Introduction
Adderall is a prescription central nervous system stimulant medication containing a combination of dextroamphetamine and levoamphetamine salts. It is classified as a Schedule II controlled substance due to its high potential for abuse and dependence. Adderall is primarily used to treat attention-deficit/hyperactivity disorder (ADHD) and narcolepsy, helping to improve focus, attention, and behavioral control.
Mechanism of Action
Adderall works primarily by increasing the activity of neurotransmitters in the brain, particularly dopamine and norepinephrine. The drug blocks the reuptake of these catecholamines and enhances their release from presynaptic neurons. Dextroamphetamine primarily affects dopamine, while levoamphetamine has more effect on norepinephrine. This dual mechanism helps regulate attention, impulse control, and executive functioning in individuals with ADHD.
Indications
- Treatment of attention-deficit/hyperactivity disorder (ADHD) in children (age 3+), adolescents, and adults
- Narcolepsy (excessive daytime sleepiness)
Dosage and Administration
ADHD:- Children (3-5 years): Initial dose 2.5 mg daily, increase by 2.5 mg weekly
- Children (6+ years) and adults: Initial dose 5 mg once or twice daily, increase by 5 mg weekly
- Maximum dose: 40 mg daily (divided doses)
- Initial dose: 10 mg daily
- Maximum dose: 60 mg daily (divided doses)
- Taken orally with or without food
- Immediate-release tablets: Typically 2-3 times daily (4-6 hour intervals)
- Extended-release capsules (Adderall XR): Once daily in the morning
- Avoid afternoon/evening dosing to prevent insomnia
- Renal impairment: Use with caution, consider dose reduction
- Hepatic impairment: Use with caution
- Geriatric patients: Initiate at lower doses
- Pregnancy: Category C - use only if potential benefit justifies potential risk
Pharmacokinetics
Absorption: Well absorbed from GI tract; food does not significantly affect bioavailability Distribution: Widely distributed throughout body tissues; crosses blood-brain barrier and placenta Metabolism: Hepatic metabolism via cytochrome P450 system; dextroamphetamine is the active metabolite Elimination: Renal excretion; urine pH affects elimination (acidic urine increases excretion) Half-life: Immediate-release: 10-13 hours; Extended-release: similar duration Onset of action: 30-60 minutes Duration: Immediate-release: 4-6 hours; Extended-release: 8-12 hoursContraindications
- Known hypersensitivity to amphetamine products
- Advanced arteriosclerosis
- Symptomatic cardiovascular disease
- Moderate to severe hypertension
- Hyperthyroidism
- Glaucoma
- Agitated states
- History of drug abuse
- Patients taking MAO inhibitors (or within 14 days of discontinuation)
Warnings and Precautions
Black Box Warning: High potential for abuse and dependence. Misuse may cause serious cardiovascular adverse events and sudden death. Cardiovascular: May increase blood pressure and heart rate; use caution in patients with hypertension, heart failure, or structural cardiac abnormalities Psychiatric: May exacerbate psychotic symptoms in patients with pre-existing psychosis; may induce manic episodes in bipolar disorder Growth Suppression: Monitor height and weight in pediatric patients Peripheral Vasculopathy: Raynaud's phenomenon reported Serotonin Syndrome: Risk when used with other serotonergic drugs Seizures: May lower seizure threshold Visual Disturbances: Difficulties with accommodation and blurred vision reportedDrug Interactions
MAO inhibitors: Contraindicated - risk of hypertensive crisis Serotonergic drugs: Increased risk of serotonin syndrome (SSRIs, SNRIs, triptans) Acidifying agents: Vitamin C, ammonium chloride - may decrease amphetamine levels Alkalinizing agents: Sodium bicarbonate, acetazolamide - may increase amphetamine levels Antihypertensics: May antagonize hypotensive effects Tricyclic antidepressants: May enhance amphetamine effects Chlorpromazine: May inhibit central stimulant effectsAdverse Effects
Common (≥5%):- Insomnia
- Decreased appetite
- Weight loss
- Dry mouth
- Headache
- Anxiety
- Irritability
- Gastrointestinal disturbances
- Tachycardia
- Increased blood pressure
- Cardiovascular events (stroke, MI, sudden death)
- Psychiatric adverse reactions (psychosis, mania)
- Peripheral vasculopathy
- Serotonin syndrome
- Seizures
- Visual disturbances
- Growth suppression (pediatrics)
- Priapism (prolonged, painful erections)
Monitoring Parameters
- Blood pressure and heart rate at baseline and regularly during treatment
- Height, weight, and BMI in pediatric patients (every 3-6 months)
- Psychiatric status assessment
- Signs of misuse, abuse, or diversion
- Growth monitoring in children
- Cardiovascular status in at-risk patients
- Complete blood count with differential
- Signs of peripheral vasculopathy
Patient Education
- Take exactly as prescribed; do not increase dose without medical supervision
- Do not share medication with others
- Avoid alcohol and other CNS depressants
- Report chest pain, palpitations, shortness of breath, or fainting
- Monitor for changes in mood or behavior
- Be aware of potential decreased appetite and weight loss
- Take early in day to avoid insomnia
- Store securely to prevent misuse by others
- Do not abruptly discontinue; taper under medical supervision
- Inform all healthcare providers of Adderall use
- Use effective contraception if sexually active (potential teratogenic effects)
References
1. Adderall® [package insert]. Lexington, MA: Shire US Inc.; 2021. 2. Stahl SM. Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 4th ed. Cambridge University Press; 2013. 3. Pliszka SR; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921. 4. Goodman DW. ADHD in adults: update for clinicians on diagnosis and assessment. Prim Psychiatry. 2009;16(11):38-47. 5. Berman SM, Kuczenski R, McCracken JT, London ED. Potential adverse effects of amphetamine treatment on brain and behavior: a review. Mol Psychiatry. 2009;14(2):123-142. 6. FDA. Drug Safety Communication: FDA warns about risk of long-lasting erection with methylphenidate and amphetamine products for attention deficit hyperactivity disorder (ADHD). Silver Spring, MD: FDA; 2013. 7. Cortese S, Holtmann M, Banaschewski T, et al. Practitioner review: current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents. J Child Psychol Psychiatry. 2013;54(3):227-246.