Choice of stimulant

There is no clear evidence to suggest that one stimulant is more effective than another for ADHD in children. Individual response to stimulants varies; if a child does not respond to one stimulant, it is likely that they will respond to another. Stimulant choice may also be influenced by tolerability.

Stimulants and their formulations can be distinguished by their duration of effect (see Stimulants for attention deficit hyperactivity disorder and their duration of effect).

When deciding which drug or formulation to initiate treatment with, consider factors such as:

• the convenience of once-daily dosing versus multiple-daily dosing
• the possibility of increased adherence with once-daily dosing
• any issues with storing a controlled drug at school
• the risk of diversion and misuse
• the potential to reduce stigma associated with taking medication at school
• the pharmacokinetic profile of the formulation, to avoid reduced effect or excessive adverse effects at certain times of the day
• accessibility of the drug on the Pharmaceutical Benefits Scheme (PBS).

There is significant interindividual variability in stimulant dosing requirements in children, and doses should be titrated according to response and tolerability. Optimised dosing may require trials of different regimens—for example:

• more frequent dosing (eg giving a small additional dose in the mid-afternoon)
• switching from a short- to a long-acting formulation
• combining short- and long-acting formulations.

If a patient’s symptoms have not significantly improved, despite optimising the dosage regimen and using the maximum tolerated dose for 1 month, trial another stimulant. A child who does not respond to or cannot tolerate the first stimulant may still respond to or tolerate another stimulant. If there is still no response to adequate trials of stimulants, review the diagnosis, consider possible comorbid diagnoses, and consider alternative pharmacotherapy for ADHD.

Because of the anorectic properties of stimulants, doses should be given at or immediately after meals. Avoid late evening doses to reduce the risk of developing tolerance and insomnia. In obese children, use ideal body weight when calculating the maximum dose.

There is a lack of consistent evidence for dosing of methylphenidate. Treatment is usually initiated with the short-acting formulation to determine the effective dose. If short-acting methylphenidate is preferred for ADHD in a child 6 years or older, a suitable regimen is:

Once the optimal dose of short-acting methylphenidate is established, consider switching to a long-acting formulation. The choice of formulation depends on whether control of symptoms was achieved with twice or three-times daily dosing, and whether an 8- or 12-hour duration of effect is desired. If previous control was achieved with twice-daily dosing, a formulation that provides an 8-hour duration of effect is most suitable. If previous control was achieved with three-times-daily dosing, a formulation that provides a 12-hour duration of effect is most suitable. The starting dose of the long-acting formulation should be as close as possible to the patient’s total daily dose of the short-acting formulation. If long-acting methylphenidate is preferred for ADHD in a child 6 years or older, a suitable regimen is:

If dexamfetamine is preferred for ADHD in a child 6 years or older, a suitable regimen is:

If lisdexamfetamine is preferred for ADHD in a child 6 years or older, a suitable regimen is:

For patients switching to lisdexamfetamine from another stimulant (eg dexamfetamine, methylphenidate), the starting dose of lisdexamfetamine is 30 mg regardless of the daily dose of stimulant the patient was stable on.