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Dexmethylphenidate Hydrochloride

Pronunciation

Class: Respiratory and CNS Stimulants
VA Class: CN802
Chemical Name: (αR,2R)-α-Phenyl-2-piperidineacetic acid methyl ester hydrochloride
Molecular Formula: C14H19NO2•HCl
CAS Number: 19262-68-1
Brands: Focalin

Warning(s)

  • Dependence and Abuse
  • Use cautiously in patients with a history of drug or alcohol dependence.1 4

  • Chronic abuse can lead to marked tolerance and psychologic dependence with varying degrees of abnormal behavior.1 4 Psychotic episodes can occur, particularly with parenteral abuse.1 4

  • Careful supervision required during withdrawal from abusive use, as severe depression may occur.1 4

  • Withdrawal following chronic therapeutic use may unmask symptoms of the underlying disorder, which may require follow-up.1 4

Introduction

Stimulant; the more pharmacologically active (d-threo) enantiomer of racemic methylphenidate; pharmacologic actions qualitatively similar to those of amphetamines.1 4

Uses for Dexmethylphenidate Hydrochloride

Attention Deficit Hyperactivity Disorder (ADHD)

Treatment of ADHD, alone or combined with behavioral treatment, as an adjunct to psychological, educational, social, and other remedial measures in carefully selected children ≥6 years of age, adolescents, and adults.1 4

Dexmethylphenidate Hydrochloride Dosage and Administration

General

  • Carefully adjust dosage according to individual requirements and response.1 4

  • For patients whose symptoms are not severe outside school, may attempt drug holidays for all or part of the summer to assess continuing efficacy and need for therapy, as well as to minimize adverse effects.5

  • Discontinue therapy if a beneficial effect is not attained after appropriate dosage adjustment over 1 month.1 4

  • If paradoxical aggravation of symptoms occurs, reduce dosage or discontinue the drug.1 4

  • Periodically discontinue therapy to assess the patient’s condition; improvement may be maintained temporarily or permanently after the drug is discontinued.1 4

Administration

Oral Administration

Conventional Tablets

Administer orally twice daily without regard to meals; administer doses at least 4 hours apart.1

Extended-release Capsules

Administer orally once daily in the morning with or without food.4 6

Swallow capsules intact.4 6 Do not crush, chew, or subdivide the capsule contents.4 6

Alternatively, open capsule(s) and sprinkle entire contents on a small amount (e.g., 1 spoonful) of applesauce immediately prior to administration.4 6 Do not store the sprinkle/applesauce mixture for later use.4 6

Dosage

Available as dexmethylphenidate hydrochloride; dosage expressed in terms of the salt.1

Pediatric Patients

ADHD
Conventional Tablets
Oral

Children ≥6 years of age: Initially, 2.5 mg twice daily for children who currently are not receiving racemic methylphenidate or are receiving stimulants other than methylphenidate.1 Increase dosage by 2.5–5 mg daily at weekly intervals (up to maximum dosage of 20 mg daily).1

Children ≥6 years of age: Initially administer one-half the current methylphenidate hydrochloride dosage in children who are being transferred from racemic methylphenidate to dexmethylphenidate therapy.1

Extended-release Capsules
Oral

Children ≥6 years of age: Initially, 5 mg once daily for children who currently are not receiving dexmethylphenidate or racemic methylphenidate or who are receiving stimulants other than methylphenidate.4 Increase dosage by 5 mg daily at weekly intervals (up to maximum dosage of 30 mg daily).4 Within the dosage range of 10–30 mg daily, no clear evidence that higher dosages provide greater average benefits than lower dosages; adverse effects and drug discontinuance are dose related.4

Children ≥6 years of age: Substitute extended-release capsules for conventional tablets at same total daily dosage.4

Children ≥6 years of age: Initially administer one-half the current methylphenidate hydrochloride dosage in children who are being transferred from racemic methylphenidate to dexmethylphenidate therapy.4

Adults

ADHD
Extended-release Capsules
Oral

Initially, 10 mg once daily for patients who currently are not receiving dexmethylphenidate or racemic methylphenidate or who are receiving stimulants other than methylphenidate.4 Increase dosage by 10 mg daily after 1 week (up to maximum dosage of 40 mg daily).4 Within the dosage range of 20–40 mg daily, no clear evidence that higher dosages provide greater average benefits than lower dosages; adverse effects and drug discontinuance are dose related.4

Substitute extended-release capsules for conventional tablets at same total daily dosage.4

Initially administer one-half the current methylphenidate hydrochloride dosage in patients who are being transferred from racemic methylphenidate to dexmethylphenidate therapy.4

Prescribing Limits

Pediatric Patients

ADHD
Oral

Maximum 20 mg daily (conventional tablets) or 30 mg daily (extended-release capsules).1 4

Long-term use (>6 weeks for conventional tablets or >7 weeks for extended-release capsules) has not been studied systematically.1 4 If used for long-term therapy, periodically reevaluate the usefulness of the drug.1 4

Adults

ADHD
Oral

Maximum 40 mg daily (extended-release capsules).4

Long-term use (>7 weeks for extended-release capsules) has not been studied systematically.4 If used for long-term therapy, periodically reevaluate the usefulness of the drug.4

Special Populations

Hepatic Impairment

No specific dosage recommendations.1 4 (See Hepatic Impairment under Cautions.)

Renal Impairment

No specific dosage recommendations.1 4 (See Renal Impairment under Cautions.)

Cautions for Dexmethylphenidate Hydrochloride

Contraindications

  • Marked anxiety, tension, and agitation.1 4

  • Glaucoma.1 4

  • Motor tics or a family history or a diagnosis of Tourette’s syndrome.1 3 4 However, the AAP states that the presence of tics before or during medical management of ADHD is not an absolute contraindication to stimulant drug use.3

  • Concomitant or recent (within 14 days) administration of MAO inhibitors.1 4 (See MAO Inhibitors under Interactions.)

  • Known hypersensitivity to dexmethylphenidate, methylphenidate, or any ingredient in the formulation.1 4

Warnings/Precautions

Warnings

Dexmethylphenidate shares the toxic potentials of racemic methylphenidate; observe the usual precautions of racemic methylphenidate therapy.1 4

Abuse Potential

Potential for abuse and dependence.1 4 (See Boxed Warning.)

Use with caution in patients with a history of drug or alcohol dependence.1 4 5 Caution may be indicated in patients with comorbid conduct disorder or a chaotic family.5 If the risk of drug abuse by the patient or the patient’s peers or family is considered high, a nonstimulant drug may be preferable.5

Withdrawal Effects

Severe depression may occur during withdrawal from abusive use; careful supervision required.1 4

Withdrawal following chronic therapeutic use may unmask symptoms of the underlying disorder; follow-up may be required.1 4

Sudden Death and Serious Cardiovascular Events

Sudden unexplained death, stroke, and MI reported in adults with ADHD receiving usual dosages of stimulants; sudden death also reported in children and adolescents with structural cardiac abnormalities or other serious cardiac conditions receiving usual dosages of the drugs.1 4

Although an initial epidemiologic study showed an association between use of stimulants and sudden unexplained death in healthy children and adolescents,8 9 10 several subsequent large epidemiologic studies in children and young adults or in adults 25–64 years of age found no association between ADHD drug use (stimulants, atomoxetine, pemoline [no longer commercially available in US]) and serious cardiovascular events (MI, stroke, sudden cardiac death), although small increases in cardiovascular risk could not be excluded.13 14 15 16

No clinically important changes in corrected QT (QTc) interval observed in healthy individuals following 40-mg dose of extended-release dexmethylphenidate hydrochloride.1 4

Thoroughly review medical history (including evaluation for family history of sudden death or ventricular arrhythmia) and perform physical examination in all children, adolescents, and adults being considered for stimulant therapy; if initial findings suggest presence of cardiac disease, perform further cardiac evaluation (e.g., ECG, echocardiogram).1 4

In general, avoid use of CNS stimulants in patients with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, CAD, or other serious cardiac conditions.1 4 13 14

Patients who develop exertional chest pain, unexplained syncope, or other manifestations suggestive of cardiac disease during stimulant therapy should undergo prompt cardiac evaluation.1 4

Effects on BP and Heart Rate

Possible modest increases in average BP (i.e., by about 2–4 mm Hg) and heart rate (i.e., by about 3–6 bpm); larger increases may occur.1 4 Modest increases not expected to have short-term sequelae; however, monitor all patients for larger changes in BP and heart rate.1 4 13 14

Caution advised in patients with underlying medical conditions that might be affected by increases in BP or heart rate (e.g., hypertension, heart failure, recent MI, ventricular arrhythmia).1 4 13 14

Exacerbation or Precipitation of Psychotic Symptoms

May exacerbate symptoms of behavior disturbance and thought disorder in patients with preexisting psychotic disorder.1 4

Psychotic symptoms (e.g., hallucinations, delusional thinking) may occur with usual dosages in children and adolescents without prior history of psychotic illness.1 4 If psychotic symptoms occur, consider causal relationship to stimulants, and discontinue therapy as appropriate.1 4

Precipitation of Manic Symptoms

May precipitate mixed or manic episodes in ADHD patients with comorbid bipolar disorder; use with caution in these patients.1 4 Prior to initiating therapy, carefully screen patients with ADHD and comorbid depressive symptoms to identify risk for bipolar disorder; screening should include a detailed psychiatric history (e.g., family history of suicide, bipolar disorder, or depression).1 4

Manic symptoms may occur with usual dosages in children and adolescents without prior history of mania.1 4 If manic symptoms occur, consider causal relationship to stimulants, and discontinue therapy as appropriate.1 4

Aggression

Aggressive behavior and hostility (frequently observed in children and adolescents with ADHD) reported in patients receiving drug therapy for ADHD.1 4 No systematic evidence that stimulants cause these adverse effects; however, monitor patients beginning treatment for ADHD for onset or worsening of aggressive behavior or hostility.1 4

Growth Suppression

Long-term (i.e., >14 months) administration expected to cause at least a temporary suppression of normal weight and/or height patterns in some children and adolescents.1 4

Manufacturer recommends monitoring growth during treatment; patients not growing or gaining weight as expected may require temporary discontinuance of treatment.1 4 However, AAP states that studies of stimulants in children found little or no decrease in expected height, with any decrease in growth early in treatment being compensated for later on.3

Seizures

Possible lowering of seizure threshold in patients with history of seizures, in those with prior EEG abnormalities but no history of seizures, and, very rarely, in those without history of seizures and with no prior evidence of EEG abnormalities.1 4 If seizures occur, discontinue therapy.1 4

Priapism

Prolonged and painful erections, in some cases requiring surgical intervention, reported in adult and pediatric patients receiving methylphenidate.1 4 12 Priapism often reported following increase in dosage; also has occurred during temporary interruptions in therapy (e.g., drug holidays) or following drug discontinuance.1 4 12 Risk of permanent penile damage if not treated immediately.12 (See Advice to Patients.)

FDA states clinicians should be cautious if they consider switching patients from methylphenidate because of this risk; certain alternative ADHD treatments (e.g., atomoxetine) also may cause priapism.12

Peripheral Vascular Effects

Peripheral vascular disorders, including Raynaud's phenomenon, reported in patients in all age groups receiving stimulants at therapeutic dosages and at various times throughout treatment course.1 4 Manifestations usually intermittent and mild, but ulceration of digits and/or breakdown of soft tissue occur rarely.1 4 Carefully observe for digital changes.1 4

Improvement generally observed following dosage reduction or drug discontinuance; however, some patients may require further evaluation (e.g., referral to a rheumatologist).1 4

Visual Disturbances

Visual disturbances (difficulty with accommodation, blurred vision) reported with stimulants.1 4

Sensitivity Reactions

Hypersensitivity reactions, including angioedema and anaphylaxis, reported.1 4

General Precautions

Hematologic Monitoring

Manufacturer recommends periodic monitoring of CBC (with differential) and platelet counts during prolonged therapy;1 4 however, AAP and many clinicians consider routine hematologic monitoring unnecessary in patients receiving recommended stimulants (e.g., methylphenidate, amphetamines) in the absence of clinical signs (e.g., fever, sore throat, unusual bleeding or bruising) suggestive of hematologic toxicity.3

Specific Populations

Pregnancy

Category C.1 4

Lactation

Not known whether dexmethylphenidate is distributed into milk; caution advised if used in nursing women.1 4

Limited data (case reports) suggest that exclusively breast-fed infants receive about 0.2–0.7% of the maternal weight-adjusted dosage of racemic methylphenidate; milk concentrations of methylphenidate ranged from undetectable to 15.4 ng/mL in lactating women receiving the racemic drug at dosages of 35–80 mg daily.4

Pediatric Use

Safety and efficacy not established in children <6 years of age.1 4

Aggressive behavior, hostility, and psychotic (e.g., hallucinations, delusional thinking) or manic symptoms reported in children and adolescents receiving stimulants for management of ADHD.1 4 (See Warnings under Cautions.)

Sudden death reported in children and adolescents with structural cardiac abnormalities or other serious cardiac conditions receiving usual dosages of stimulants.1 4 (See Sudden Death and Serious Cardiovascular Events under Cautions.)

Long-term administration expected to cause at least a temporary suppression of normal weight and/or height patterns in some children and adolescents.1 4 (See Growth Suppression under Cautions.)

Hepatic Impairment

Safety and efficacy not established.1 4

Renal Impairment

Safety and efficacy not established.1 4

Common Adverse Effects

Conventional tablets: Abdominal pain, fever, anorexia, nausea.1

Extended-release capsules: Decreased appetite/anorexia, headache, dyspepsia, dry mouth, anxiety, insomnia, vomiting, pharyngolaryngeal pain.4

Interactions for Dexmethylphenidate Hydrochloride

Does not inhibit CYP isoenzymes in vitro.1 4

MAO Inhibitors

Pharmacologic interaction (potentiation of pressor effects, possible hypertensive crisis); dexmethylphenidate is contraindicated in patients currently or recently (i.e., within 14 days) receiving MAO inhibitors.1 4

Pressor Agents

Possible pharmacologic interaction (increased hypertensive effects); use with caution.1 4

Drugs Affecting GI pH

Studies to evaluate the effects of changes in gastric pH on absorption of dexmethylphenidate hydrochloride extended-release capsules have not been performed.4 However, potential exists for pharmacokinetic interaction (altered release of dexmethylphenidate hydrochloride) between Focalin XR extended-release capsules and drugs that alter gastric pH (e.g., antacids, acid suppressants).4

Interactions Involving Methylphenidate

The possibility that drug interactions reported with racemic methylphenidate also could occur with dexmethylphenidate should be considered.1 4

Drug

Interaction with Methylphenidate

Comments

Anticonvulsants (e.g., phenobarbital, phenytoin, primidone)

Possible inhibition of anticonvulsant metabolism1 4

Monitor plasma anticonvulsant concentrations when initiating or discontinuing methylphenidate; reduction of anticonvulsant dosage may be required during concomitant therapy1 4

Coumarin anticoagulants (e.g., warfarin)

Possible inhibition of anticoagulant metabolism1 4

Monitor PT when initiating or discontinuing methylphenidate; reduction of anticoagulant dosage may be required during concomitant therapy1 4

Hypotensive agents

Antagonism of hypotensive effect1 4

Serotonin-reuptake inhibitors

Possible inhibition of antidepressant metabolism1

Reduction of antidepressant dosage may be required during concomitant therapy1

Tricyclic antidepressants (e.g., clomipramine, desipramine, imipramine)

Possible inhibition of antidepressant metabolism1 4

Reduction of antidepressant dosage may be required during concomitant therapy1 4

Dexmethylphenidate Hydrochloride Pharmacokinetics

Absorption

Bioavailability

Readily absorbed following oral administration.1 Mean absolute bioavailability is 22–25% due to high first-pass metabolism.4

Peak plasma concentrations for conventional tablets are achieved within 60–90 minutes following oral administration in fasting patients.1

Peak plasma concentrations for extended-release capsules (Focalin XR) are attained at 1.5 hours and again at 6.5 hours after a dose.4

Extended-release capsules are absorbed more slowly but to the same extent as conventional tablets.4 AUC is similar for extended-release capsules (administered once daily) and conventional tablets (same daily dosage administered in 2 divided doses 4 hours apart).4

Comparable plasma concentrations achieved following single-dose administration of dexmethylphenidate hydrochloride capsules or single-dose administration of racemic methylphenidate hydrochloride capsules at equimolar doses (twice the total mg amount of dexmethylphenidate hydrochloride).1

Food

Conventional tablets: High-fat meal slows rate of absorption but does not alter peak concentration or extent of absorption compared with administration in fasting state.1

Extended-release capsules: Effects of food on absorption characteristics not studied but thought to be similar to those observed with similar extended-release formulation of racemic methylphenidate.4 Administration of extended-release racemic methylphenidate formulation with high-fat meal results in delayed absorption during first and second absorption phases and lower peak concentration during second absorption phase; extent of absorption not affected.4 Plasma concentration-time profile is similar following administration of extended-release racemic methylphenidate formulation with applesauce compared with administration under fasting conditions.4

Special Populations

Following administration of conventional tablets, AUC is higher in women than in men; pharmacokinetics parameters are similar between boys and girls.1 Following administration of extended-release capsules, peak plasma concentration during first absorption phase is higher in women than in men.4

Following administration of conventional tablets, AUC is lower in children than in adults.1 Pharmacokinetics of extended-release capsules not studied in children; however, following administration of a similar formulation of racemic methylphenidate, between-peak minimum and second peak concentrations were delayed and more variable in children than in adults.4

Distribution

Extent

Not known whether dexmethylphenidate crosses placenta or distributes into milk.1

Elimination

Metabolism

Metabolized principally by de-esterification to form d-ritalinic acid, which has little or no pharmacologic activity.1 4

Elimination Route

Excreted in urine, principally as ritalinic acid.1 4

Half-life

2–3 hours in children or 2–4.5 hours in adults.1 4

Stability

Storage

Oral

Conventional Tablets

25°C (may be exposed to 15–30°C).1 Protect from light and moisture.1

Extended-release Capsules

Tight container at 25°C (may be exposed to 15–30°C).4

Actions

  • Appears to block norepinephrine and dopamine reuptake into the presynaptic neuron and increases their release into the extraneuronal space.1 4 Mechanism of action for treatment of ADHD not determined.1 4

Advice to Patients

  • Provide patient or caregiver with a copy of manufacturer’s patient information (medication guide); discuss and answer questions about its contents as needed.1 4 Instruct patient or caregiver to read and understand contents of medication guide before initiating therapy and each time the prescription is refilled.1 4 6 7

  • Possibility of hypersensitivity reactions, including angioedema and anaphylaxis.1 4

  • Importance of informing clinicians immediately of any adverse cardiovascular (e.g., chest pain, shortness of breath, fainting) or psychiatric effects (e.g., hallucinations, delusional thinking, mania).6 7

  • Importance of taking the drug exactly as prescribed.6 7

  • Importance of not chewing or crushing the beads contained in the capsules and of not storing the sprinkle/food mixture for later use.4 6

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and herbal products, as well as any concomitant illnesses/conditions (e.g., glaucoma, cardiac/cardiovascular disease, mental/psychiatric disorder, seizures, suicidal ideation or behaviors, history of substance abuse).1 4 6 7

  • Inform male patients and their caregivers about the signs and symptoms of priapism, stressing the need for immediate treatment if it occurs.1 4 12 Younger males, especially prepubertal males, may not recognize the problem or may be embarrassed to tell anyone if it occurs.12

  • Inform patients about the risk of peripheral vascular disorders, including Raynaud's phenomenon, and the associated signs and symptoms (e.g., feelings of numbness, coolness, or pain in fingers or toes; changes in color from pale to blue to red).1 4 Advise patients to report any new numbness, pain, skin color change, or sensitivity to temperature in fingers or toes and to immediately contact their clinician if any signs of unexplained wounds appear on fingers or toes; further clinical evaluation may be appropriate.1 4

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 4 6 7

  • Importance of informing patients of other important precautionary information.1 4 6 7 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Subject to control under the Federal Controlled Substances Act of 1970 as a schedule II (C-II) drug.1 4

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Dexmethylphenidate Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Capsules, extended-release (containing beads)

5 mg (beads, delayed-release, enteric-coated extended-release 2.5 mg with immediate-release 2.5 mg)*

Dexmethylphenidate Hydrochloride Extended-release Capsules (C-II)

Focalin XR (C-II)

Novartis

10 mg (beads, delayed-release, enteric-coated extended-release 5 mg with immediate-release 5 mg)*

Dexmethylphenidate Hydrochloride Extended-release Capsules (C-II)

Focalin XR (C-II)

Novartis

15 mg (beads, delayed-release, enteric-coated extended-release 7.5 mg with immediate-release 7.5 mg)*

Dexmethylphenidate Hydrochloride Extended-release Capsules (C-II)

Focalin XR (C-II)

Novartis

20 mg (beads, delayed-release, enteric-coated extended-release 10 mg with immediate-release 10 mg)*

Dexmethylphenidate Hydrochloride Extended-release Capsules (C-II)

Focalin XR (C-II)

Novartis

25 mg (beads, delayed-release, enteric-coated extended-release 12.5 mg with immediate-release 12.5 mg)

Focalin XR (C-II)

Novartis

30 mg (beads, delayed-release, enteric-coated extended-release 15 mg with immediate-release 15 mg)*

Dexmethylphenidate Hydrochloride Extended-release Capsules (C-II)

Focalin XR (C-II)

Novartis

35 mg (beads, delayed-release, enteric-coated extended-release 17.5 mg with immediate-release 17.5 mg)

Focalin XR (C-II)

Novartis

40 mg (beads, delayed-release, enteric-coated extended-release 20 mg with immediate-release 20 mg)*

Dexmethylphenidate Hydrochloride Extended-release Capsules (C-II)

Focalin XR (C-II)

Novartis

Tablets

2.5 mg*

Dexmethylphenidate Hydrochloride Capsules (C-II)

Focalin (C-II)

Novartis

5 mg*

Dexmethylphenidate Hydrochloride Capsules (C-II)

Focalin (C-II)

Novartis

10 mg*

Dexmethylphenidate Hydrochloride Capsules (C-II)

Focalin (C-II)

Novartis

AHFS DI Essentials. © Copyright, 2016, American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814. Review Date: September 06, 2016.

References

1. Novartis. Focalin (dexmethylphenidate hydrochloride) tablets prescribing information. East Hanover, NJ; 20-15 Apr.

2. FDA approval package, Medical review (part 2). Rockville, MD; 2001. From the FDA website.

3. American Academy of Pediatrics Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical treatment guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001; 108:1033-44. [IDIS 470916] [PubMed 11581465]

4. Novartis. Focalin XR (dexmethylphenidate hydrochloride) extended-release capsules prescribing information. East Hanover, NJ; 20-15 -Jun.

5. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1997; 36(Suppl):85-121S. [PubMed 9000785]

6. Novartis. Focalin XR (dexmethylphenidate hydrochloride) extended-release capsules medication guide. East Hanover, NJ; -13 -2015 Jun.

7. Novartis. Focalin (dexmethylphenidate hydrochloride) tablets medication guide. East Hanover, NJ; 20-13 Dec.

8. Food and Drug Administration. FDA Alert: Information for healthcare professionals: Communication about an ongoing safety review of stimulant medications [dexmethylphenidate (marketed as Focalin, Focalin XR), dextroamphetamine (marketed as Dexedrine, Dexedrine Spansules, Dextrostat, and generics), lisdexamfetamine (marketed as Vyvanse), methamphetamine (marketed as Desoxyn), methylphenidate (marketed as Concerta, Daytrana, Metadate CD, Metadate ER, Methylin, Methylin ER, Ritalin, Ritalin-LA, and Ritalin-SR), mixed salts amphetamine (marketed as Adderall and Adderall XR), and pemoline (marketed as Cylert and generics)] used in children with attention-deficit/hyperactivity disorder (ADHD). Rockville, MD; 2009 Jun 23. From the FDA website.

9. Gould MS, Walsh BT, Munfakh JL et al. Sudden death and use of stimulant medications in youths. Am J Psychiatry. 2009; 166:992-1001. [PubMed 19528194]

10. Vitiello B, Towbin K. Stimulant treatment of ADHD and risk of sudden death in children. Am J Psychiatry. 2009; 166:955-7. [PubMed 19528196]

11. US Food and Drug Administration. AHRQ and FDA to collaborate in largest study ever of possible heart risks with ADHD medications. FDA News September 17, 2007. From FDA web site.

12. Food and Drug Administration. FDA Drug Safety Communication: FDA warns of rare risk of long-lasting erections in males taking methylphenidate ADHD medications and has approved label changes. 2013 Dec 17. From FDA website. Accessed 2015 May 21.

13. Food and Drug Administration. FDA Drug Safety Communication: Safety review update of medications used to treat attention-deficit/hyperactivity disorder (ADHD) in children and young adults. 2011 Nov 1. From FDA website. Accessed 2015 Jul 24.

14. Food and Drug Administration. FDA Drug Safety Communication: Safety review update of medications used to treat attention-deficit/hyperactivity disorder (ADHD) in adults. 2011 Dec 12. From FDA website. Accessed 2015 Jul 24.

15. Habel LA, Cooper WO, Sox CM et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. JAMA. 2011; 306:2673-83. [PubMed 22161946]

16. Cooper WO, Habel LA, Sox CM et al. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med. 2011; 365:1896-904. [PubMed 22043968]

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