Transitioning from Strattera to Concerta in Adolescents

Initial Dosing and Titration

The American Academy of Child and Adolescent Psychiatry recommends starting with Concerta 18mg once daily in the morning, which is approximately equivalent to methylphenidate immediate-release 5mg given three times daily 1
Concerta utilizes an osmotically released, timed drug-delivery system (OROS) that produces an ascending plasma drug level throughout the day with effects lasting for a full 12-hour period 2
Morning administration is recommended to minimize potential sleep disturbances 2
After starting with 18mg, assess clinical response after 1 week 1
If needed, increase to 36mg once daily, then potentially to 54mg once daily based on clinical response 2
Clinical efficacy should guide dosing rather than weight or plasma concentrations, as plasma levels of methylphenidate do not correlate well with clinical response 1

Monitor for common side effects of Concerta, including decreased appetite 3
Potential changes in heart rate and blood pressure should be monitored 4
Watch for emergence of tics, which can occur with stimulant medications 5
For appetite loss: administer Concerta with meals and provide a high-calorie snack in the evening when stimulant effects have worn off 3
For difficulty falling asleep: ensure morning administration of Concerta and consider implementing a bedtime routine 3
For irritability: evaluate when it occurs (peak effect vs. rebound) and adjust dosing accordingly 3

Concerta has several advantages over immediate-release methylphenidate, including eliminating the midday "trough" in medication levels 1
Concerta has a lower potential for abuse compared to immediate-release formulations 1
Once-daily dosing improves compliance, particularly important for adolescents 2
If oral tics develop while on Concerta, consider adjusting the dose of Concerta or adding an alpha-agonist such as clonidine or guanfacine as a first-line option for managing tics 5
Allow at least 1-2 weeks to evaluate the initial response to Concerta 2

Schedule a follow-up appointment 1-2 weeks after initiating Concerta to assess efficacy and side effects 5
If Concerta is not effective or poorly tolerated after adequate trial, consider other treatment options 5