Methylphenidate


Article Author:
Corinne Verghese


Article Editor:
Sara Abdijadid


Editors In Chief:
Melissa Max
Danyae Lee
Manouchkathe Cassagnol


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
1/4/2019 3:04:21 PM

Indications

Methylphenidate is FDA-approved for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adults and as a second-line treatment for narcolepsy in adults. [1][2] Children with a diagnosis of ADHD should be at least six years of age or older before being started on this medication. The treatment of both ADHD and narcolepsy have significantly better outcomes when used concurrently with nonpharmacologic treatments (i.e., social skills training in ADHD or sleep hygiene measures in narcolepsy). 

Off-label uses of methylphenidate include as a treatment for fatigue in cancer patients, refractory depression in the geriatric population, apathy in Alzheimer disease, and to enhance cognitive performance (i.e., memory). [3][4][5][6][7][8] Since it has the potential of being abused as a cognitive enhancer, it is a Schedule II substance that is federally controlled. The efficacy of methylphenidate for its off-label uses varies from limited to moderate. Most of these relatively newer uses are still being studied and implemented into clinical practice. 

Mechanism of Action

Methylphenidate blocks the reuptake of two neurotransmitters, norepinephrine (NE) and dopamine, by presynaptic neurons. More specifically, it inhibits the transporters of these neurotransmitters, increasing the concentration of dopamine and NE in the synaptic cleft.[9] Overall, this creates its classic stimulant effect within the central nervous system (CNS), mainly in the prefrontal cortex. It is chemically derived from phenethylamine and benzylpiperazine. It undergoes metabolism by the liver to ritalinic acid through a process called de-esterification via carboxylesterase CES1A1. Compared to other medications (i.e., amphetamines) that are phenethylamine derivatives, methylphenidate appears to increase the firing rate of neurons.[10] It is also a weak agonist at the 5HT1A receptor, which is an additional mechanism that contributes to the increased levels of dopamine.[11] 

With the increase in dopamine levels, methylphenidate can provide neuroprotection in certain conditions like Parkinson disease, which involves loss of dopaminergic neurons, and methamphetamine abuse.[12] This occurs not only through its direct inhibition of the dopamine transporter but also via indirect regulation of the vesicular monoamine transporter 2. The combined interactions methylphenidate has on both of these transporters reduces the amount of dopamine that accumulates within the cytoplasm in patients with these conditions, thereby preventing the formation of reactive oxygen species that would otherwise be dangerously toxic to the brain. 

Dependence

The therapeutic dosages for ADHD or narcolepsy that are prescribed by physicians are not harmful enough to activate the reward system within the CNS, known as the nucleus accumbens. However, excessively higher dosages taken by those who intentionally abuse the drug lead to an overexpression of deltaFosB, a transcriptional activator, in certain neurons within the striatum. This accumulation of deltaFosB in the nucleus accumbens activates a series of signaling cascades that further triggers the addiction.[13]

Administration

For medical purposes, methylphenidate is mainly given orally or, less commonly, as a transdermal patch. There are multiple oral formulations available that are divided into how quickly the drug is released: immediate (IR), extended (XR or ER), and sustained. Two of the more unique formulations of methylphenidate is its ER sphenoidal oral drug absorption system that has a bimodal release and the osmotic (controlled) release delivery system. For children, there are chewable tablets (either IR or ER) as well as an IR solution. The dosages range from 5 mg to 60 mg. Doses should not exceed 72 mg, the maximum dose of the ER tablet. If the transdermal patch is given, then it is important that the patient is aware to place the patch on the opposite hip each time to achieve its full effect. Those who abuse methylphenidate for recreational purposes prefer to use either the intravenous (IV) or intranasal route. 

Adverse Effects

Insomnia and nervousness are the most commonly reported adverse effects in patients on methylphenidate. Other frequent side effects mainly involve the CNS (dizziness, headache, tics, restlessness/akathisia), gastrointestinal (nausea/vomiting, dry mouth, decreased appetite, weight loss, abdominal pain) and cardiovascular systems (tachycardia, and palpitations). Dermatologically, patients can complain of excessive sweating and ulceration of their digits. Some patients may even develop blurry vision or decreased libido. Patients are more prone to become easily agitated, irritable, or depressed and go through mood swings/lability). While many of the common side effects can be relieved by adjusting the dosage or avoidance of an afternoon or evening dose, some must be treated emergently to prevent complications. While it rarely occurs, priapism is a medical emergency that requires immediate attention.[14] 

It is important to note that there have been reported cases of sudden death in both children and adults with a pre-existing structural cardiac abnormality. Stroke and myocardial infarction also have been noted in adults. Due to the risk of such fatal side effects, it is advised to avoid methylphenidate in patients with a structural cardiac abnormality, cardiomyopathy, or arrhythmias.[15] 

Contraindications

Methylphenidate must not be used if a patient is currently on monoamine oxidase inhibitors (MAOIs). There should be a minimum of at least 14 days after discontinuation of MAOIs before methylphenidate can be considered a safe treatment option to begin due to the risk of hypertensive crisis. Medical conditions that are not compatible with methylphenidate include glaucoma, severe hypertension, motor tics, and Tourette syndrome or a family history of Tourette syndrome. If a patient is noticeably anxious, tense, or agitated, then seek alternative treatment options. However, it can be given cautiously in patients with a history of bipolar disorder or psychosis as long as physicians are wary of mania or psychotic episodes induced by the medication.[12] Any patient who develops a hypersensitive reaction to methylphenidate or a certain component of a formulation should have the medication immediately discontinued and be switched to another pharmacologic agent. Children under the age of six years old should not be prescribed this medication as there are limited studies to prove its safety or benefit, and it could possibly cause learning impairments. 

Monitoring

A complete blood count with differential should be obtained periodically for those on methylphenidate. At each visit, the main vitals to note are blood pressure and heart rate, especially in patients with underlying hypertension, heart failure, a recent MI, or ventricular arrhythmia as slight elevations can occur with methylphenidate use. If a patient complains of cardiac symptoms, such as chest pain, that worsens with exertion or has a near-syncope episode, then a full cardiac workup should be performed. Physicians should screen for symptoms of depression, agitation, aggressiveness, new-onset or pre-existing psychosis or mania, and suicidality as these can be worsened when initially starting methylphenidate. On physical exam, look for peripheral vasculitis (digital ulceration). Physicians should also monitor for signs of intravenous abuse as frank psychotic episodes can develop. There has been controversial evidence on the potential for methylphenidate to affect seizure threshold.[16][17] If seizures develop while being treated with methylphenidate, then it should be stopped immediately. 

In adults, patients should limit their alcohol use while taking methylphenidate as its stimulant action can mask the actual sedative effect caused by alcohol intoxication, possibly inducing severe respiratory depression. Additionally, a patient who is concurrently on warfarin (Coumadin), phenytoin, tricyclic antidepressants, or SSRIs should have their drug levels monitored and adjust doses as needed to achieve a therapeutic effect. This is mainly because methylphenidate can inhibit the metabolism of these drugs. 

In children, it is particularly important to evaluate their growth curve for a stable progression in height and weight since methylphenidate has been shown to suppress growth when used on a daily, long-term basis. The medication should either be readjusted or discontinued if children are not in a healthy percentile on their growth curve.

Toxicity

The first step in a medication overdose is to immediately contact a poison control center for the next appropriate steps in management. Doses that exceed 60 mg of the IR (immediate release) formulation or 120 mg of the ER (extended release) formulation can be considered toxic. If the overdosed quantity is unknown, look for signs and symptoms such as tremors, hyperreflexia, convulsions, euphoria, confusion, hallucinations, delirium, flushing, and fever in addition to the common adverse effects mentioned above. Supportive care with supplemental oxygen, IV fluids, and external cooling methods is the mainstay of treatment. Multiple studies have shown that benzodiazepines can be given, especially if dystonia, agitation, or convulsions are present.[14]

Enhancing Healthcare Team Outcomes

It is important that a thorough history is gathered from the patient (or patient’s legal guardian) regarding their past medical history, current medications, and social history (developmental history should be obtained if the patient is a child). Management should be overseen by an interdisciplinary team consisting of the patient’s primary care provider, psychiatrist, nurses, nurse practitioners, physician assistants, social workers, therapists, school teachers, etc. Communication between each member of the treatment team is crucial as medication combined with non-pharmacologic treatment measures provide the most long-term success. Evaluation for side effects should be closely monitored at each visit. If the patient is a child, it is highly important to provide education about the medication and its side effects to the patient’s legal guardian.

Outcomes

Studies have shown that medication alone is not as effective compared to when the medication is in combination with non-pharmacologic treatment measures. Patients with ADHD managed on both medication and non-pharmacologic treatments have been shown to have higher self-esteem and social functioning skills versus those untreated. There have been long-term beneficial effects shown in adults with ADHD who continue to take methylphenidate. Further long-term studies are still being conducted.[18][19](Level V)


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Methylphenidate - Questions

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Methylphenidate is used to treat symptoms of attention-deficit/hypersensitivity disorder. Which of the following is the correct statement about this medication?



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Which of the following medications is often used for the treatment of attention deficit hyperactivity disorder?



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Which of the following is a common side effect of methylphenidate?



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Which of the following is most similar to an amphetamine?



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Which of these drugs is pharmacologically most similar to amphetamine?



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A parent brings a prescription for methylphenidate into your pharmacy for their grade school aged child. What condition is being treated?



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In addition to attention deficit hyperactivity disorder (ADHD), what other use is methylphenidate FDA-approved for?



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A 17-year-old male student has been on phenelzine, a monoamine oxidase inhibitor (MAOI) for depression, but discontinued the medication as he felt it did not help. His last dose of phenelzine was a week ago. His other medical conditions include diabetes mellitus and bipolar disorder. His final exams are quickly approaching, and he has been trying to do all-nighters cramming for his exams. To stay awake longer and have better focus, he began to use methylphenidate recreationally as he heard that it could enhance performance. Is the combination of methylphenidate and phenelzine safe and if not, what are the concerns that should be addressed with this medication based on the patient's history?



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What part of the brain becomes activated in a person who abuses methylphenidate?



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The parents of a 9-year-old boy with a past medical history of epilepsy and ADHD make a doctor's appointment after the patient suffered a seizure shortly after starting methylphenidate. Before taking the medication, he had been seizure free for 2 years. The parents are concerned and want your opinion on whether it is safe for their child to take this medication. Would you recommend this patient to continue taking methylphenidate?



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A 7-year-old boy is brought to the clinic for a routine check-up with his grandfather. His grandfather states that the child has had mental issues and he used to create problems at home and in his school. He is not aware what the boy is suffering from but narrates that medication was prescribed to him, after which he became much better. For the past two months, the child has been living with his grandfather, and he has noticed that the boy is losing weight. On physical examination, the child is happy and interactive with normal vitals. His grandfather does not remember the name of the medication. Which of the following is the medicine that the child has most likely been taking?



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Methylphenidate - References

References

Stimulants Do Not Increase the Risk of Seizure-Related Hospitalizations in Children with Epilepsy., Liu X,Carney PR,Bussing R,Segal R,Cottler LB,Winterstein AG,, Journal of child and adolescent psychopharmacology, 2017 Oct 13     [PubMed]
Epilepsy, Attention-Deficit/Hyperactivity Disorder and Methylphenidate: Critical Examination of Guiding Evidence., Ravi M,Ickowicz A,, Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent, 2016 Winter     [PubMed]
Overdose of drugs for attention-deficit hyperactivity disorder: clinical presentation, mechanisms of toxicity, and management., Spiller HA,Hays HL,Aleguas A Jr,, CNS drugs, 2013 Jul     [PubMed]
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A randomized, double-blind, 2-period, placebo-controlled crossover trial of a sustained-release methylphenidate in the treatment of fatigue in cancer patients., Escalante CP,Meyers C,Reuben JM,Wang X,Qiao W,Manzullo E,Alvarez RH,Morrow PK,Gonzalez-Angulo AM,Wang XS,Mendoza T,Liu W,Holmes H,Hwang J,Pisters K,Overman M,Cleeland C,, Cancer journal (Sudbury, Mass.), 2014 Jan-Feb     [PubMed]
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The problem of fatigue in patients suffering from neoplastic disease., Kolak A,Kamińska M,Wysokińska E,Surdyka D,Kieszko D,Pakieła M,Burdan F,, Contemporary oncology (Poznan, Poland), 2017     [PubMed]
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Dysfunctions in dopamine systems and ADHD: evidence from animals and modeling., Viggiano D,Vallone D,Sadile A,, Neural plasticity, 2004     [PubMed]
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Citalopram, methylphenidate, or their combination in geriatric depression: a randomized, double-blind, placebo-controlled trial., Lavretsky H,Reinlieb M,St Cyr N,Siddarth P,Ercoli LM,Senturk D,, The American journal of psychiatry, 2015 Jun     [PubMed]
Prescription Stimulants' Effects on Healthy Inhibitory Control, Working Memory, and Episodic Memory: A Meta-analysis., Ilieva IP,Hook CJ,Farah MJ,, Journal of cognitive neuroscience, 2015 Jun     [PubMed]
The Medical and Economic Burden of Narcolepsy: Implications for Managed Care., Thorpy MJ,Hiller G,, American health & drug benefits, 2017 Jul     [PubMed]
Liu H,Feng W,Zhang D, Association of ADHD medications with the risk of cardiovascular diseases: a meta-analysis. European child     [PubMed]
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