Dr. Larry Silver: Update on ADHD Medications
By: Larry B. Silver, M.D.
Over the past few years there have been additions to the list of medications for ADHD. All but one are the same basic medications we have always used but using different release mechanisms that extend the time they are effective. The one new medication is Focalin, released by the company that produces Ritalin. This article is meant to be an overview. The reader should read the literature from the pharmaceutical company to learn the specific details.
The pharmaceutical companies that make these new, longer-lasting products advertise that they last all day or that they cover the whole school day. This might not be a correct statement for your child.
There are three basic stimulant medications used for ADHD: methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and dextroamphetamine plus levoamphetamine (Adderall). Very recently a modification of methylphenidate was released, Focalin.
To summarize these additions:
- Brand Name: Ritalin Ritalin SR 20
- Longer-acting forms: Metadate ER Metadate CD Concerta
- Brand Name: Dexedrine
- Longer-acting form: Dexedrine Spansule
- Brand Name Adderall
- Longer-acting form: Adderall XR
- Brand Name Focalin
This product has been available since 1954. The brand name is Ritalin. Each tablet last about four hours and comes in a 5 mg, 10 mg and 20 mg size.
The longer-acting form has also been available, Ritalin-SR20. (SR means sustained release; 20 means that the total amount of methylphenidate is 20 mg.) The mechanism of action releases 10 mg initially and 10 mg four hours later. Note that "SR20" does not mean that the person gets 20 mg over eight hours. The surface of the SR product can not be crushed, chewed, or cut. If the surface is broken, all of the medication will be released at once. The release process has been inconsistent. Sometimes it last six hours and sometimes each release lasts thee hours, resulting in down times between hours three and four of each release.
Metadate is a longer-acting methylphenidate. It comes in two forms, Metadate ER and Metadate CD. Metadate ER is designed to last eight hours. It comes in a 10 mg and a 20 mg strength. The Metadate ER 10 mg releases the equivalent of 5 mg initially and 5 mg four hours later. The Metadate ER 20 mg releases the equivalent of 10 mg immediately and 10 mg four hours later. (Again, do not be confused by the number, thinking that this is the level released.) The surface of the tablet can not be broken. If it is, all of the medication is released immediately.
Metadate CD is the newest form of this brand and lasts eight hours. It is a capsule with multiple beads inside. 6 mg are released initially and 14 mg are released over the remainder of time. Unlike the Metadate ER, the capsule can be opened and the beads sprinkled over food and taken in this way.
Concerta is a long acting form of methylphenidate that uses a unique and different release mechanism. It slowly releases the medication in an even flow over 10 to 12 hours. The full length of action may vary with each person. The conversion model between methylphenidate and Concerta is as follows:
If the person has been taking methylphenidate The equivalent Concerta is
5 mg three times a day Concerta 18 10 mg three times a day Concerta 36 15 mg three times a day Concerta 54 20 mg three times a day two Concerta 36*
*A 72 mg form will be coming out soon
Concerta must be used as a whole capsule. If the surface is broken by chewing or cutting it in half, the release mechanism will not work.
This product has been available in the tablet form since the 1950s. The brand name, Dexedrine, comes in a 5 mg tablet only. Thus, the individual would take multiple tablets to equal the dose desired. The generic form, Dextrostat, comes in a 10 mg strength.
The longer-acting form is Dexedrine Spansule. It comes in a 5 mg, 10 mg, and 15 mg strength. If the individual needs a 20 mg strength, two 10 mg spansules are used. The spansule is a capsule with small beads inside and releases a steady strength of the dose over eight hours. It, too, can be opened and sprinkled over food.
Dextro-Amphetamine and Levo-Amphetamine
The trade name is Adderall. There are no generic forms at this time. The shorter-acting tables come in 5 mg, 10 mg, 20 mg, and 30 mg strengths. Each is scored so that by breaking it in half, the physician can set an individual dose from 2.5 mg to 20 mg. (The 30 mg is to provide the flexibility of a 15 mg dose; it is not recommended that 30 mg be used for an individual dose.) The ads state that one dose will last through the school day. In reality, each tablet lasts for an average of five hours.
The new, longer-acting form is Adderall XR. It comes in a 10 mg, 20 mg, and 30 mg capsule. Fifty percent of the beads release immediately and 50 percent are released slowly over about 8 hours. Thus, the Adderall XR 10 releases 5 mg immediately and 5 mg over the remaining time. The XR 20 releases 10 immediately and 10 over time. And, the XT 30 releases 15 mg immediately and 15 mg over time. Again, do not misunderstand the amount in the name as the amount released at any one time. Like the other capsules with beads, it can be opened and sprinkled over food.
Focalin is a new product. It is a refined form of Ritalin. The pharmaceutical company studied the two forms of methylphenidate, dextro-methylphenidate and levo-methylphenidate, and found that the dextro form was significantly more potent than the levo form. Focalin is dextro-methylphenidate. Each tablet is described as being twice as effective as Ritalin. Thus, half the dose that was used with Ritalin is needed. It comes in a 2.5 mg, 5 mg, and 10 mg strength. This is equivalent to the 5 mg, 10 mg, and 20 mg Ritalin tablets. Each tablet lasts about four hours.
Be an informed consumer
Labels and strengths can be misleading. The length of action advertised may be exaggerated and you must learn how long it last for each individual. The numbers in the name of the product can be misleading, suggesting that this is the amount released throughout the time of effectiveness.
It is difficult to know which medication is best for which individual. Also, although there are common side effects, some individuals have these side effects with one product and not with another. It takes trial and experience to find the best medication, dose, and timing.
When using a longer-acting form of a medication, be sure to learn how long it lasts. It may be necessary to add a short-acting tablet to cover the end of the day. For example, if a student takes a Concerta tablet at 7:00 A.M., it might wear off between 5:00 and 7:00 P.M. If homework is done until 9;00 or 10:00 P.M., a short acting methylphenidate might be needed to cover the end of the day. If the eight hour longer-acting tables are used, they might wear off at about 3:00 or 4:00 P.M. and a shorter acting tablet might be needed to cover homework.
This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition.
Dr. Larry Silver May 2002