High dose methylphenidate treatment in adult Attention Deficit Hyperactivity Disorder: a case report

INTRODUCTION: Stimulant 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 PRESENTATION: We report the case of a 38-year-old Caucasian patient who was diagnosed with ADHD when he was nine years old. He then received up to 10mg Ritalinand 20mg 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) 75mg/d. 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 60mg/d was re-established. During the 14 months that followed, he began to use Ritalin excessively, both orally and rectally, in dosages from 4800-6000mg/d. Four years ago, he was referred to our outpatient service, where his ADHD was re-evaluated. At that point, the patient's daily Ritalin dosage was reduced to 200mg/d orally, but he still experienced pronounced symptoms of ADHD, 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 40mg/d. Finally, on a dosage of 378mg Concerta, his symptoms of ADHD have improved dramatically and no further use of methylphenidate has been recorded during the 24 months preceding this report. CONCLUSION: Symptoms of 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

Are there any potentially dangerous pharmacological effects of combining ADHD medication with alcohol and drugs of abuse? A systematic review of the literature

BACKGROUND: Among young people up to 18 years of age, approximately 5 % have attention deficit hyperactivity disorder (ADHD), many of whom have symptoms persisting into adulthood. ADHD is associated with increased risk of co-morbid psychiatric disorders, including substance misuse. Many will be prescribed medication, namely methylphenidate, atomoxetine, dexamphetamine and lisdexamfetamine. If so, it is important to know if interactions exist and if they are potentially toxic. METHODS: Three databases (Medline, EMBASE and PsychINFO) from a 22 year period (1992 – June 2014) were searched systematically. Key search terms included alcohol, substance related disorders, methylphenidate, atomoxetine, dexamphetamine, lisdexamfetamine, and death, which identified 493 citations (344 after removal of duplicates). The eligibility of each study was assessed jointly by two investigators, leaving 20 relevant articles. RESULTS: We identified only a minimal increase in side-effects when ADHD medication (therapeutic doses) was taken with alcohol. None of the reviewed studies showed severe sequelae among those who had overdosed on ADHD medication and other coingestants, including alcohol. CONCLUSIONS: The numbers across all the papers studied remain too low to exclude uncommon effects. Also, studies of combined effects with novel psychoactive substances have not yet appeared in the literature. Nevertheless, no serious sequelae were identified from combining ADHD medication with alcohol/illicit substances from the pre-novel psychoactive substance era