methylphenidate

ROUTE	ONSET	PEAK	DURATION
PO	unknown	1–3 hr	4–6 hr
PO-ER	unknown	4–7 hr	3–12 hr‡
Transdermal	unknown	unknown	12 hr

Contraindicated in:

Hypersensitivity;
Hyperexcitable states;
Hyperthyroidism;
Patients with psychotic personalities or suicidal or homicidal tendencies;
Serious structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmia, coronary artery disease, or other serious cardiac disease (may ↑ risk of sudden death);
Glaucoma;
Concurrent use or use within 14 days of MAO inhibitors or MAO-inhibitor-like drugs (linezolid or methylene blue);
Fructose intolerance, glucose-galactose malabsorption, or sucrose-isomaltase insufficiency;
Surgery.

Use Cautiously in:

Tics or family history/diagnosis of Tourette's syndrome (may worsen condition);
Hypertension;
Diabetes mellitus;
History of contact sensitization with transdermal product (may be at ↑ risk for systemic sensitization reactions with oral products);
History or family history of vitiligo (may be at ↑ risk for loss of skin pigmentation with transdermal product);
History of substance use disorder;
Seizure disorders (may lower seizure threshold);
Concerta product should be used cautiously in patients with esophageal motility disorders or severe GI narrowing (may ↑ the risk of obstruction);
OB: Use during pregnancy only if potential maternal benefit outweighs potential fetal risk; may lead to premature delivery and low birth weight infants;
Lactation: Use while breastfeeding only if potential maternal benefit outweighs potential risk to infant;
Pedi: Growth suppression may occur in children with long-term use; children 6 yr ( risk of adverse reactions, particularly weight loss in children 4–6 yr);
Geri: Safety and effectiveness of many of the products have not been evaluated in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: hypertension, palpitations, tachycardia, hypotension, peripheral vasculopathy, SUDDEN DEATH

Derm: contact sensitization (erythema, edema, papules, vesicles) (transdermal), erythema, loss of skin pigmentation (transdermal), rash

EENT: blurred vision, ↑intraocular pressure, teeth grinding

GI: anorexia, constipation, cramps, diarrhea, dry mouth, metallic taste, nausea, vomiting

GU: priapism

Metab: growth suppression (especially with prolonged use), weight loss (especially with prolonged use)

MS: RHABDOMYOLYSIS

Neuro: hyperactivity, insomnia, restlessness, tremor, akathisia, behavioral disturbances, dizziness, dyskinesia, hallucinations, headache, irritability, mania, thought disorder, tics, Tourette's syndrome

Misc: fever, HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS AND ANGIOEDEMA), physical dependence, psychological dependence, tolerance

Interactions ⬆ ⬇

Drug-drug:

Concurrent use with MAO inhibitors or MAO-inhibitor-like drugs, such as linezolid or methylene blue, may result in serious, potentially fatal reactions; wait at least 14 days following discontinuation of MAO inhibitor before initiation of amphetamine mixtures.
Drugs that affect serotonergic neurotransmitter systems, including MAO inhibitors, tricyclic antidepressants, SSRIs, SNRIs, fentanyl, buspirone, tramadol, lithium, and triptans, ↑ risk of serotonin syndrome.
↑sympathomimetic effects with other adrenergics, including vasoconstrictors, decongestants, and halogenated anesthetics.
Metabolism of warfarin, phenytoin, phenobarbital, primidone, SSRIs, and tricyclic antidepressants may be ↓ and effects ↑.
Avoid concurrent use with pimozide (may mask cause of tics).
May ↓ the effectiveness of antihypertensives.
Alcohol may ↑ rate of release of drug from some methylphenidate formulations (Metadate CD, Ritalin LA).
Concurrent use with risperidone may ↑ risk of extrapyramidal symptoms.

Drug-Natural Products:

Use with caffeine-containing herbs (guarana, tea, coffee) ↑ stimulant effect.
St. John's wort may ↑ risk of serotonin syndrome.

Excessive use of caffeine-containing foods or beverages (coffee, cola, tea) may cause ↑ CNS stimulation.

Route/Dosage ⬆ ⬇

Attention-Deficit/Hyperactivity Disorder

PO (Adults <65 yr): Immediate-release tablets: 5–20 mg 2–3 times daily. When maintenance dose is determined, may change to extended-release formulation. Methylphenidate SR: May be used in place of the immediate-release tablets when the 8-hr dose corresponds to the titrated 8-hr dosage of the immediate-release tablets. Concerta and Relexxii (patients who have not taken methylphenidate previously): 18–36 mg once daily in the morning initially; may be titrated as needed up to 72 mg/day. Concerta and Relexxii (patients are currently taking other forms of methylphenidate): 18 mg once daily in the morning if previous dose was 5 mg 2–3 times daily; 36 mg once daily in the morning if previous dose was 10 mg 2–3 times daily; 54 mg once daily in the morning if previous dose was 15 mg 2–3 times daily; 72 mg once daily in the morning if previous dose was 20 mg 2–3 times daily. Aptensio XR: 10 mg once daily; may ↑ dose in 10-mg increments at weekly intervals (maximum dose = 60 mg/day). Quillivant XR and Quillichew ER: 20 mg once daily; may ↑ dose in 10–20-mg increments at weekly intervals (maximum dose = 60 mg/day). Jornay PM: 20 mg once daily in the evening; may ↑ dose in 20-mg increments at weekly intervals (maximum dose = 100 mg/day).
PO (Children ≥6 yr [Ritalin LA for children 6–12 yr]): Immediate-release tablets: 0.3 mg/kg/dose or 2.5–5 mg before breakfast and lunch; may ↑ dose by 0.1 mg/kg/dose or by 5–10 mg/day at weekly intervals (not to exceed 60 mg/day or 2 mg/kg/day). When maintenance dose is determined, may change to extended-release formulation. Methylphenidate SR: May be used in place of the immediate-release tablets when the 8-hr dose corresponds to the titrated 8-hr dosage of the immediate-release tablets. Ritalin LA (patients who have not taken methylphenidate previously): 20 mg once daily; may ↑ by 10 mg/day at weekly intervals (max = 60 mg/day). Ritalin LA (patients currently taking other forms of methylphenidate): Can be used in place of immediate-release twice daily regimen given once daily at same total dose or in place of SR product at same dose. Concerta (patients who have not taken methylphenidate previously): 18 mg once daily in the morning initially; may be titrated as needed up to 54 mg/day (children 6–12 yr old) or up to 72 mg/day (children 13–17 yr old). Concerta (patients are currently taking other forms of methylphenidate): 18 mg once daily in the morning if previous dose was 5 mg 2–3 times daily; 36 mg once daily in the morning if previous dose was 10 mg 2–3 times daily; 54 mg once daily in the morning if previous dose was 15 mg 2–3 times daily; 72 mg once daily in the morning if previous dose was 20 mg 2–3 times daily. Aptensio XR: 10 mg once daily; may ↑ dose in 10-mg increments at weekly intervals (maximum dose = 60 mg/day). Quillivant XR and Quillichew ER: 20 mg once daily; may ↑ dose in 10–20-mg increments at weekly intervals (maximum dose = 60 mg/day). Jornay PM: 20 mg once daily in the evening; may ↑ dose in 20-mg increments at weekly intervals (maximum dose = 100 mg/day). Cotempla XR-ODT: 17.3 mg once daily in the morning; may ↑ dose in 8.6–17.3-mg increments at weekly intervals (maximum dose = 51.8 mg/day).
Transdermal (Children ≥6 yr): Apply one 10-mg patch initially (should be applied 2 hr before desired effect and removed 9 hr after application); may be titrated based on response and tolerability; may ↑ to 15-mg patch after 1 wk, then to 20-mg patch after another wk, and then to 30-mg patch after another wk.

Narcolepsy

PO (Adults ): Immediate-release tablets: 10 mg 2–3 times/day; maximum dose = 60 mg/day.

Availability ⬆ ⬇

(Generic available)

Immediate-release tablets (Ritalin): 5 mg; 10 mg; 20 mg
Extended-release capsules (Aptensio XR): 10 mg; 15 mg; 20 mg; 30 mg; 40 mg; 50 mg; 60 mg
Extended-release capsules (Jornay PM): 20 mg; 40 mg; 60 mg; 80 mg; 100 mg
Extended-release capsules (Ritalin LA): 10 mg; 20 mg; 30 mg; 40 mg
Extended-release capsules (Foquest): 25 mg; 35 mg; 45 mg; 55 mg; 70 mg; 85 mg
Extended-release tablets (Concerta): 18 mg; 27 mg; 36 mg; 54 mg
Extended-release tablets (Relexxii): 18 mg; 27 mg; 36 mg; 45 mg; 54 mg; 63 mg; 72 mg
Extended-release orally disintegrating tablets (Cotempla XR-ODT): 8.6 mg; 17.3 mg; 25.9 mg
Chewable tablets grape flavor: 2.5 mg; 5 mg; 10 mg
Extended-release chewable tablets (Quillichew ER): 20 mg; 30 mg; 40 mg
Oral solution (Methylin)grape flavor: 5 mg/5 mL; 10 mg/5 mL
Extended-release oral suspension (Quillivant XR)banana flavor: 25 mg/5 mL
Transdermal patch: 10 mg/9 hr; 15 mg/9 hr; 20 mg/9 hr; 30 mg/9 hr

Assessment ⬆ ⬇

Assess cardiac history, BP, HR, and respiratory rate prior to and periodically during therapy. Sudden death has been reported in patients with serious cardiac disease.
- Assess risk for and signs of addiction, abuse, and overdose.
- Assess for pre-existing psychiatric disorders, including family and personal history of bipolar disorder, mania, depression, and suicidal ideation. Monitor for behavior or mood changes during therapy.
- Assess for pre-existing and family history of tics and Tourette's syndrome. Monitor for worsening motor and verbal tics during therapy and discontinue therapy when medically appropriate.
- Monitor for signs and symptoms of peripheral vasculopathy (intermittent pain, numbness, burning or color changes in digits). May require ↓ in dose or discontinuation.
- Monitor growth (height and weight) in children. May need to interrupt therapy in patients who are not growing as expected.
- Assess for risk of acute angle closure glaucoma. If at risk,obtain ophthalmic evaluation.
ADHD: Assess children for attention span, impulse control, and interactions with others. Therapy may be interrupted at intervals to determine whether symptoms are sufficient to continue therapy.
Narcolepsy: Observe and document frequency of episodes.
Assess skin for signs of contact sensitization (erythema with edema, papules, or vesicles that does not improve within 48 hr or spreads beyond patch site) during therapy. May lead to systemic sensitization to other forms of methylphenidate. If symptoms occur,may change to oral preparation with close monitoring.
- Monitor for signs of skin depigmentation at application site and at distant sites. Discontinue transdermal patch if depigmentation occurs.

Lab Test Considerations:

Monitor CBC with differential during prolonged therapy.

Implementation ⬆ ⬇

Do not confuse methylphenidate with methadone.
PO: Administer immediate and ER tablets (with the exception of Concertaon an empty stomach (30–45 min before a meal); Concerta may be administered without regard to food, but must be taken with water, milk, or juice. DNC: ER tablets should be swallowed whole; do not break, crush, or chew. Quillichew ER chewable tablets may be broken in half. Aptensio XL, Metadate CD, and Ritalin LA capsules may be opened and sprinkled on cool applesauce; entire mixture should be ingested immediately and followed by a drink of water. Do not store for future use.
- Shake ER oral suspension for 10 sec before administering. May be given with or without food.
Apply patch to a clean, dry site on the hip; do not apply to waistline where tight clothing may rub it. Press firmly in place with palm of hand for 30 sec to secure. Alternate site daily. Apply patch 2 hr before desired effect and remove 9 hr after applied; effects last several more hr. Do not apply or reapply with dressings, tape, or other adhesives. Do not cut patches.
- If difficulty in separating patch from release liner, tearing, or other damage occurs during removal from liner, discard patch and apply a new patch. Inspect release liner to ensure no adhesive containing medication has transferred to liner; if transfer has occurred, discard patch. Avoid touching adhesive during application; wash hands immediately after application.
- If patch does not fully adhere or partially detaches, remove and replace with another patch. Exposure to water during bathing, swimming, or showering may affect patch adherence.
- Patches may be removed earlier before ↓ dose if an unacceptable loss of appetite or insomnia occurs.
- Store patches at room temperature in safe place to prevent abuse and misuse; do not refrigerate or freeze.
- To remove patch, peel off slowly. An oil-based product (petroleum jelly, olive oil, mineral oil) may be applied gently to facilitate removal. On removal, fold so that adhesive side of patch adheres to itself and flush down toilet or dispose of in an appropriate lidded container.

Patient/Family Teaching ⬆ ⬇

Instruct patient to take medication as directed. If an oral dose is missed, take the remaining doses for that day at regularly spaced intervals; do not double doses. Take the last dose before 6 pm to minimize the risk of insomnia. Instruct patient not to alter dose without consulting health care professional. Abrupt cessation of high doses may cause extreme fatigue and mental depression. Instruct parent/caregiver to read the Medication Guide prior to use and with each Rx refill as changes may occur.
- Advise patient to check weight 2–3 times weekly and report weight loss to health care professional.
- Advise patient that methylphenidate is a drug with known abuse potential; store in safe, locked location away from children.
- May cause dizziness or blurred vision. Caution patient to avoid driving or activities requiring alertness until response to medication is known.
- Inform patient that shell of Concerta tablet may appear in the stool. This is no cause for concern.
- Advise patient to avoid eating or drinking caffeine-containing substances concurrently with therapy.
- Advise patient to notify health care professional if nervousness, insomnia, palpitations, vomiting, skin rash, fever, painful and prolonged erections, or peripheral circulation problems occur.
- Advise patient to notify health care professional of behavior or mood changes.
- Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially St. John's wort.
- Inform patient that health care professional may order periodic holidays from the drug to assess progress and to decrease dependence.
- Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. May lead to premature delivery and low birth weight infants. Inform patients who become pregnant while taking methylphenidate of National Pregnancy Registry of ADHD Medications, which monitors pregnancy outcomes in patients exposed to ADHD medications. Enroll by calling 1-866-961-2388 or visit online at https://womensmentalhealth.org/adhd-medications/. Monitor breastfed infants exposed to methylphenidate for agitation, insomnia, anorexia, and ↓ weight gain.
- Emphasize the importance of routine follow-up exams to monitor progress.
Encourage parent/caregiver to use the administration chart included in package to monitor application and removal time and disposal method.
- Caution patient to avoid exposing patch to direct external heat sources (hair dryers, heating pads, etc.). May ↑ rate and extent of absorption.
- Inform parent/caregiver that skin redness, itching, and small bumps on the skin are common. If swelling or blistering occurs, the patch should not be worn and health care professional notified. Caution parent/caregiver not to apply creams or ointments prior to application.
Advise patient to discuss patch with referring health care professional prior to undergoing an MRI.
Home Care Issues: Pedi: Advise parent/caregiver to notify school nurse of medication.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆ ⬇

Contr. Subst. Schedule ⬆ ⬇

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