Home What is Adult ADD? Does ADD Exist? ADD Questionnaire How I treat ADD Questions / Answers Psych/Neuro Tests Vyvanse Adderall vs Ritalin High Dose Stimulants Coaching Gems Research on ADD Reminder System ADD and Psychotherapy Getting Help Nick Schwartz, MD Marc Schwartz, MD Info for Clinicians
Note: After reading this page, you may think that you should try a higher dose of your medication. Do not increase your dose of stimulants without checking with your doctor first as there may be medical or other reasons that a higher dose may not be healthy for you.
Dr. Joseph Biederman, MD, Professor of Psychiatry, Harvard Medical School, Boston, MA and Head of the Attention Deficit Disorder Program of Massachusetts General Hospital, has noted that effective stimulant doses in adolescents and adults are usually higher than those for children. If this is not taken into account by clinicians treating adults, the doses they prescribe for their patients may not reach the range needed to achieve therapeutic benefit. (Biederman, J: Practical Considerations in Stimulant Drug Selection for the Attention Deficit/Hyperactivity Disorder Patient - Efficacy, Potency, and Titration)
For a medication to be approved by the US Food and Drug Administration (FDA) for sale to the public, the pharmaceutical company producing it must submit the results of extensive research on the medication demonstrating its effectiveness and safety. Such studies can take years to complete and can be quite expensive (millions of dollars). It is easier for a drug to pass the FDA testing requirement if it is tested at the lowest dose levels at which it may be effective. This way, side effects and other problems are less likely to occur, and the medication is more likely to be approved.
About forty years ago, drug manufacturers carried out tests on stimulants on children at doses up to 60 mg per day. The tests proved the medications worked and were safe for children. They fairly consistently showed that the higher the dose, up to the highest level tested, the better the effect. But they said nothing about the benefits or risks of higher doses. So the highest dose the FDA approved was 60 mg per day.
At the time the tests were done, it was generally believed that ADD did not exist in adults, that children outgrew it. We now know that hyperactive symptoms often disappear in adulthood but that inattentive symptoms persist throughout the lifetime of well over half of all children with ADD.
Fortunately for adults with ADD, doctors are permitted by law to prescribe medication at doses that are higher than those approved by the FDA. This is called "off-label" prescribing. However, if doctors can legally prescribe higher doses off-label, and pharmacies can legally fill those prescriptions, there is little motivation for pharmaceutical companies to carry out costly studies to determine whether higher doses are safe and more effective in adults. This task is left up to practicing doctors, who learn what doses work well and which do not, which are dangerous and which are not through experience, reading, and observing leaders in the field.
However, the FDA does not change its rules about dosing unless a pharmaceutical company submits a new application for it to do so, and that has not happened with the stimulants. So many doctors and pharmacists who are not familiar with current advances in the treatment of ADD still honor on the original FDA approved limits on dosing. For one thing, doing so protects them against malpractice claims, as they can always defend their treatment by noting that they prescribed according to government guidelines. However, once an off-label treatment becomes common enough, it is a sufficient legal defense to note that the clinician and patient were aware that the dosage was not within FDA limits but was in line with the standards of practice in their community. So while the FDA approval for most stimulants remains limited to use in children, their use in adults is now so widespread that most clinician feel secure prescribing them for adults as well.
Doctors who use off-label (higher) doses have found that, as a general rule (but not always), the more a person weighs, the higher the dose of stimulants they will need to get a beneficial effect. Thirty milligrams twice a day might work for a 12 year old facing an eight hour school day, but twice that dose might be needed by a 180 pound adult who finishes with work at 5 PM and then has to do work at home and/or interact calmly and productively with family members in the evening. As Dr. Biederman has often said, "pediatric dosing, pediatric effects." This became clear even with the treatment of children. In one of the largest studies of the effects of treatment for ADD ever carried out, the Multimodal Treatment Study, one of the most common causes of poor outcome was under-dosing.
In addition, there are differences in how stimulants are absorbed from the gut, how they are transported to the brain, and how they act in the brain. For these reasons, the same dose of a medication might be much too low for one person and much too high for another. Setting a fixed dosage does not make sense scientifically.
I am aware of no published research articles on the benefits or risks of supervised treatment using daily doses higher than 60 mg per day despite the fact that many patients have benefited from such doses with no ill effects. Patients who require more frequent dosing may especially benefit from higher total daily dosing. For example, patients who become irritable when their medication wears off at the end of the day often benefit from an additional dose in the mid-to late afternoon - even though the dose goes over the FDA limit.
The abusive use of high, or even standard, doses of stimulants or the use of stimulants for recreational purposes has cast a shadow on the therapeutic use of off-label doses by responsible clinicians. However, the excessive use of stimulants by some people and/or the unsupervised prescription of higher doses by a few irresponsible clinicians does not justify withholding helpful doses of medication from responsible patients being treated by responsible doctors.
A repeated note of caution: After reading this page, you may think that you should try a higher dose of your medication. Do not increase your dose of stimulants without the approval of your doctor as there may be medical or other reasons that a higher dose may not be healthy, or might even be dangerous, for you.
The table below lists maximum daily doses used by some treatment groups. (Note, these are maximum, not average or standard doses.)
methylphenidate maximum dose amphetamine maximum dose Vyvanse maximum dose* 100 pounds 90 mg per day 50 mg per day 115 mg per day 120 pounds 110 mg per day 80 mg per day 140 mg per day 140 pounds 125 mg per day 100 mg per day 165 mg per day 160 pounds 145 mg per day 120 mg per day 190 mg per day 180 pounds 165 mg per day 140 mg per day 200 mg per day 200 pounds 185 mg per day 150 mg per day 225 mg per day
Note: Vyvanse (which contains dextroamphetamine) has a maximum dose two and a half times larger that the other amphetamines. This is because each molecule of dextroamphetamine in Vyvanse is bound to an inactive but heavy molecule that keeps the dextroamphetamine from working. After Vyvanse is taken orally, the inactive molecule is split from the dextroamphetamine by digestive enzymes in the intestines, allowing the dextroamphetamine to be slowly absorbed and used by the brain.
Note once again: most of the "maximum" doses listed above are higher than those approved by the FDA. They are the maximums used by some medical practitioners. Check with your prescriber before taking such doses. "High" doses may require more careful checks of blood pressure and may be contraindicated in the presence of certain health conditions.
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What is Adult ADD? Does ADD Exist? ADD Questionnaire How I treat ADD Questions / Answers Psych/Neuro Tests Vyvanse Adderall vs Ritalin High Dose Stimulants Coaching Gems Research on ADD Reminder System ADD and Psychotherapy Getting Help Nick Schwartz, MD Marc Schwartz, MD Info for Clinicians