Fine-Tuning Stimulant Dosing to Find Your Treatment Sweet Spot
The optimal dose of first-line ADHD medications will ease symptoms with minimal stimulant side effects. Here’s how to find it.
Stimulants are the first-line treatment for most people with ADHD, yet few clinicians receive training on fine-tuning medications like Adderall, Ritalin, or Vyvanse to achieve the best outcomes.
No practical, modern protocol exists regarding how to efficiently adjust stimulants to optimize their performance in managing ADHD symptoms and mitigating side effects. The only guidance available stems from the Multimodal Treatment of ADHD (MTA) Study, published in 1999, but the MTA’s research methodology often took as long as eight months to determine each subject’s optimal medication and dose.
This is completely impractical in the real world, where insurance coverage pays for only two or three sessions of clinical assessment and medication adjustments. As such, I developed a method for optimizing ADHD stimulant medications that I have used successfully in my own practice for 30 years.
Choosing the Right ADHD Medication
Two molecules comprise the first-line stimulants prescribed to most people with ADHD: methylphenidate (brand names include Ritalin and Concerta) and amphetamine (brand names include Vyvanse and Adderall). More than 39 different brand name medications are made from these two molecules, and they all provide a comparable level of benefits, side effects, and response rates, according to large group studies. One molecule is not intrinsically better than the other.
That said, nothing (including genetics) predicts which molecule will work best for any individual. Patients may need to try both kinds of stimulants to arrive at optimal ADHD treatment — a process that takes time and collaboration with their clinicians.
Roughly 30% of people with ADHD either do not respond to or tolerate the first stimulant they try. When that happens, we stop the first molecule and try the other one. When both are tried sequentially, the combined response rate is about 85%; the remaining 15% of people do not respond to or tolerate either medication.
[Read: Complete ADHD Medication List for Comparing Popular Meds]
No single factor, such as weight, age, gender, ethnic background, or severity of impairments, predicts any individual’s optimal dose. That is discovered by adjusting the dose through trial and error. Only about half of people achieve their optimal response within the range of dosages approved by the FDA. In my practice, more than 40% of patients required doses higher than the FDA-approved doses, and about 6 to 8% optimized below the lowest dose manufactured, underscoring the need to give feedback to your clinician to guide the fine-tuning process.
3 Rules of Medication Titration
Three general rules should guide your medication expectations and adjustments:
1. You shouldn’t feel medicated.
Once you find your optimal dose, you should experience “the very best version of you.” ADHD medications should not change your personality. If you feel dulled or like a zombie, the dose is too high.
[Free Resource: ADHD Medication Tracking Log]
2. Benefits should outweigh stimulant side effects.
With the right medication at the right dose, you should achieve life-changing benefits without meaningful or lasting side effects. A measure called “effect size” tells us how well any medical treatment works compared to the other available treatments. Almost everything in medicine has an effect size of 0.4 (barely but consistently detectable benefits) up to 1.0 (a very robust level of benefits). When stimulants are fine-tuned to suit a unique individual, the effect size can fall in the range of 1.6 to 1.8 – better than almost any other treatment in all of medicine.
In other words, the right stimulant will deliver very noticeable benefits. If you have tried a full range of doses and have not experienced an “oh, wow” level of response, this was not the right molecule for you and you need to try the other molecule. If a medication is not dramatically effective, don’t settle for it.
Often, intolerable side effects mean this was the wrong molecule for you or the dose was too high. More is not better.
3. You must commit to treatment.
Medication doesn’t work if you stop taking it. The first-line stimulant medications are completely effective as soon as they reach the brain, which takes about an hour (except in the case of backloaded methylphenidate formulations, like Concerta, which gradually increase to their full blood level). Most people will see all the benefits and side effects of a medication within about 90 minutes of taking it. It may take a clinician a week to determine whether a dose adjustment is needed for a child because they often lack self-appraisal and feedback skills; also, it may take this long to collect observations from parents and teachers.
The biggest obstacle to success is failing to accept that you have a lifelong condition. Virtually every patient with whom I have ever worked has stopped taking their medication at times “to see if I still need it.” Science confirms that the impairments of ADHD are always present, and that stimulant medications can reliably work for a lifetime without significant adjustments in dose after adolescence.
Getting Started with ADHD Medication
Create a list of symptoms that you would like to ease, then work with your clinician to fine-tune medications according to how well they relieve these symptoms. Impairments that respond particularly well to medication are:
- Procrastination
- Distractibility
- Poor reading speed, comprehension, and retention
- Poor emotional control
- Restlessness; fidgeting
- Impulsiveness
- Misplacing things; forgetfulness
- Blurting without thinking
With each dose increase of your newly prescribed medication, jot down the improvements and side effects that you experience. At some point, a dose increase will bring no further symptom improvement. If that dose and its predecessor seem to equally relieve the impairments of your ADHD, then the lower dose is your optimal one.
For children younger than 16, the American Academy of Pediatrics recommends refining the dose once a year because it commonly fluctuates in childhood. This readjustment is usually done in August before the new school year begins.
Citric Acid and Adderall, Ritalin, Other ADHD Meds
Some soft drinks, artificial juices, and cereal bars contain high levels of citric acid, a preservative, which can interfere with stimulant medication efficacy. Foods high in citric acid and ascorbic acid (Vitamin C) prevent stimulants from being absorbed, and should be avoided one hour before and after taking a stimulant to achieve its full benefit.
Adderall Dosage & Medication Titration: Next Steps
- Read: 10 Things Your Doctor May Not Have Told You About ADHD Medications
- Download: How Do We Know the Medication is Working?
- Watch: Combination Therapy: Medication Strategies for Hard-to-Treat Complex ADHD
William M. Dodson, M.D., is a board-certified psychiatrist.
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