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Table 2 Summary of medications prescribed for the management of children and adults with ADHD

From: Adapting evidence-based clinical practice guidelines for people with attention deficit hyperactivity disorder in Saudi Arabia: process and outputs of a national initiative

Medications

Dose

Comments

Methylphenidate

Immediate-release

(RITALIN)

Child 4–5 years:

Starting dose: 2.5 mg twice daily, PO, increased in steps of 2.5 mg daily if required, at weekly intervals

Maximum dose: 1.4 mg/kg daily in 2–3 divided doses

Child 6–17 years:

Starting dose: 5 mg 1–2 times a day, PO, increased in steps of 5–10 mg daily if required, at weekly intervals increased if necessary up to 60 mg daily in 2–3 divided doses, increased if necessary up to 2.1 mg/kg daily in 2–3 divided doses

Maximum dose: 60 mg daily in 2–3 doses, higher dose (up to a maximum of 90 mg daily) under the direction of a specialist

Cautions:

Agitation, anxiety, drug dependence, epilepsy (discontinue if increased seizure frequency), family history of Tourette syndrome, susceptibility to angle-closure glaucoma, and tics

Contraindications:

Anorexia nervosa, arrhythmia, cardiomyopathy, cardiovascular disease, cerebrovascular disorders, heart failure, hyperthyroidism, phaeochromocytoma, psychosis, severe depression, severe hypertension, structural cardiac abnormalities, suicidal ideation, uncontrolled bipolar disorde, and vasculitis

Common side effects:

Alopecia, anxiety, decreased appetite, arrhythmias. Arthralgia, Abnormal behaviour, cough, depression, diarrhoea, dizziness, drowsiness, dry mouth, fever, gastrointestinal discomfort, growth retardation, headaches, hypertension, laryngeal pain, altered mood, movement disorders, nasopharyngitis, nausea, palpitations, sleep disorders, vomiting, and decreased weight

Modified-release CONCERTA ® XL

Starting dose: 18 mg once daily to be taken in the morning, increased in steps of 18 mg every week adjusted according to response increased if necessary up to 2.1 mg/kg daily

Maximum dose: 54 mg once daily

Dose equivalence and conversion

Total daily dose of 15 mg of standard-release formulation is considered equivalent to Concerta ® XL 18 mg once daily

Lisdexamfetamine

Child 6–17 years:

Starting dose: 30 mg once daily, PO, alternatively initially 20 mg once daily, increased in steps of 10–20 mg every week if required, dose to be taken in the morning, discontinue if response insufficient after 1 month;

Maximum dose: 70 mg per day

Cautions:

Bipolar disorder, history of cardiovascular disease, history of substance abuse, may lower seizure threshold (discontinue if seizures occur), psychotic disorders, susceptibility to angle-closure glaucoma, tics, and Tourette syndrome

Contraindications:

Advanced arteriosclerosis, agitated states, hyperthyroidism, moderate to severe hypertension, and symptomatic cardiovascular disease

Common side effects:

Upper abdominal pain, anxiety, decreased appetite, abnormal behaviour, constipation, depression, diarrhoea, dizziness, drowsiness, dry mouth, dyspnoea, fatigue, feeling jittery, fever, headache, insomnia, mood altered, nausea, palpitations, psychiatric disorders, skin reactions, tachycardia, tremor, vomiting, and decreased weight

Dexamfetamine

Child 6–17 years:

Starting dose: 2.5 mg 2–3 times a day,PO, increased in steps of 5 mg once weekly if required

Maximum dose: 1 mg/kg daily, up to 20 mg daily (40 mg daily has been required in some children). maintenance dose to be given in 2–4 divided doses

Cautions:

Anorexia, bipolar disorder, history of epilepsy (discontinue if seizures occur), mild hypertension, psychosis, susceptibility to angle-closure glaucoma, tics, and Tourette syndrome

Contraindications:

Agitated states, cardiovascular disease, history of drug abuse, hyperexcitability, hyperthyroidism, moderate hypertension, severe hypertension, and structural cardiac abnormalities

Common side effects:

Abdominal pain, anxiety, decreased appetite, arrhythmias, arthralgia, abnormal behaviour, depression, dry mouth, headache, altered mood, movement disorders, muscle cramps, nausea, palpitations, poor weight gain, sleep disorders, vertigo, vomiting, and decreased weight

Atomoxetine

Child 6–17 years (body-weight up to 70 kg):

Starting dose:

0.5 mg/kg daily, PO, for 7 days, dose is increased according to response; maintenance 1.2 mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening,

Maximum dose: 1.8 mg/kg/day or

120 mg per day (high daily doses to be given under the direction of a specialist)

Child 6–17 years (body-weight 70 kg and above):

Starting dose: 40 mg daily for 7 days, dose is increased according to response; maintenance 80 mg daily, total daily dose

may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening, high daily doses to be given under the direction of a specialist

Maximum dose: 120 mg per day

Cautions:

Aggressive behaviour, cardiovascular disease, cerebrovascular disease, emotional lability, history of seizures, hostility, hypertension, mania, psychosis, QT interval prolongation, structural cardiac abnormalities, susceptibility to angle-closure glaucoma and tachycardia

Contraindications

Phaeochromocytoma, severe cardiovascular disease. Severe cerebrovascular disease

Common side effects:

Anxiety, decreased appetite, asthenia, chest pain, constipation, depression, dizziness, drowsiness, gastrointestinal discomfort, headaches, insomnia, altered mood, mydriasis, nausea, skin reactions, tic, vomiting and decreased weight

Guanfacine

Child 6–12 years (body-weight 25 kg and above):

Starting dose: 1 mg once daily; PO, adjusted in steps of 1 mg every week if necessary and if tolerated; maintenance 0.05–0.12 mg/kg once daily

Maximum dose: 4 mg per day

Child 13–17 (body weight 41.5–49.4 kg): maximum dose 5 mg,

Child 13–17 (body weight 49.5–58.4 kg): maximum dose 6 mg

Child 13–17 (body weight 58.4 kg and above): maximum dose 7 mg

Cautions:

Bradycardia (risk of torsade de pointes), heart block (risk of torsade de pointes), history of cardiovascular disease, history of QT-interval prolongation, and hypokalaemia (risk of torsade de pointes)

Common side effects:

Anxiety, decreased appetite, arrhythmias, asthenia, constipation, depression, diarrhoea, dizziness, drowsiness, dry mouth, gastrointestinal discomfort, headache, hypotension, mood altered, nausea, skin reactions, sleep disorders, urinary disorders, vomiting, and increased weight

Clonidine

Child ≥ 6 year and adolescent):

Immediate-release product (PO):

Starting dose: 0.05 mg  at bed time; if needed, increase by 0.05 mg every 3–7 days

Maximum dose: 0.4 mg/24 h in 3–4 divided doses

Extended-release product (PO):

Starting dose: 0.1 mg  at bed time; if needed increase by 0.1 mg every 7 days BID

Maximum dose: 0.4 mg/24 h

Cautions:

Cerebrovascular disease, constipation, heart failure, history of depression, mild to moderate bradyarrhythmia, polyneuropathy, Raynaud’s syndrome or other occlusive peripheral vascular disease, sleep disturbance, rages or tics

Contraindications

Severe bradyarrhythmia secondary to second—or third-degree AV block or sick sinus syndrome

Common side effects:

Constipation, depression, dizziness, dry mouth, fatigue, headache, nausea, postural hypotension, salivary gland pain, sedation, sexual dysfunction, sleep disorders, and vomiting

  1. For the complete Medication tables, please refer to the official link: https://cpg.adhd.org.sa/implementation-tools-considerations/medication-tables/