Adderall
Adderall
Generic Name
Adderall
Mechanism
- Central Sympathomimetic Stimulation:
- Blocks presynaptic reuptake of dopamine and norepinephrine by inhibiting their transporters (DAT & NET).
- Enhances synaptic release of these monoamines in the prefrontal cortex and basal ganglia.
- Resultant increase in neurotransmission improves attention span, impulse control, and increased psychomotor activity.
Pharmacokinetics
| Parameter | Details |
| Absorption | Rapid, peak plasma concentration at ~30–60 min (immediate‑release). Delayed‑release formulations peak at 1–3 h. |
| Distribution | Protein binding ~56%. CNS penetration is efficient due to lipophilicity. |
| Metabolism | Hepatic via CYP2D6 and CYP3A4; metabolite phenylacetate is inactive. |
| Elimination | Renal excretion (≈70 % unchanged), half‑life 9–14 h (IR), 12–16 h (ER). |
| Drug–Drug Interactions | Weak inhibitors/inducers of CYP2D6 affect plasma levels. MAO inhibitors markedly increase CNS stimulation risk. |
Indications
- Attention‑Deficit/Hyperactivity Disorder (ADHD) in children, adolescents, and adults.
- Narcolepsy (cataplexy, excessive daytime sleepiness).
- Off‑label in chronic fatigue and some neuropsychiatric disorders (under physician discretion).
Contraindications
| Category | Details |
| Absolute Contraindications | Known hypersensitivity; concurrent MAO inhibitor use (within 14 days). |
| Relative Contraindications | Recent cardiovascular events, uncontrolled hypertension, thyrotoxicosis, severe anxiety. |
| Warnings | Potential for abuse, dependence, cardiovascular toxicity (tachycardia, hypertension, arrhythmias). Monitor for psychiatric agitation, psychosis, or mood swings. |
Dosing
- Immediate‑Release (IR)
- Children (6–12 yr): 1 mg once daily (first day), titrate in 1–2 mg increments every 3–7 days up to 20 mg/day (max 30 mg/3 days cumulative).
- Children (3–5 yr): 0.3 mg/kg/day (max 5 mg/day).
- Adults (ADHD): 5 mg twice daily; titrate by 5 mg/day each week up to 30 mg/day.
- Extended‑Release (ER) (Adderall XR)
- Single daily dose in the morning; split dosing not recommended.
- Starting dose 10 mg daily; titrate in 5 mg increments weekly to a typical maximum of 40 mg/day.
- Narcolepsy: 5 mg once or twice daily; titrate to 20–30 mg/day as tolerated.
- Administration: Oral; with food to reduce GI upset. Avoid late‑day dosing to reduce sleep impairment.
Adverse Effects
| Category | Examples |
| Common | Insomnia, decreased appetite, dry mouth, weight loss, abdominal pain, increased heart rate, headache, irritability. |
| Serious | Hypertension, tachyarrhythmias, cardiac ischemia, sudden cardiac death (rare), severe psychiatric events (agitation, hallucinations), dependency, emergence of stimulant‑induced psychosis. |
| Reversible | Symptom resolution upon dose reduction or cessation. |
| Uncommon/Rare | Torsades de pointes, valvular heart disease (rare with chronic high doses). |
Monitoring
- Baseline:
- Blood pressure & pulse.
- Weight, growth (for pediatric).
- ECG if cardiac risk factors present.
- Ongoing:
- BP & HR each visit for first 4–6 weeks, then quarterly if stable.
- Weight and appetite/food intake monthly in children.
- Cognitive and behavioral scales (e.g., Vanderbilt, Conners) to assess efficacy.
- Lab:
- Not routine, but consider CBC, CMP if signs of systemic toxicity.
- Safety:
- Monitor for signs of misuse or diversion; educate on proper storage.
Clinical Pearls
- Start Low, Go Slow: Pediatric patients often require lower initial doses; adult titration may need blunted increments if GI upset occurs.
- Splitting ER pills is ineffective: Unlike IR, the coating contains a matrix that releases drug gradually; splitting alters release kinetics and can precipitate a dosing burst.
- Role of Food: Meals, especially high‑fat foods, delay absorption but do not significantly reduce peak levels; may reduce GI discomfort in sensitive patients.
- Cardio Screening: For patients over 45 or with family history of sudden death, perform baseline ECG before initiating therapy.
- Psychiatric Triage: Any emergent mood changes should trigger immediate assessment for stimulant‑induced mania or psychosis.
- Abuse Potential: Use prescription monitoring programs and counsel patients on non‑resistance (avoid snorting or injecting).
- Drug Interactions: Acids (e.g., omeprazole) may decrease absorption; alkalinization (e.g., potassium carbonate) can increase.
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• *This card offers a high‑yield, pharmacology‑centric snapshot of Adderall, integrating evidence‑based guidelines and clinically actionable insights for professionals in training or practice.*