Key Medication Classes

Choosing Between Classes

Start with Methylphenidate if:

• History of substance use
• Concerns about side effects
• Comorbid mood disorders
• Need smoother effect

Start with Amphetamines if:

• Previous good response
• Need stronger symptom control
• Methylphenidate insufficient
• Severe ADHD symptoms

Key Formulation Factors

1. Enantiomer Composition
   • Amphetamines: D-amphetamine vs L-amphetamine
   • Methylphenidate: Dexmethylphenidate vs Levomethylphenidate
   • Different ratios affect potency and side effects
2. Route of Administration
   • Primarily pills for adults
   • Alternatives: ODT, chewables, liquids, patches
3. Release Mechanism
   • Immediate Release (IR): 3–6 hours
   • Extended Release (ER): 8–12 hours
   • Most adults benefit from ER formulations

Prodrugs

Lisdexamphetamine (Vyvanse):

• Inactive until metabolized
• Lower abuse potential
• Smoother action
• Once-daily dosing

Serdexmethylphenidate (Azstarys):

• Combines immediate and extended control
• Gradual metabolism

Practical Guidelines

1. Starting Treatment
   • Begin with long-acting formulation
   • Use symptom rating scales (ASRS)
   • 1–2 month initial trial
   • Aim for 50% symptom improvement
2. Dosing
   • Start low, titrate slowly
   • Amphetamine: 5–10 mg daily
   • Methylphenidate: 10–20 mg daily
   • Adjust based on response
3. When to Switch
   • Insufficient response
   • Significant side effects
   • ~30% who don't respond to one class will respond to the other

IR Stimulant Uses

• Targeted symptom needs
• Variable schedules
• Side effect management
• Reduced long-term exposure
• Individual metabolism considerations