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May 28, 2019

A Maximum Dose for Methylphenidate—How Much Is Too Much?

Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
  • 2Cambridge Health Alliance, Cambridge, Massachusetts
JAMA Pediatr. 2019;173(7):621-622. doi:10.1001/jamapediatrics.2019.0911

In this issue of JAMA Pediatrics, Ching and colleagues1 analyzed 11 randomized clinical trials and 38 cohort studies involving multiple methylphenidate formulations and summarized titration methods and dose ranges, including the rationale (empirical or guidelines based) for maximum dose. The authors found that dosing decisions were rarely explicitly justified. When they were justified, the investigators typically pointed to established US Food and Drug Administration dosing guidelines or referenced previous studies. This finding is not surprising given funding and regulatory agency policies as well as the administrative barriers and safety issues associated with exceeding recommended doses. As a result, prescribers are left with incomplete information about determining when a stimulant titration should stop. The authors conclude that there is insufficient evidence to recommend a maximum methylphenidate dose and identify anorexia, insomnia, and headache as common adverse effects.