Methylphenidate dose titration follows no rhyme or reason

  • JAMA Pediatr

  • International Clinical Digest
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Takeaway

  • Clinician reasons for methylphenidate dosing choices are so unsystematic that the authors of this meta-analysis of 49 studies could not tell if the selections were arbitrary or evidence-based.
  • Clinical studies yield a range of maximum doses for treating ADHD for a drug that can cause insomnia, abdominal pain, headache, and anorexia. 

Why this matters

  • An accompanying editorial says that these authors have “done the pediatric field a great service” in asking and attempting to answer the question of why clinicians choose the doses they do.

Key results

  • Maximum methylphenidate dose range: 0.8-1.8 mg/kg/day.
  • Although studies described titration methods, rationales for the chosen range were not always provided.
  • Adverse effects were as expected: insomnia, anorexia, abdominal pain, headache, all significantly more common with the drug.
  • Adverse event risks were slightly higher in cohort studies vs randomized controlled trials. 

Study design

  • Meta-analysis of 11 randomized clinical trials (n=1304 on drug; 887 controls) and 38 cohort studies (n=5524).
  • Outcomes: doses, justification for selected dose range, adverse effects when dose established by titration. 
  • Funding: None disclosed.

Limitations

  • Small sample sizes in most included studies.
  • Drug formulation varied across studies.