High dose methylphenidate treatment in adult attention deficit hyperactivity disorder: a case report

Abstract

IntroductionStimulant medication improves hyperactivity, inattention, and impulsivity in both pediatric and adult populations with Attention Deficit Hyperactivity Disorder (ADHD). However, data regarding the optimal dosage in adults is still limited.Case presentationWe report the case of a 38-year-old Caucasian patient who was diagnosed with Attention Deficit Hyperactivity Disorder when he was nine years old. He then received up to 10 mg methylphenidate (Ritalin®) and 20 mg sustained-release methylphenidate (Ritalin SR®) daily. When he was 13, his medication was changed to desipramine (Norpramin®), and both Ritalin® and Ritalin SR® were discontinued; and at age 18, when he developed obsessive-compulsive symptoms, his medication was changed to clomipramine (Anafranil®) 75 mg daily. Still suffering from inattention and hyperactivity, the patient began college when he was 19, but did not receive stimulant medication until three years later, when Ritalin® 60 mg daily was re-established. During the 14 months that followed, he began to use Ritalin® excessively, both orally and rectally, in dosages from 4800-6000 mg daily. Four years ago, he was referred to our outpatient service, where his Attention Deficit Hyperactivity Disorder was re-evaluated. At that point, the patient’s daily Ritalin® dosage was reduced to 200 mg daily orally, but he still experienced pronounced symptoms of, Attention Deficit Hyperactivity Disorder so this dosage was raised again. The patient’s plasma levels consistently remained between 60–187 nmol/l—within the recommended range—and signs of his obsessive-compulsive symptoms diminished with fluoxetine 40 mg daily. Finally, on a dosage of 378 mg extended-release methylphenidate (Concerta®), his symptoms of Attention Deficit Hyperactivity Disorder have improved dramatically and no further use of methylphenidate has been recorded during the 24 months preceding this report.ConclusionsSymptoms of Attention Deficit Hyperactivity Disorder (ADHD) in this adult patient, who also manifested a co-occurring obsessive compulsive disorder, dramatically improved only after application of a higher-than-normal dose of methylphenidate. We therefore suggest that clinicians consider these findings in relation to their adherence to current therapeutic guidelines.

Methylphenidate for attention deficit hyperactivity disorder and drug relapse in criminal offenders with substance dependence: a 24‐week randomized placebo‐controlled trial

“…A patient with a long history of daily illicit use of up to several grams of amphetamine is likely to need a higher dose of MPH to reduce ADHD symptoms than previously stimulant-naive patients. Clinical experience indicates a significant individual variation in therapeutic doses 17 , with some individuals requiring a higher dose of stimulants to achieve a clinical response 17 , 19 . Taken together, this suggests that a wider range of doses is needed to evaluate the efficacy and safety of MPH in substance-dependent patients with ADHD.…”

Attention-Deficit/Hyperactivity Disorder

“…Liebrenz and colleagues describe a case of an adult with ADHD receiving a methylphenidate dose of 378 extended-release methylphenidate. 65 Factors that may affect the variability of doses include genetic factors involving the DRD4 and DAT polymorphisms. 60 Pharmacogenetic factors may also play a role in the metabolism of methylphenidate.…”

Perioperative Outcome of Dyssomnia Patients on Chronic Methylphenidate Use

“…Methylphenidate is one of the most prescribed psychostimulants. The drug is approved for treatment of attention deficit hyperactivity disorder (ADHD), the prevalence of adults with ADHD is estimated at around 4.4% (1), postural orthostatic tachycardia syndrome, and dyssomnia disorders-narcolepsy and hypersomnia as an off-label medication. Based on an overview published by Do It Now Fundation, in 2005, 1.9 million U.S. prescriptions were written for methylphenidate.…”