Am Fam Physician. 2001;63(1):144
Methylphenidate (Ritalin) is a commonly used medication in the United States. It is estimated that more than 2 million Americans are currently being treated with this drug. While concerns about overuse have been raised, the drug clearly has utility in several clinical situations. While the U.S. Food and Drug Administration has labeled it for the treatment of attention-deficit/hyperactivity disorder (ADHD) and narcolepsy, other proposed uses include depression in the medically ill (including the elderly), patients with traumatic brain injury and stroke, cancer patients and some patients with human immunodeficiency virus (HIV) infection. Challman and Lipsky have prepared a concise review for clinicians facing these situations.
| Clinical use | Efficacy supported by double-blind, placebo-controlled trial |
|---|---|
| Attention-deficit/hyperactivity disorder | Yes |
| Narcolepsy | Yes |
| Depression in medically ill (including stroke) elderly persons | Yes |
| Alleviation of neurobehavioral symptoms after traumatic brain injury | Mixed |
| Improvement in pain control, sedation or both in patients receiving opiates | Yes |
| Treatment of cognitive impairment in patients with human immunodeficiency virus infection | No |
The evidence for uses of methylphenidate is outlined in Table 1. This table is based on efficacy data from double-blind, placebo-controlled trials. Efficacy for treatment of ADHD and narcolepsy is well known. However, the results of similar trials for other clinical problems are less evident. For depression in medically ill patients, antidepressants remain the first choice; however, interest is developing in the use of stimulants for treatment of depression in patients with treatment-refractory depression. For alleviation of neurobehavioral symptoms after traumatic brain injury, the results have been mixed. It is likely that the limited benefits seen are the result of improvement in symptoms of depression. Cancer patients commonly experience depression during the course of their illness, with the disease and the associated treatments contributing to their symptoms. Studies involving methylphenidate tend to suggest efficacy, including a rapid response of these symptoms. Furthermore, as an adjunct to opiates for pain control, methylphenidate tends to result in significant reductions in pain intensity and sedation. In the treatment of cognitive dysfunction in patients with HIV, well-controlled trials have failed to show targeted symptom improvement, but these results may be confounded by small sample size.
Appropriate dosing regimens for methylphenidate are presented in Table 2.
| Age group | Indication | Typical initial dose | Usual maximal daily dose |
|---|---|---|---|
| Children (>6 years) | Attention-deficit/hyperactivity disorder | Regular release: 5 mg twice daily, with or after breakfast and lunch | 60 mg |
| Sustained release: 20 mg once daily | |||
| Adults | Attention-deficit/hyperactivity disorder, narcolepsy | Regular release: 5 to 20 mg two to three times daily, with or after meals | 90 mg |
| Sustained release: 20 mg one to three times daily, at eight-hour intervals | |||
| Depression due to medical illness | Regular release: 5 to 10 mg two to three times daily | 30 mg |