CNS Stimulant — Schedule 2 Controlled Drug (ADHD Treatment) Pregnancy: Avoid — insufficient safety data; limited animal studies suggest possible harm. ADHD management in pregnancy: psychosocial interventions first; discuss risk-benefit with specialist if medication essential.

Methylphenidate

Brand names: Ritalin (immediate-release), Concerta XL, Equasym XL, Medikinet XL

Adult dose

Dose: ADHD (adults): immediate-release 5mg BD–TDS initially, increase by 5–10mg weekly; usual range 20–60mg daily. Modified-release: 18–54mg OD (Concerta XL); 20–60mg OD (Equasym/Medikinet XL). Maximum 100mg daily.

Route: Oral

Frequency: Twice to three times daily (IR — last dose by 4pm to avoid insomnia); once daily (MR)

Max: 100mg daily

Schedule 2 Controlled Drug — requires written CD prescription; maximum 30-day supply; no repeats. Mechanism: blocks dopamine and noradrenaline reuptake in prefrontal cortex — enhances executive function, attention, impulse control. NICE recommends as first-line pharmacotherapy for ADHD in children and adolescents (and adults where indicated). Drug holidays (weekends, school holidays) may be considered in children to assess continued need.

Paediatric dose

Dose: 0.3 mg/kg

Route: Oral

Frequency: Twice to three times daily (IR); once daily (MR)

Max: 60mg daily (children); 2.1mg/kg/day

BNFc / NICE NG87: Children ≥6 years: 5mg BD–TDS initially; increase by 5–10mg weekly; usual range 0.3–0.7mg/kg/dose TDS (max 60mg daily). Modified-release (Concerta XL): 18mg OD initially; titrate to 54mg OD. Under 6 years: not recommended. Specialist ADHD assessment required before prescribing.

Dose adjustments

Renal

Use with caution in severe renal impairment — limited data.

Hepatic

Use with caution — primarily hepatically metabolised to ritalinic acid.

Paediatric weight-based calculator

Patient weight (kg)

Clinical pearls

Cardiac screening before prescribing: ECG and cardiologist review if personal or family history of sudden cardiac death, arrhythmia, or structural heart disease — stimulants increase HR and BP
NICE NG87: methylphenidate first-line for ADHD in children ≥5 years; if inadequate response after 6 weeks at optimal dose — switch to alternative (dexamfetamine, lisdexamfetamine, or atomoxetine)
Growth monitoring in children: measure height and weight every 6 months — sustained growth restriction: consider drug holiday, reduce dose, or switch
Modified-release formulations preferred for school-age children — single morning dose, avoids midday school administration, smoother coverage

Contraindications

Symptomatic cardiovascular disease, structural cardiac defects, cardiomyopathy
Severe hypertension
Hyperthyroidism
Phaeochromocytoma
Severe anxiety or agitation (stimulants may worsen)
Current or past psychosis or mania
MAOIs (within 14 days)
Glaucoma
Hypersensitivity to methylphenidate

Side effects

Decreased appetite and weight loss (common in children)
Insomnia (dose and timing dependent — avoid late doses)
Headache, abdominal pain
Tachycardia and blood pressure elevation
Growth suppression (children — drug holidays may help)
Tics (may worsen or unmask — monitor)
Anxiety, irritability
Rebound effect (irritability when dose wears off)
Psychosis (rare — particularly at high doses)
Dependence (Schedule 2 — abuse potential)

Interactions

MAOIs — contraindicated (hypertensive crisis)
Antihypertensives — methylphenidate raises BP; may antagonise antihypertensive effect
Warfarin, phenytoin, TCAs — methylphenidate inhibits metabolism; increased levels — monitor
Alcohol — avoid (increases CNS side effects and may increase abuse potential)

Monitoring

Blood pressure and heart rate (baseline; every 3–6 months)
Height and weight (6 monthly in children)
Sleep quality
Appetite and weight
Tics
Mood (psychosis/mania screening)
ADHD symptom rating (Conners, SNAP-IV)

Reference: BNFc; BNF 90; NICE NG87 (ADHD); MHRA Methylphenidate Safety Update. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways