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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 useEfficacy supported by double-blind, placebo-controlled trial
Attention-deficit/hyperactivity disorderYes
NarcolepsyYes
Depression in medically ill (including stroke) elderly personsYes
Alleviation of neurobehavioral symptoms after traumatic brain injuryMixed
Improvement in pain control, sedation or both in patients receiving opiatesYes
Treatment of cognitive impairment in patients with human immunodeficiency virus infectionNo

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 groupIndicationTypical initial doseUsual maximal daily dose
Children (>6 years)Attention-deficit/hyperactivity disorderRegular release: 5 mg twice daily, with or after breakfast and lunch60 mg
Sustained release: 20 mg once daily
AdultsAttention-deficit/hyperactivity disorder, narcolepsyRegular release: 5 to 20 mg two to three times daily, with or after meals90 mg
Sustained release: 20 mg one to three times daily, at eight-hour intervals
Depression due to medical illnessRegular release: 5 to 10 mg two to three times daily30 mg

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