Laboratory Studies
Workup in attention deficit hyperactivity disorder (ADHD), previously termed attention deficit disorder (ADD), includes the following:
Liver function tests
Liver function tests (LFTs) may be indicated if the patient has a history of hepatic dysfunction.
Amphetamines, methylphenidate, atomoxetine, and tricyclic antidepressants are metabolized hepatically and excreted mainly in the urine.
A cause-and-effect relationship has been established between the use of atomoxetine and reversible hepatic failure. However, no evidence suggests that baseline LFT results assist care with atomoxetine in any way.
Consider checking LFTs if a patient who is taking atomoxetine presents with signs of hepatitis including early signs, such as nausea, vomiting, diarrhea, and muscle aches lasting longer than 5 days.
Determination of CBC counts
A coincident relationship has been reported, but no cause-and-effect relationship has been established between use of methylphenidate and blood dyscrasias.
A few clinical authorities recommend periodic determination of the CBC counts, but their necessity is not generally endorsed, even for patients receiving long-term treatment.
Drug screening
Consider periodic random drug screening by means of urine testing (witnessed) or serum testing (if witnessing of urine testing is not possible) in all patients with a history of chemical abuse or suspected chemical abuse.
Any suspected substances should be investigated.
Imaging Studies
Evidence suggests that MRI and positron emission tomography (PET) may be useful as future diagnostic methods. Current use is appropriate for research purposes only.
At present, no laboratory studies, imaging studies, or procedures help with the diagnosis of ADHD (ADD), unless the patient's history suggests that other pathology must be ruled out.
Other Tests
Psychometric and educational testing is often important for the diagnosis of ADHD (ADD). The patient's initial history may indicate a need for additional tests, as follows:
-
Examine children by using the Conners' Parent and Teacher Rating Scale and examine adolescents according to the Brown Attention Deficit Disorder Scale (BADDS) for Adolescents and Adults. [2]
-
Assess impulsivity and inattention using timed computer tests such as the Conners Continuous Performance Test (CPT), the Integrated Visual and Auditory (IVA) CPT, or both.
-
Assess girls using the Nadeau/Quinn/Littman ADHD Self-Rating Scale for Girls.
-
Assess the patient's executive function by using various neuropsychologic tests.
-
Perform a learning disability evaluation (intelligence quotient [IQ] vs achievement).
-
Several well-validated IQ tests are available. The Wechsler tests are the standards. Many believe that untimed tests are most appropriate for persons with ADHD (ADD). A large discrepancy between the patient's IQ and other measures, such as visual or auditory abilities or an ability to work with numbers, is not uncommon, particularly in older children and adolescents
-
Baseline ECG to access the QT interval may be indicated before a tricyclic antidepressant is prescribed.
In 2013, the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System became the first FDA-approved, brain function–based medical device for use in the diagnosis of ADHD in children and adolescents aged 6-17 years. Although it is not meant to be used alone as a means of confirming the presence of ADHD, it can be employed in combination with a complete medical and psychological assessment to help confirm the diagnosis or to indicate the direction that further testing should take. Using electroencephalographic technology, the NEBA system calculates the ratio of theta and beta brain waves, which is comparatively high in children and adolescents with ADHD. [7, 8]
Tables
Medication |
Initial Pediatric Dose |
Pediatric Dosage Range and Maximum Dose* |
Common Pediatric Dose* |
Preparations |
Methylphenidate immediate release (IR) (Ritalin, Methylin, generic) |
2.5-5 mg |
0.1-0.8 mg/kg/dose PO qd to 5 times/d; not to exceed 60 mg/d |
0.3-0.5 mg/kg/dose PO tid/qid |
All preparations available as 5-mg, 10-mg, or 20-mg scored tabs; Methylin also available as 2.5-mg, 5-mg, or 10-mg chewable tab and PO solution (5 mg/5 mL and 10 mg/mL) |
Methylphenidate sustained-release (SR) (Ritalin LA, Metadate CD) |
Convert from IR or use 10 mg. |
0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d |
0.6-1 mg/kg/dose PO qd/bid |
10-mg, 20-mg, 30-mg, or 40-mg tabs (Metadate also has 50-mg and 60-mg tabs.); can be sprinkled into soft food (Do not cut, crush, or chew.) |
Methylphenidate extended release (ER)‡ (Ritalin SR, Methylin ER, Metadate ER, Quillivant XR, generic SR) |
Convert from IR May initiate treatment with Quillivant XR |
0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d Quillivant XR: Once daily dosing |
0.6-1 mg/kg/dose PO qd/bid |
20-mg Spansules (Do not cut, crush, or chew) Quillivant XR 5 mg/mL suspension |
Methylphenidate OROS tablets (Concerta) |
Convert from IR or use 18 mg. |
0.3-2 mg/kg PO qd; not to exceed 54 mg/d |
0.8-1.6 mg/kg PO qd |
18-mg, 27-mg, 36-mg, and 54-mg tabs (Do not cut, crush, or chew.) |
Methylphenidate Delay-release/extended-release (Jornay PM) |
20 mg PO at 8 pm | Titrate weekly in increments of 20 mg; not to exceed 100 mg/day | Adjust timing of administration between 6:30 pm and 9:30 pm to optimize tolerability and efficacy the next morning and throughout the day | 20-mg, 40-mg, 60-mg, 80-mg, 100-mg capsules; can be sprinkled into soft food (Do not cut, crush, or chew) |
Methylphenidate transdermal patch (Daytrana)† |
Convert from IR or use 10 mg (12.5 cm2 patch) released over 9 h and titrate up prn. |
0.3-2 mg/kg released over 9 h; not to exceed one 30-mg patch |
10-30 mg released over 9 h |
10-mg, 15-mg, 20-mg, 30-mg patches, applied to the hip |
Dexmethylphenidate IR (Focalin) |
2.5-5-mg |
0.1-0.5 mg/kg/dose PO qd to qid; not to exceed 20 mg/d |
0.2-0.3 mg/kg/dose PO bid/tid |
2.5-mg, 5-mg, or 10-mg scored tabs (Do not cut, crush, or chew.) |
Dexmethylphenidate extended release (Focalin-XR) |
5-10-mg |
0.2-1 mg/kg/dose PO qd to bid; not to exceed 20 mg/d |
0.4-0.6 mg/kg/dose PO qd/bid |
5-mg, 10-mg, or 20-mg scored tabs; can be sprinkled into soft food (Do not cut, crush, or chew.) |
| Serdexmethylphenidate/dexmethylphenidate (Azstarys) | 26.1mg/5.2mg | After 1 week, increase to 52.3 mg/10.4 mg qAM
OR
Decrease to 26.1 mg/5.2 qAM |
Not to exceed 52.3 mg/10.4 mg | Capsules: 26.1mg/5.2mg; 39.2mg/7.8mg; 52.3mg/10.4mg
May open capsule and sprinkle entire contents into 50 mL of water or over 2 tablespoons of applesauce |
Dextroamphetamine (Dexedrine, Dextrostat) |
2.5-5 mg |
0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 60 mg/d |
0.3-0.5 mg/kg/dose PO qd/tid |
Dexedrine: 5-mg scored tabs; Dextrostat: 5-mg and 10-mg scored tabs |
Dextroamphetamine Spansules (Dexedrine CR) |
5 mg |
0.1-0.75 mg/kg/dose PO qd/bid; not to exceed 60 mg/d |
0.3-0.6 mg/kg/dose PO qd/bid |
5-mg, 10-mg, or 15-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.) |
| Dextroamphetamine Transdermal (Xelstrym) | 6-17 years: Apply 4.5 mg/9 hr patch initially |
May increase by increments of 4.5 mg/week; not to exceed 18 mg/9 hr Titrate dose according to patient’s clinical response and tolerability |
4.5 mg/9hr to 18 mg/9hr |
Apply to application site 2 hr before an effect is needed and remove within 9 hr after application
Use only 1 patch/24 hr |
Mixed amphetamine salts IR (Adderall, generic) |
2.5-5 mg |
0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 40 mg/d |
0.3-0.5 mg/kg/dose PO tid/qid |
5-mg, 7.5-mg, 10-mg, 12.5-mg, 15-mg, 20-mg, or 30-mg scored tabs |
Mixed amphetamine salt XR (Adderall-XR) |
Convert from IR or use 5-10 mg |
0.2-1.4 mg/kg/dose PO qd/tid Not to exceed 30 mg/d |
0.6-1 mg/kg/dose PO qd/bid |
5-mg, 10-mg, 15-mg, 20-mg, 25-mg, or 30-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.) |
Lisdexamfetamine (Vyvanse) |
30 mg PO qam |
30-70 mg PO qam |
Data limited |
20-mg, 30-mg, 40-mg, 50-mg, 60-mg, or 70-mg caps (Swallow cap whole, sprinkle into soft food, or dissolve contents in glass of water and drink immediately.)Risk of apnea in patients with chronic pulmonary disease; closely monitor these patients, when initiating and titrating therapy; alternatively, consider the use of alternative non-opioid analgesics in these patients (see Black Box Warnings and Contraindications) |
| Amphetamine (Evekeo, Dyanavel XR), Adzenys XR-ODT | Evekeo: 2.5 mg PO BID/TID
Dyanavel XR: 2.5-5 mg PO once daily
Adzenys XR-ODT: 6.3 mg PO qAM |
Evekeo: 2.5 mg BID/TID; only in rare cases is it necessary to exceed 40 mg/day
Dyanavel XR: 2.5-5 mg/day; not to exceed 20 mg/day
Adzenys XR-ODT: Not to exceed 18.8 mg/day (aged 6-12 y) or 12.5 mg/day (aged 13-17 y) |
Data limited | Evekeo: 5-mg, 10-mg tablets
Dyanavel XR: 2.5-mg/mL extended-release oral suspension (do not substitute oral suspension for other amphetamine products on a milligram-per-milligram basis)
Adzenys XR-ODT: 3.1-mg, 6.3-mg, 9.4-mg, 12.5-mg, 15.7-mg, 18.8-mg extended-release oral disintegrating tablets |
Note. In general, when the terms methylphenidate, Dexedrine, and Ritalin are used without abbreviations for extended-release preparations (eg, continuous release [CR], SR, osmotic-release oral system [OROS]), a short-acting, IR preparation is implied. * Maximum pediatric dose suggested by the US Food and Drug Administration (FDA). Although some children benefit greatly from doses greater than these, benefit from use of either the lowest and highest ends of the dose range is uncommon. †The methylphenidate patch contains a different total methylphenidate dose than the name implies because it is designed to last 12 hours (eg, 10-mg patch [patch size 12.5 cm2] delivers about 10 mg over 9 h [estimated delivery rate is 1.1 mg/h for this particular patch]). Delivery rate varies depending on patch size. ‡Many patients describe their experience with methylphenidate SR preparations as erratic and uncomfortable. |
||||
