Initiating, monitoring and switching ADHD pharmacotherapy (MEQ)

(i) First-line class and example regimen. After confirmed multi-setting adult ADHD with functional impairment and normal baseline vitals, stimulants remain first-line pharmacotherapy for most adults, preferably long-acting given workday coverage needs and prior IR diversion behaviour.[1][10] Example: OROS methylphenidate 18 mg orally each morning, titrate weekly (e.g. toward 36–54 mg as tolerated/product label) against functional targets, or lisdexamfetamine 30 mg orally each morning, titrate weekly toward a usual maximum of 70 mg/day if amphetamine class preferred — prodrug kinetics also address diversion risk relative to IR dexamfetamine.[2][3][1] Local controlled-drug and authority rules apply in ANZ jurisdictions.[10]

(ii) Monitoring and diversion safeguards. Baseline: cardiac history/syncope/family sudden death, BP/HR, weight, mood/bipolar screen, pregnancy potential if relevant, substance history, concurrent meds (MAOI contraindication). Early follow-up: efficacy, appetite, sleep, mood/irritability, BP/HR, adherence, early refill or lost-script requests; smaller dispensed quantities; no multi-month IR supplies; written driving advice when relevant. Serious CV events are rare in large adult observational data, but small BP/HR rises occur and red-flag symptoms need investigation rather than dose escalation.[6][7][10]

(iii) Cortese 2018. Network meta-analysis: most ADHD medications beat placebo for core symptoms at about 12 weeks; stimulants show the largest average effect sizes, with amphetamines performing particularly well in adult strata in that analysis — supports stimulant-first shared decision while still leaving room for non-stimulants when risk profile demands.[1]

(iv) After optimised methylphenidate failure. (1) Cross-class switch to lisdexamfetamine (e.g. 30 mg → titrate) or another amphetamine product within labelled ranges — incomplete cross-response is expected clinically.[1][3] (2) Atomoxetine e.g. 40 mg daily then 80 mg daily (up to 100 mg if needed), counselling that full trial takes weeks; adult RCTs support efficacy and Newcorn differential-response logic means ATX remains legitimate after stimulant pathways.[4][5] Alpha-2 agonists are more youth-evidence heavy but may be discussed if residual hyperarousal/tics dominate; not the default first adult switch for pure inattention.

(v) Substance use counselling. Prior non-prescribed IR use is a diversion risk flag, not proof that prescribed treatment causes addiction. Wilens meta-analysis does not support the claim that stimulant treatment of ADHD increases later SUD; treat binge drinking with motivational and harm-reduction care in parallel; prefer long-acting/prodrug or non-stimulant; never combine with MAOIs; safety-net for escalating use.[8][9][10]