval for age < 6 years, there is potential benefit in a
cohort of patients less than age 6; use may be considered in selected
populations.62-65 Consultation with Pediatric Psychiatry is strongly
encouraged for children under 6 years of age.
ξ Consider initiation with lower doses to improve tolerability
ξ Medication of choice if concern about abuse or diversion
ξ Monitor patient weight and vital signs
ξ Can be used in patients with history of tics or worsening of tics from
stimulants
ξ Sedation can occur with atomoxetine, clonidine and guanfacine
ξ Avoid bupropion if history of seizure disorders
ξ Taper off to avoid rebound hypertension for clonidine or guanfacine
ξ Consider cardiovascular risk factors before initiating tricyclics,
atomoxetine, bupropion, guanfacine
ξ Monitor closely for behavioral side effects including suicidal ideation
with atomoxetine and bupropion (see Black Box Warning)
ξ Guanfacine and clonidine may be used as adjunctive therapy with
stimulants.

Non-Stimulant Products
Product Names Strengths Available
Duration of
Action
Usual Dosing
(titrate every 7 days, until
otherwise indicated)
Maximum Dosing
Anti-depressants
bupropion* (Wellbutrin) tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
75, 100 mg tabs 4-5 hours
3 -6 mg/kg/day (or 150 mg – 300 mg,
whichever is lowest)
Divide into 2 or 3 daily doses
6 mg/kg/day (or 300 mg
Whichever is lowest)
Divide into 2 or 3 daily
doses
bupropion SR* (Wellbutrin SR)
tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
100, 150, 200 mg
tabs
12 hours
3 -6 mg/kg/day (or 150 mg – 300 mg,
whichever is lowest)
Divide into 2 daily doses.
6 mg/kg/day (or 300 mg,
whichever is lowest)
Divide into 2 daily doses.
bupropion XL* (Wellbutrin XL)
tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
150, 300 mg tabs 24 hours 3 -6 mg/kg/day (or 150 mg – 300 mg, whichever is lowest)
6 mg/kg/day (or 300 mg
Whichever is lowest)
Norepinephrine
reuptake inhibitor
atomoxetine^ (Strattera) caps 10, 18, 25, 40, 60,
80, 100 mg caps
At least 10-
12 hours
0.5 mg/kg/day (≤ 70kg) or 40 mg/day
(>70 kg) to 1.4 mg/kg/day (≤ 70kg) or
100 mg/day (dose given once or twice
daily)
Titration: after 3-4 days
FDA: 1.4 mg/kg/d (≤
70kg),
children/adolescents;
100 mg/day (>70kg)
*Generic product
^ FDA Approved


ADHD – Pediatric – Ambulatory Guideline
Copyright © 2016 University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org

30

Alpha-agonists
clonidine ER*^ (Kapvay) tabs 0.1mg ER tabs At least 10-
12 hours
0.1-0.4 mg/day
Titration: 0.1 mg FDA: 0.4 mg
clonidine* (Catapres) tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
0.1, 0.2, 0.3 mg tabs At least 4-6
hours
0.05 mg
at bedtime; 01 mg (≥ 45 kg)
Titrate by 0.05 mg (<45 kg) or 0.1 mg
(≥ 45 kg) increments to twice daily,
three times daily, four times daily
0.2 mg (27 – 40.5 kg)
0.3 mg (40.5-45 kg)
0.4 mg (>45 kg)
guanfacine* (Tenex) tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
1, 2 mg tabs 6-8 hours
0.5 mg at bedtime (<45 kg),
1 mg at bedtime (≥ 45 kg)
Titrate by 0.5 mg (<45 kg) or 1 mg
(≥ 45 kg) increments to twice daily,
three times daily, four times daily
2 mg (27–40.5 kg)
3 mg (40.5- 45 kg)
4 mg (>45 kg)
guanfacine ER^* (Intuniv) tabs 1, 2, 3, 4 mg ER
tabs
At least 10-
12 hours
1-4 mg once daily
(or 0.05-0.12 mg daily) Titration: 1 mg FDA: 4 mg
*Generic product
^ FDA Approved

Potential Harms: Side Effects of Pharmacotherapy
ξ The U.S. Food and Drug Administration (FDA) and its Pediatric Advisory Committee have reviewed data regarding psychiatric adverse events to
medications for the treatment of attention deficit/hyperactivity disorder (ADHD). For each agent examined (all stimulants, atomoxetine), there were
reports of rare events of psychotic symptoms, specifically involving visual and tactile hallucinations of insects. Symptoms of aggression, suicidality
(but no completed suicides), and cardiovascular issues were also reported.
ξ Stimulants: The most common side effects include appetite decrease, weight loss, insomnia, or headache. Less common side effects include tics
and emotional lability/irritability, liver toxicity, hypertension, cardiac arrhythmia and psychosis.
ξ Atomoxetine: Side effects of atomoxetine that occurred more often than those with placebo include gastrointestinal distress, sedation, and
decreased appetite.
ξ Bupropion may cause mild insomnia or loss of appetite. The highest recommended dose of bupropion is 450 mg. Higher doses may increase the
risk of seizure.
ξ Alpha- agonists: Side effects of alpha-agonists include sedation, dizziness, and possible hypotension. Abrupt discontinuations of alpha-agonist are
to be avoided.
ξ Combinations of Medications: There have been four deaths reported to the FDA of children taking a combination of methylphenidate and
clonidine, but there were many atypical aspects of these cases.
ADHD – Pediatric – Ambulatory Guideline
Copyright © 2016 University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org