Managing Medications

How Do ADHD Doctors Titrate Medication?

There is no way to predict the dosage of ADHD medication that will work best for any given patient. So, doctors titrate medication, meaning they slowly increase the dosage until you or your child reaches maximum symptom relief with minimal side effects.

A doctor holds a patient's hand while meeting to titrate medication.

Medically Reviewed by William Dodson, M.D., a member of ADDitude’s ADHD Medical Review Panel

What does it mean to titrate medication?

Titration is a process used to find the right dosage of a medication. Typically, doctors start with a low dose, and gradually increase the dose until the patient reaches maximum symptom relief with minimum side effects1.

It takes trial and error to titrate medication. During the process, the patient must notice and report when a target symptom improves, and when a side effect occurs. The patient’s doctor must then adjust the medication dosage accordingly. The titration process can take several weeks or months, but it is the best way to achieve the best result with medication.

Titrating Medication to Treat ADHD

Stimulant medication is the first-line treatment for attention deficit hyperactivity disorder (ADHD or ADD). There are two main types of stimulant ADHD medications: methylphenidates (Ritalin, Concerta, Daytrana, etc.) and amphetamines (Adderall, Vyvanse, Evekeo, etc.). Most stimulant medications are different forms of these two types of medication. Methamphetamine is FDA-approved to treat ADHD, but is not regularly prescribed.

Methylphenidates work better for some patients with ADHD. Amphetamines work better for others. There is no way to predict which type will work for you or your child. Likewise, there is no way to predict the ideal dosage.

ADHD medication dosage is not based on a person’s height or weight. There is no average starting dose. The dosage that works best is influenced by many factors: history of taking stimulant medications, genetic or metabolic differences, comorbid conditions or treatment, and severity of symptoms. In other words, there’s no one-size-fits-all approach to treating ADHD with stimulant medication. Titrating medication helps to find the right dose. It can be used for any medication you plan to take for a long time, including for the nonstimulants that treat ADHD, like Strattera, blood pressure medications, or antidepressants.

How do doctors titrate medication for ADHD?

While titrating medication, the patient should check in with his or her prescribing physician weekly, and schedule monthly office visits to review overall health, symptom improvement, and change dosage when necessary.

One study found that waiting several weeks between dosage changes allowed sufficient time for all of the benefits of medication to emerge2. Stimulant medications work immediately; they don’t need to build up in the body to have maximum effect. However, it can take several days or weeks to get an accurate read on how it’s impacting behavior or functioning. Nonstimulant medications that treat ADHD take from two to six weeks to reach full effectiveness, so the titration process is much longer.

Titrating Medication to Address Side Effects

Before prescribing any ADHD medication, a physician should explain its potential adverse side effects. Patients should ask the pharmacist any lingering questions.

Common side effects of ADHD medication include:

  • Appetite loss
  • Sleeplessness
  • Stomachaches
  • Headaches
  • Tics
  • Emotional problems or mood swings
  • Medication rebound

Rare, more serious side effects include heart problems, psychotic or manic symptoms, seizures, eyesight changes, or circulation problems.

The patient should track and log mild side effects to share at forthcoming doctors’ visits. Severe side effects should be reported immediately. They may be an adverse reaction that requires taking a different medication or titrating medication dosage down.

Some side effects improve with time, so it’s important not to change the dose too quickly. Everyone gets headaches, or isn’t hungry occasionally. Taking time between dosage adjustments lets patients assess if that weird feeling is really a result of medication, or just a poor night’s sleep.

Tracking Symptoms While Titrating Medication

When titrating medication, patients should create a list of symptoms they would like to see alleviated.

A checklist or rating scale, like The Weiss Functional Impairment rating scale, can help patients track and record changes to easily communicate them to their physician. ADDitude recommends using this ADHD medication log to track symptom relief and side effects on a daily basis: www.additudemag.com/download/adhd-medication-monitoring-log

Patients should keep a symptom diary that tracks each daily dose of medication, and how it makes them feel. It should note if:

  • The medication isn’t working. No or inadequate symptom improvement may mean the dose is too low. The response rate to either methylphenidates or amphetamines is only about 70%.  That means that about one in three of people will not experience benefits from either medication.  If there is no response to the first medication tried, the other medication should be tried.  About 15% of people do not respond to or tolerate either stimulant.
  • Side effects are severe. Certain side effects are intolerable, or make it hard to function. A patient’s notes about bothersome side effects can help a doctor decide if another medication is best, or if a different dosage is required. The side effects of the ADHD stimulant medications are almost always mild and can be removed by simply lowering the dose or moving the doses further apart.
  • Feeling muted, sedated, or unlike yourself. This can mean the dose is too high, and is sometimes called the “zombie effect.” It can be reversed by lowering the dose.

Patients should track the times of day they feel symptom relief, and when symptoms return. Some people require a second, short-acting dose of medication to alleviate symptoms all evening after a daytime dose wears off.

Finding the right dosage can seem like a long process, or feel aggravating at times. Just as ADHD symptoms are different for everyone, ADHD treatment is slightly different for everyone. Clear and regular communication between patient and doctor, along with symptom tracking, is the only way to find the best treatment plan for an adult or a child.


Sources

1 Olfson, Mark et al. “Stimulant Dosing for Children With ADHD: A Medical Claims Analysis.” Journal of the American Academy of Child & Adolescent Psychiatry, 48:1, pp. 51-59. 2009. doi: 10.1097/CHI.0b013e31818b1c8f
2 Goodman, David, et al. “Randomized, 6-Week, Placebo-Controlled Study of Treatment for Adult Attention-Deficit/Hyperactivity Disorder: Individualized Dosing of Osmotic-Release Oral System (OROS) Methylphenidate With a Goal of Symptom Remission.” The Journal of Clinical Psychiatry, 78:1, pp. 105-114. 2017. doi: 10.4088/JCP.15m10348

Updated on July 22, 2019

Leave a Reply