Intermediate- and long-acting medications for children with attention deficit hyperactivity disorder

Medication	United States trade name (generic availability)	Description of release and duration of action	Initial dose^*	Dose advancement	Maximum dose (per day)
Methylphenidate
Methylphenidate ER chewable tablets 20 mg (scored), 30 mg (scored), 40 mg (not scored)	Quillichew ER	Continuous release over 6 to 8 hours with duration of action up to 13 hours.	20 mg	Increments of 10 mg, 15 mg, or 20 mg per day every 7 days	60 mg
Methylphenidate XR-ODT 8.6, 17.3, 25.9 mg tablets as methylphenidate base (equivalent to 10, 20, 30 mg of methylphenidate hydrochloride)^¶	Cotempla XR-ODT	25% immediate-release and 75% extended-release for duration of action up to 12 hours. Whole tablet must be dissolved on tongue; should be taken consistently either with or without food.^Δ	17.3 mg	Increments of 8.6 to 17.3 mg per day every 7 days	51.8 mg
Methylphenidate ER (OROS) 18, 27, 36, 45, 54, 63, 72 mg tablets	Concerta, Relexxii^◊	20% immediate-release and 80% continuous-release over 10 to 12 hours by osmotic delivery. Tablet must be swallowed whole.	18 mg	Increments of 9 to 18 mg per dose every 3 to 7 days	<13 years: 54 mg ≥13 years: 72 mg
Methylphenidate LA 10, 20, 30, 40 mg capsules	Ritalin LA (generic available)	50% immediate-release and 50% delayed-release over 8 to 12 hours (bimodal). Capsule may be swallowed whole or opened and contents sprinkled over a spoonful of cold applesauce and swallowed immediately; capsule or contents should not be crushed or chewed.	10 or 20 mg	Increments of 10 or 20 mg per dose every 3 to 7 days	≤50 kg: 60 mg >50 kg: 100 mg^§
Methylphenidate CD 10, 20, 30, 40, 50, 60 mg capsules	Metadate CD (generic available)	30% immediate-release and 70% delayed-release over 8 to 12 hours (bimodal). Capsule may be swallowed whole or opened and contents sprinkled over a spoonful of cold applesauce and swallowed immediately; capsule or contents should not be crushed or chewed.	20 mg	Increments of 10 mg per dose every 3 to 7 days	≤50 kg: 60 mg >50 kg: 100 mg^§
Methylphenidate XR 10, 15, 20, 30, 40, 50, 60 mg capsules	Aptensio XR (generic available)	40% immediate release and 60% controlled release for duration of action of 12 hours. Capsule may be swallowed whole or opened and contents sprinkled over a spoonful of cold applesauce and swallowed immediately; capsule or contents should not be crushed or chewed.	10 mg	Increments of 10 mg every 7 days	60 mg
Methylphenidate XR oral suspension 5 mg/mL	Quillivant XR	20% immediate-release and 80% extended-release for duration of action up to 12 hours.	20 mg	Increments of 10 mg every 7 days	60 mg
Methylphenidate delayed and extended release capsules 20, 40, 60, 80, 100 mg capsules	Jornay PM	<5% of total drug is available within the first 10 hours after administration. Peak concentration occurs 14 hours after dose with gradual decline thereafter. Capsules may be swallowed whole or opened and the contents sprinkled over a spoonful of cold applesauce; capsule or contents should not be crushed or chewed.	20 mg per day in the evening (adjust timing to optimize tolerability and efficacy)	Increments of 20 mg per day every 7 days	100 mg
Methylphenidate transdermal patch^¥ 10, 15, 20, 30 mg patch	Daytrana (generic available)	Onset 2 hours after application of patch and continuous release over 9 to 12 hours.	10 mg^¥	Increments of 5 mg per dose every 3 to 7 days	30 mg
Dexmethylphenidate
Dexmethylphenidate XR 5, 10, 15, 20, 25, 30, 35, 40 mg capsules	Focalin XR (generic available)	50% immediate-release and 50% delayed-release over 10 to 12 hours (bimodal). Capsule may be swallowed whole or opened and contents sprinkled over a spoonful of cold applesauce and swallowed immediately; capsule or contents should not be crushed or chewed.	5 mg	Increments of 5 mg per dose every 3 to 7 days	40 mg
Serdexmethylphenidate-dexmethylphenidate 26.1 mg/5.2 mg, 39.2 mg/7.8 mg, 52.3 mg/10.4 mg capsules	Azstarys	70% serdexmethylphenidate (dexmethylphenidate prodrug) and 30% dexmethylphenidate (immediate release). Peak dexmethylphenidate concentration occurs approximately 2 hours after the dose (onset of action within 1 hour), with gradual decline thereafter for duration of action of up to 13 hours. Capsule may be swallowed whole or opened and contents sprinkled over 2 tablespoons of applesauce or into 50 mL of water and consumed within 10 minutes of mixing.	Age 6 to 12 years: 39.2 mg/7.8 mg	Increase or decrease by 13.1 mg/2.6 mg after one week	52.3 mg/10.4 mg
	Azstarys		Age ≥13 years: 39.2 mg/7.8 mg	Increase to 52.3 mg/10.4 mg after 1 week	52.3 mg/10.4 mg
Amphetamines
Dextroamphetamine-amphetamine ER 5, 10, 15, 20, 25, 30 mg capsules^‡	Adderall XR (generic available)	Combination of immediate- and continuous-release over 10 to 12 hours.	5 mg	Increments of 5 mg per dose every 3 to 7 days	≤50 kg: 40 mg >50 kg: 60 mg^†
Dextroamphetamine-amphetamine ER 12.5, 25, 37.5, 50 mg capsules^‡,**	Mydayis (generic available)	Combination of immediate- and two different delayed-release beads for duration up to 16 hours. Capsule may be swallowed whole or sprinkled over a spoonful of cold applesauce and swallowed immediately; capsule or contents should not be crushed or chewed.	12.5 mg	Increments of 12.5 mg every 7 days	13 through 17 years: 25 mg ≥18 years: 50 mg
Amphetamine ER Oral suspension 2.5 mg/mL (amphetamine base)^‡ 5, 10, 15, and 20 mg tablets (amphetamine base)^‡	Dyanavel XR	Combination of immediate- and extended-release for duration of action up to 13 hours. Tablets may be chewed or swallowed whole.	2.5 or 5 mg	Increments of 2.5 to 10 mg per day every 4 to 7 days	20 mg
Amphetamine ER ODT 3.1, 6.3, 9.4, 12.5, 15.7, 18.8 mg (amphetamine base)^‡	Adzenys XR-ODT	Combination of 50% immediate- and 50% extended-release; levels are comparable to dextroamphetamine-amphetamine ER capsules when equivalent doses are used.^‡	6.3 mg	Increments of 3.1 or 6.3 mg per day every 7 days	6 to 12 years: 18.8 mg ≥13 years: 12.5 mg
Dextroamphetamine SR 5, 10, 15 mg capsules	Dexedrine Spansule (10 mg only); generic available for all strengths	Combination of immediate- and continuous-release over 8 to 12 hours. May require dividing dose twice daily.	5 mg	Increments of 5 mg per day every 3 to 7 days	≤50 kg: 40 mg >50 kg: 60 mg^†
Dextroamphetamine transdermal patch^¥ 4.5, 9, 13.5, 18 mg per 9 hour patches	Xelstrym	Strength is amount of dextroamphetamine released from patch over 9 hours. Onset 2 hours after application of patch; continuous release from application site over 9 to 12 hours.	4.5 mg^¥	Increments of 4.5 mg per day every 7 days	18 mg
Lisdexamfetamine 10, 20, 30, 40, 50, 60, 70 mg capsules 10, 20, 30, 40, 50, 60 mg chewable tablets	Vyvanse (generic available)	Prodrug converted to dextroamphetamine in bloodstream with an effect over approximately 10 hours. Capsule may be opened and dissolved in water or juice for immediate use. Chewable tablets must be chewed completely before swallowing.	20 mg	Increments of 10 or 20 mg per day every 3 to 7 days	70 mg
Nonstimulants
Selective norepinephrine reuptake inhibitors
Atomoxetine 10, 18, 25, 40, 60, 80, 100 mg capsules	Strattera (generic available)	At least 10 to 12 hours. May administer in 1 or 2 divided doses.	≤70 kg: 0.5 mg/kg per day >70 kg: 40 mg	≤70 kg: Increase to 1.2 mg/kg/day after a minimum of 3 days >70 kg: Increase to 80 mg after a minimum of 3 days	≤70 kg: 1.4 mg/kg >70 kg: 100 mg
Viloxazine ER 100, 150, 200 mg capsules	Qelbree	Lasts throughout the day. Capsule may be swallowed whole or opened and contents sprinkled over a teaspoonful of applesauce and swallowed immediately; neither the capsule nor contents should be crushed or chewed.	Age 6 to 11: 100 mg	Increments of 100 mg weekly	400 mg
Viloxazine ER 100, 150, 200 mg capsules	Qelbree		Age 12 to 17: 200 mg	Increments of 200 mg weekly	400 mg
Alpha-2 adrenergic agonists
Guanfacine ER^¶¶ 1, 2, 3, 4 mg tablets	Intuniv (generic available)	At least 10 to 12 hours.	1 mg per day	Increments of 1 mg per day at no less than weekly intervals	≤12 years: 4 mg >12 years: 7 mg^ΔΔ
Clonidine ER tablets^¶¶ 0.1 mg	Generic available (Kapvay brand discontinued)	At least 10 to 12 hours.	0.1 mg at bedtime	Increments of 0.1 mg per day every 7 days; doses >0.1 mg per day are divided twice daily (either split equally or with higher dose administered at bedtime)	0.4 mg
Clonidine ER oral suspension^¶¶ 0.1 mg/mL	Onyda XR	At least 24 hours.	0.1 mg at bedtime	Increments of 0.1 mg per day every 7 days; administer total daily dose once daily at bedtime.	0.4 mg

CD: controlled dispense; ER: extended release; LA: long-acting; ODT: orally disintegrating tablet; OROS: osmotic controlled release formulation; SR: sustained release; XR: extended release.

* Suggested doses for initiating treatment with long-acting stimulant medications for treatment of children aged ≥6 years.

¶ Cotempla XR-ODT strengths are expressed by the manufacturer as methylphenidate base. Most other methylphenidate product doses are expressed as methylphenidate hydrochloride salt. Cotempla XR-ODT dose needs to be converted to methylphenidate hydrochloride for comparison with other methylphenidate products.

Δ Although the prescribing information indicates that Cotempla XR-ODT should be taken consistently with or without food, we suggest that it be taken consistently with food – given the general stimulant effect of appetite suppression.

◊ Generic (ie, nonproprietary) products are available, however they are not therapeutic equivalents to Concerta or Relexxii. Only Relexxii is available as 45, 63, and 72 mg tablets.

§ This maximum dose exceeds the US Food and Drug Administration (FDA)-approved maximum dose; careful monitoring for adverse effects is warranted.

¥ Patch is applied 2 hours before needed effect and worn for a total of 9 hours. Doses for the methylphenidate and dextroamphetamine patches are not equivalent to those for the oral preparations.

‡ Amphetamine ER oral suspension, tablet, and ODT strengths reflect milligrams of amphetamine base, whereas dextroamphetamine-amphetamine ER capsule strengths reflect milligrams of dextroamphetamine-amphetamine salts. These cannot be substituted on an mg-per-mg basis. Refer to UpToDate content related to dose equivalents of stimulants for attention deficit hyperactivity disorder in children.

† Doses above 40 mg per day total are rarely necessary and warrant close monitoring.

** Mydayis is not approved by the FDA for children <13 years.

¶¶ Different formulations (eg, immediate-release tablets, extended-release tablets, extended-release oral suspension) may not be substituted on a mg-for-mg basis due to pharmacokinetic differences. Discontinuation requires dose tapering to prevent rebound increase in blood pressure.

ΔΔ The typical maximum dose for this age group is 4 mg/day; a maximum dose of 7 mg/day may be used for adolescents >12 years who weigh >58.5 kg (120 pounds), but the 7 mg dose may be associated with somnolence.

Prepared with data from:

Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46:894.
Drugs for ADHD. Med Lett Drugs Ther 2020; 62:9.
Wender EH. Managing stimulant medication for attention-deficit/hyperactivity disorder. Pediatr Rev 2001; 22:183.
US Food and Drug Administration (FDA) approved product information. www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm (Accessed on March 26, 2024).

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Intermediate- and long-acting medications for children with attention deficit hyperactivity disorder