Stimulant prescribing for attention deficit hyperactivity disorder (ADHD): what guides clinicians in their choice of an upper limit for dose titration?

Abstract

Objective:

There is little evidence to support the current stimulant dose upper limit restrictions in the treatment of attention deficit hyperactivity disorder (ADHD). Within Australasia, there is inconsistency in dose maxima in different jurisdictions. Clinician experience in this area may be worth gauging when trying to improve the understanding of optimal maximal dosing. Our objective was to survey prescribers’ experience of whether the current stimulant maximum doses ever conflict with dose optimisation and how such conflicts are managed.

Method:

We conducted an anonymous online survey of health professionals treating children, adolescents and adults with ADHD.

Results:

Responses were received from 128 prescribers, mainly paediatricians (52%) and adult psychiatrists (39%). The designated maximum dose of stimulant was a constraint to dose optimisation experienced by 91% for the Product Information maxima and 82% for their respective state/territory regulations maxima. When clinically indicated, 72% would exceed the designated maxima, either with or without obtaining a second opinion or applying for special authority. Of the remaining 28%, the majority (16%) would opt for polypharmacy, with only two accepting a suboptimal dose.

Conclusion:

The current stimulant dose maxima act as a constraint to stimulant dose optimisation and may promote undertreatment and polypharmacy.