II. Indications: Methylphenidate (Ritalin)

  1. Attention Deficit Hyperactivity Disorder (ADHD)
  2. Narcolepsy
  3. Depression in medically ill elderly patients
  4. Enhanced pain control in patients on opiates

III. Contraindications

  1. See Drug interactions below
  2. Congenital Heart Defect (ask related PMH, Family History and screen on ADHD exam)
    1. Consider an EKG before prescribing
    2. Vetter (2008) Circulation 117(18):2407-23. [PubMed] (or open in [QxMD Read])
  3. Motor Tics or Tourette's Syndrome
  4. Glaucoma
  5. Seizure disorder
  6. Hypertension
  7. Pregnancy

IV. Pharmacokinetics: Methylphenidate

  1. Immediate Release: Ritalin-IR, Methylin IR
    1. Onset of action: within 20 to 30 minutes of dose (up to 60 minutes)
    2. Peaks at 1.9 hours on average
    3. Duration: 3 to 6 hours
  2. Immediate Release: Focalin (Dexmethylphenidate)
    1. D-isomer of Ritalin (l-isomer is inactive)
    2. Prescribed at half dose of Ritalin
    3. Same pharmacokinetics as immediate release Methylphenidate
    4. Fewer Headaches but more Stomache pain than with Methylphenidate
  3. Long-Acting: Ritalin-LA
    1. Duration: 8 hours
    2. Biphasic release
      1. Immediate release: 50%
      2. Modified release beads: 50%
    3. Preferred over Ritalin SR
  4. Long-Acting: Ritalin-SR, Metadate ER, Methylin ER
    1. Onset of action: within 90 minutes of dose
    2. Peaks at 3 hours on average
    3. Duration: 5-8 hours (gradual decrease after 3 hours)
    4. Less effective than Ritalin IR bid
    5. Other sustained release forms are preferred
  5. Very-Long-Acting: Concerta
    1. Onset of action: within 60 to 120 minutes of dose
    2. Duration: 12 hours
    3. Comparable to Ritalin-IR tid
  6. Very-Long-Acting: Metadate-CD
    1. Flat concentration curve despite biphasic release
    2. Duration: 8-10 hours
    3. Biphasic peaks at 1.5 hours and again at 4.5 hours
      1. Immediate release beads: 30%
      2. Extended release beads: 70%
  7. Very-Long Acting: Quillivant XR
    1. Combination of Immediate release Methylphenidate (20%) and extended release Methylphenidate (80%)
    2. Peaks at 5 hours
    3. Duration: 12 hours
    4. Niche is that it is suspension (compounded by pharmacy) at 5 mg/ml
      1. Other stimulant capsules can be sprinkled on apple sauce (Focalin XR, Metadate CD, Ritalin LA, Adderall XR)
    5. References
      1. (2013) Presc Lett 20(2): 8-9

V. Dosing: Children (over age 6 years)

  1. Maximum total daily dose: 60 mg/day
  2. Immediate Release: Methylphenidate
    1. Usual Range: 0.5 - 1 mg/kg/day
    2. Start: 2.5 to 5 mg per dose, twice daily
    3. Initial Schedule (lasts 4 hours - dose up to 4 times daily)
      1. Morning: 2.5 to 5 mg PO 30 minutes before breakfast
      2. Noon: 2.5 to 5 mg PO 30 minutes before lunch
      3. Afternoon: 1.25 to 2.5 mg PO at 3-4 pm
    4. Titrate dose up weekly
      1. Increase dose by 0.1 mg/kg/dose (or 5-10 mg/day)
    5. Maximum dose: 2 mg/kg/day or 60 mg/day (some sources suggest maximum up to 90)
  3. Immediate Release: Focalin (Dexmethylphenidate)
    1. Start: 2.5 mg orally twice daily
    2. Usual Dose: 5-10 mg orally twice daily
    3. Maximum Dose: 20 mg orally daily
  4. Sustained Release
    1. Concerta 18 to 54 mg orally daily
      1. Start: 18 mg qAM
      2. May increase weekly by 18 mg/day
      3. Conversions
        1. Ritalin 5 mg or 20 mg SR: Concerta 18 mg
        2. Ritalin 10 mg or 40 mg SR: Concerta 36 mg
        3. Ritalin 15 mg or 60 mg SR: Concerta 54 mg
      4. Maximum: 72 mg/day
    2. Ritalin LA or Metadate CD
      1. Start: 20 mg orally daily
      2. May increase weekly by 10-20 mg/day
      3. Usual dose: 20-40 mg orally once daily
      4. Maximum: 60 mg/day
    3. Ritalin-SR (Other long-acting agents are preferred)
      1. Dose: 0.6 to 2 mg/kg up to 20-40 mg orally daily
      2. Dose is directly converted from Regular Ritalin
      3. Conversion to Ritalin SR (Metadate ER, Methylin ER)
      4. Administer cumulative 8 hour regular dose
      5. Example: Conversion
        1. Child takes Ritalin 10 mg, 5 mg, and 5 mg
        2. Ritalin SR dosing will be 20 mg qAM
      6. Example: Schedule
        1. Morning: 20-40 mg orally
        2. Early afternoon: 20 mg orally
    4. Daytrana (Methylphenidate patch)
      1. Start: 10 mg patch worn 9 hours daily
      2. Max: 30 mg patch worn 9 hours daily
      3. Skin irritation or rash may occur

VI. Dosing: Adults with ADHD or Narcolepsy

  1. Maximum total daily dose: 90 mg
  2. Regular Release: 5 to 20 mg PO bid to tid at meals
  3. Sustained Release: 20 mg PO up to q8 hours

VII. Dosing: Elderly with comorbid Depression

  1. Maximum total daily dose: 30 mg
  2. Regular Release: 5 to 10 mg bid to tid

VIII. Precautions: Maximum Dosing

  1. Adults and older adolescents (>50 kg) may in some cases need dosing in excess of listed maximum
  2. Exercise caution and Informed Consent as these doses are not FDA approved and exceed the manufacturers recommendation
  3. Absolute maximum doses
    1. Methylphenidate: 100 mg per day in divided doses
    2. Concerta 108 mg per day
  4. (2013) Presc Lett 20(9): 50-1

IX. Drug Interactions

  1. Avoid concurrent Decongestant use
  2. Avoid within 14 days of MAO inhibitor

X. Monitoring: Each Visit

  1. Height
  2. Weight
  3. Blood Pressure
  4. Pulse

XI. Adverse Effects

Images: Related links to external sites (from Google)

Cost: Medications

Dexmethylphenidate HCl (on 2/9/2012 at DrugStore.com)
Dexmethylphenidate HCl 2.5mg Tablets #20 for $21.99 ($1.10/unit)
Dexmethylphenidate HCl 10mg Tablets #30 for $43.99 ($1.47/unit)
Methylphenidate HCl (on 2/9/2012 at DrugStore.com)
Methylphenidate HCl 5mg Tablets #20 for $29.99 ($1.50/unit)
Methylphenidate HCl 10mg Tablets #20 for $22.24 ($1.11/unit)
Methylphenidate HCl 20mg Tablets #20 for $20.99 ($1.05/unit)
Methylphenidate HCl 18mg Controlled Release Tabs #20 for $115.99 ($5.80/unit)
Methylphenidate HCl 27mg Controlled Release Tabs #20 for $115.99 ($5.80/unit)
Methylphenidate HCl 36mg Controlled Release Tabs #20 for $119.99 ($6.00/unit)
Methylphenidate HCl 54mg Controlled Release Tabs #20 for $129.99 ($6.50/unit)
Methylphenidate HCl 20mg 24 Hour Capsule #20 for $95.99 ($4.80/unit)
Methylphenidate HCl CR (on 2/9/2012 at DrugStore.com)
Methylphenidate HCl CR 20mg Controlled Release Tabs #20 for $35.99 ($1.80/unit)
Ritalin LA (on 2/9/2012 at DrugStore.com)
Ritalin LA 20mg 24 Hour Capsule #20 for $100.99 ($5.05/unit)
Ritalin LA 30mg 24 Hour Capsule #20 for $100.99 ($5.05/unit)
Ritalin LA 40mg 24 Hour Capsule #20 for $101.98 ($5.10/unit)
Ritalin LA 10mg 24 Hour Capsule #20 for $100.99 ($5.05/unit)
Ritalin (on 2/9/2012 at DrugStore.com)
Ritalin 5mg Tablets #20 for $41.20 ($2.06/unit)
Ritalin 10mg Tablets #20 for $29.99 ($1.50/unit)
Ritalin 20mg Tablets #20 for $42.39 ($2.12/unit)
Ritalin SR (on 2/9/2012 at DrugStore.com)
Ritalin SR 20mg Controlled Release Tabs #20 for $59.99 ($3.00/unit)
Methylin (on 2/9/2012 at DrugStore.com)
Methylin 10mg Tablets #20 for $13.99 ($0.70/unit)
Methylin ER (on 2/9/2012 at DrugStore.com)
Methylin ER 10mg "this Med Is Currently Not Available, No Release Date Is Listed." #20 for $21.99 ($1.10/unit)
Concerta (on 2/9/2012 at DrugStore.com)
Concerta 18mg Controlled Release Tabs #20 for $119.99 ($6.00/unit)
Concerta 36mg Controlled Release Tabs #20 for $132.99 ($6.65/unit)
Concerta 54mg Controlled Release Tabs #20 for $144.99 ($7.25/unit)
Concerta 27mg Controlled Release Tabs #20 for $133.99 ($6.70/unit)

Ontology: Methylphenidate (C0025810)

Definition (CHV) a drug that stimulates the brain
Definition (MSH) A central nervous system stimulant used most commonly in the treatment of attention-deficit disorders in children and for narcolepsy. Its mechanisms appear to be similar to those of DEXTROAMPHETAMINE.
Definition (CSP) central stimulant used in treatment of hyperkinetic children, various types of depression, and narcolepsy.
Definition (NCI) A synthetic central nervous system stimulant. Methylphenidate appears to activate the brain stem arousal system and cortex to produce its stimulant effect and, in some clinical settings, may improve cognitive function.
Definition (NCI) A drug that is a central nervous system stimulant.
Concepts Organic Chemical (T109) , Pharmacologic Substance(T121)
MSH D008774
SnomedCT 18548003, 373337007
English Methylphenidate, methylphenidate, 2-Piperidineacetic acid, alpha-phenyl-, methyl ester, alpha-Phenyl-2-piperidineacetic Acid Methyl Ester, METHYLPHENIDATE, Methylphenidate [Chemical/Ingredient], Methylphenidate (product), Methylphenidate (substance), d-methylphenidate
Swedish Metylfenidat
Czech methylfenidát
Finnish Metyylifenidaatti
Russian METILFENIDAT, FENIDILAT, МЕТИЛФЕНИДАТ, ФЕНИДИЛАТ
Japanese フェニジレート, リタリン, 塩酸メチルフェニデート, メチルフェニデート
Polish Rytalin, Metylofenidat
Spanish metilfenidato (producto), metilfenidato (sustancia), metilfenidato, Metilfenidato, Ritalin
French Méthylphénidate
German Methylphenidat
Italian Metilfenidato
Portuguese Metilfenidato, Ritalin

Ontology: Ritalin (C0728759)

Concepts Organic Chemical (T109) , Pharmacologic Substance(T121)
MSH D008774
German Ritalin
English Ritalin, Cephalon Brand of Methylphenidate Hydrochloride, Novartis Brand 1 of Methylphenidate Hydrochloride, Ritaline

Ontology: Methylin (C0876085)

Concepts Organic Chemical (T109) , Pharmacologic Substance(T121)
MSH D008774
English methylin, Methylin, Mallinckrodt Brand of Methylphenidate Hydrochloride

Ontology: Concerta (C0939301)

Concepts Organic Chemical (T109) , Pharmacologic Substance(T121)
English Concerta, concertas, concerta