Which ADHD Medication Is Best?
The market for ADHD medications is so bloated that finding the right treatment feels impossible and overwhelming at times. Here, an ADHD specialist explains the options in terms we can all understand.
I saw a child who, after receiving extensive evaluation, was diagnosed with inattentive attention deficit hyperactivity disorder (ADHD). When I talked with his mother about starting him on the ADHD stimulant medication methylphenidate, she asked, “Why not Vyvanse? That’s the one that Ty Pennington takes, right? It works great for him!” I explained my reasons for prescribing methylphenidate, not Vyvanse, and realized that the flurry of ads for ADHD medications had confused her.
Dexedrine or Adderall? Concerta or Strattera?
Many parents and adults are similarly confused. The Food and Drug Administration requires that a medication be given a different name according to its form (capsule, tablet, liquid, patch) or release mechanism (released immediately or over an extended period of time). Here’s an example: Ritalin is a tablet that is released immediately into the bloodstream and works for four hours. Ritalin LA, on the other hand, is a capsule that releases over a longer period of time and works for eight hours. Different names, even though both contain the same medicine — methylphenidate.
Before we go any further, I want to give you a quick refresher on why doctors prescribe stimulants for the condition.
How Do Stimulant Medications Treat ADHD?
ADHD is a neurologically based disorder, resulting from the deficiency of a neurotransmitter, or a group of neurotransmitters, in specific areas of the brain. Neurotransmitters are chemicals that transmit signals between nerve cells by bridging the synapse (or gap) between them.
The key neurotransmitter involved is norepinephrine, along with its building blocks, dopa and dopamine. The primary medications used to treat ADHD stimulate specific cells within the brain to produce more of the deficient neurotransmitter. That’s why these medications are called stimulants.
The two main classes of stimulant medications, methylphenidate and dextro-amphetamine — both are generic names — have been used since the 1960s. All brand-name stimulants are variations of these two medications. Adderall is a modification of dextro-amphetamine, for instance, while methylphenidate comes as an immediate-release tablet, a chewable tablet, a liquid, a skin patch, an intermediate-acting (extended-release) tablet, a long-acting (extended-release) capsule, and a long-acting (extended-release) tablet. Each variation has its own name, but the medicine that treats symptoms is the same — methylphenidate.
ADHD Medication Dosing
Parents of children with ADHD ask me: “My child was on Adderall 10 mg, and my doctor changed her prescription to Vyvanse 60 mg. Why was the dose increased?” The reasons for the numbers have to do with target dose and release mechanism.
Target dose: Each product releases a specific amount of medication into the blood over a given period of time. The FDA requires that the number value for each product represent the total amount of the medication in the tablet/liquid/capsule/patch, not the amount in the blood at any one time. Thus, if the medication, let’s say methylphenidate, is in the form of a four-hour tablet, and it releases 5 mg over that time, it is called methylphenidate 5 mg. A capsule of Adderall that releases 10 mg immediately and 10 mg four hours later is called Adderall XR 20. The number is not based on the amount released at any one time, but on the total amount of the medication in the capsule.
Release mechanism: This indicates the length of time a medication will remain available and active. Stimulants come in a variety of forms — tablet, capsule, liquid, skin patch — and release medication in an hour, four hours, or over eight or 12 hours.
Confused About Concerta?
Many people are confused about Concerta. Designed to last 12 hours, Concerta has a “sponge” on the bottom of the capsule, medication on top, and a tiny hole above the medication. As the capsule passes through the gastrointestinal tract and absorbs moisture, the sponge expands and pushes the medication out of the hole.
The number value assigned to each dose is confusing. Take Concerta 18 mg. If the goal is to release 5 mg consistently every four hours over a 12-hour period, then there needs to be 15 mg in the capsule. However, it takes time for the sponge to become moist enough to start to expand. So an initial release of medication is needed until the sponge starts working. Researchers figured out that it should be 3 mg. Thus, to release 5 mg over 12 hours, one needs the initial 3 mg, plus 5 mg every four hours during the 12 hours. The total amount of medication is 18 mg. That’s why the medication is called Concerta 18.
Same ADHD Medication, Different Forms
Medications such as methylphenidate and dextro-amphetamine also come in liquid forms. The patient information sheet inside the medication’s box or packaging states how much medication is in each unit of liquid; for example, 5 mg per 5 ml of liquid. Another methylphenidate product — Daytrana* — is a patch that releases medication through the skin and into the bloodstream. It should start to work in about one hour, and remain effective until about one hour after being removed (usually around nine hours). Daytrana 30 mg contains about 30 mg of methylphenidate, and releases about 3.3 mg of it per hour.
As if that weren’t challenging enough, amphetamine and methylphenidate are made of two isomers, called dextro and levo isomers. When the first amphetamine products used for ADHD were studied, experts learned that the dextro form was more effective in managing symptoms than the levo form. Thus, dextro-amphetamine became the primary product used to treat the condition. (Adderall, prescribed to many patients who have been diagnosed with ADHD, is a mixture of dextro- and levo-amphetamine, plus other amphetamine salts.) A similar finding was recently made on methylphenidate. Researchers learned that the dextro form was more effective than the levo form. Dextro-methylphenidate is manufactured under the name of Focalin.
*FDA is warning that permanent loss of skin color may occur with use of the Daytrana patch (methylphenidate transdermal system) for Attention Deficit Hyperactivity Disorder (ADHD). FDA added a new warning to the drug label to describe this skin condition, which is known as chemical leukoderma. See the FDA Drug Safety Communication for more information.
Which ADHD Stimulant Medication Is Best?
The next time a doctor rattles off medications and dosages that might be appropriate for you or your child, you should have a much better idea of what he’s talking about and how to decide which might be the best choice if you consult this comprehensive list.
Generic; tablet; immediate release; lasts about four hours; comes in 5, 10, 15 mg dosages
Concerta: brand name; tablet; lasts about 12 hours; comes in 18, 27, 36, 54 mg dosages
Daytrana: brand name; skin patch; lasts about eight hours; comes in 10, 15, 20, 30 mg dosages
Ritalin: brand name; tablet; immediate release; lasts about four hours; comes in 5, 10, 15 mg dosages
Ritalin LA: brand name; capsule; lasts about eight hours; comes in 10, 20, 30, 40 mg dosages
Ritalin SR: brand name; tablet; lasts about eight hours; comes in 20 mg dosage
Metadate CD: brand name; capsule; lasts eight hours; comes in 10, 20, 30, 40, 50, 60 mg dosages
Metadate ER: brand name; tablet; lasts eight hours; comes in 10, 20 mg dosages
Methylin: brand name; liquid and chewable tablets; immediate release; lasts four hours; tablets come in 2.5, 5, 10 mg dosages, liquid in 5 mg/tsp and 10mg/tsp dosages
More ADHD Stimulant Medications
In addition to methylphenidates, there are several other families of stimulant medications that treat ADHD.
Focalin: brand name; tablet; lasts four hours; immediate release; comes in 2.5, 5, 10 mg dosages
Focalin XR: brand name; capsule; lasts eight hours; immediate release followed by second delayed release; comes in 5, 10, 15, 20, 30, 40 mg dosages
Generic; tablet; immediate release; lasts four hours; comes in 5, 10 mg dosages
Dexedrine Spansule: brand name; capsule; immediate release followed by gradual release; lasts eight hours; comes in 5, 10, 15 mg dosages
ProCentra: brand name; liquid; immediate release; lasts four hours; comes in 5 mg/tsp dosage
Modified Amphetamine Mixture
Adderall: brand name; tablet; immediate release; lasts four hours; comes in 5, 7.5, 10, 12.5, 15, 20, 30 mg dosages
Adderall XR: brand name; capsule; immediate and delayed release; lasts eight hours; comes in 5, 10, 15, 20, 25, 30 mg dosages
Vyvanse: brand name; capsule; lasts 10 to 12 hours; comes in 20, 30, 40, 50, 60, 70 mg dosages