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Aggression Aggressive behavior or hostility is often observed in children and adolescents with ADHD, and has been reported in clinical trials and the postmarketing experience of some medications indicated for the treatment of ADHD including methylphenidate. Although there is no systematic evidence that stimulants cause aggressive behavior or hostility, patients beginning treatment for ADHD should be monitored for the appearance of or worsening of aggressive behavior or hostility.

Long-Term Suppression of Growth Careful follow-up of weight and height in children ages 7 to 10 years who were randomized to either methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic subgroups of newly methylphenidate-treated and non-medication treated children over 36 months to the ages of 10 to 13 years , suggests that consistently medicated children i. Published data are inadequate to determine whether chronic use of amphetamines may cause a similar suppression of growth, however, it is anticipated that they likely have this effect as well.

Therefore, growth should be monitored during treatment with stimulants, and patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted. Seizures There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very rarely, in patients without a history of seizures and no prior EEG evidence of seizures.

In the presence of seizures, the drug should be discontinued. Visual Disturbance Difficulties with accommodation and blurring of vision have been reported with stimulant treatment. Use in Children Under Six Years of Age Ritalin LA should not be used in children under six years of age, since safety and efficacy in this age group have not been established. Monitor blood glucose to avoid hypoglycemia or hyperglycemia. Major Sympathomimetics, such as amphetamines, phentermine, and decongestants e.

Due to the risk of unopposed alpha-adrenergic activity, sympathomimetics should be used cautiously with beta-blockers.

Increased blood pressure, bradycardia, or heart block may occur due to excessive alpha-adrenergic receptor stimulation. Close monitoring of blood pressure or the selection of alternative therapeutic agents to the sympathomimetic agent may be needed. Moderate Caffeine is a CNS stimulant and such actions are expected to be additive when coadministered with other CNS stimulants or psychostimulants.

Avoid excessive caffeine intake during use of methylphenidate. Excessive caffeine ingestion via medicines, foods like chocolate, dietary supplements, or beverages including coffee, green tea, other teas, colas may contribute to side effects like nervousness, irritability, nausea, insomnia, or tremor. Patients should avoid medications and dietary supplements which contain high amounts of caffeine. Acetaminophen; Butalbital; Caffeine; Codeine: Acetaminophen; Caffeine; Magnesium Salicylate; Phenyltoloxamine: Acetaminophen; Caffeine; Phenyltoloxamine; Salicylamide: Acetaminophen; Chlorpheniramine; Dextromethorphan; Phenylephrine: Major Methylphenidate can potentiate the actions of both exogenous such as dopamine and epinephrine and endogenous such as norepinephrine vasopressors.

It is advisable to monitor cardiac function if these medications are coadministered. Vasopressors include medications such as epinephrine, dopamine, midodrine, and non-prescription medications such as pseudoephedrine and phenylephrine.

Acetaminophen; Chlorpheniramine; Phenylephrine; Phenyltoloxamine: Acetaminophen; Dextromethorphan; Guaifenesin; Phenylephrine: Moderate Endogenous epinephrine is released in response to hypoglycemia; epinephrine, through stimulation of alpha- and beta- receptors, increases hepatic glucose production and glycogenolysis and inhibits insulin secretion in order to increase serum glucose concentrations.

A pharmacodynamic interaction may occur when pseudoephedrine and other sympathomimetics are administered to patients as these agents may increase blood glucose concentrations by a similar mechanism. Patients receiving alogliptin should be closely monitored for loss of diabetic control when therapy with sympathomimetic agents is instituted. Moderate Sympathomimetics, such as methylphenidate, may increase blood sugar via stimulation of beta-2 receptors which leads to increased glycogenolysis.

Patients receiving antidiabetic agents should be closely monitored for loss of diabetic control when therapy with sympathomimetic agents is instituted. Moderate Methylphenidate can reduce the hypotensive effect of antihypertensive agents such as alpha-blockers.

Periodic evaluation of blood pressure is advisable during concurrent use of methylphenidate and antihypertensive agents, particularly during initial coadministration and after dosage increases of methylphenidate. Minor The modified release characteristics of extended-release methylphenidate Ritalin LA are pH-dependent.

Administration of antacids could alter the release of methylphenidate. Aluminum Hydroxide; Magnesium Carbonate: Aluminum Hydroxide; Magnesium Hydroxide: Aluminum Hydroxide; Magnesium Hydroxide; Simethicone: Aluminum Hydroxide; Magnesium Trisilicate: Moderate Careful observation is required when amantadine is administered concurrently with central nervous system CNS stimulants such as methylphenidate.

An increase in stimulant effects, such as nervousness, irritability, insomnia, tremor, seizures, or cardiac arrhythmias may occur. Moderate Methylphenidate can reduce the hypotensive effect of antihypertensive agents. Moderate Methylphenidate can reduce the hypotensive effect of antihypertensive agents such as potassium-sparing diuretics.

Moderate Because of the potential risk and severity of serotonin syndrome, caution should be observed when coadministering drugs that have serotonergic properties such as methylphenidate and tricyclic antidepressants TCAs. There are rare reports of serotonin syndrome occurring during use of other serotonergic antidepressants i. Serotonin syndrome is characterized by the rapid development of hyperthermia, hypertension, myoclonus, rigidity, autonomic instability, mental status changes e.

Patients receiving this combination should be monitored for the emergence of serotonin syndrome. If serotonin syndrome occurs, all serotonergic agents should be discontinued and appropriate medical management should be implemented.

There does not appear to be a pharmacokinetic interaction between methylphenidate and TCAs. In one study, use of methylphenidate did not increase plasma concentrations of the CYP2D6 substrate desipramine. Nevertheless, a dose adjustment of the TCA, and monitoring of TCA plasma concentrations when applicable, may be required when initiating or discontinuing methylphenidate. Moderate Both methylphenidate and amoxapine may lower the seizure threshold; therefore, caution is particularly advisable when this combination is administered to patients susceptible to seizures.

In addition, methylphenidate is thought to exert some of its beneficial effects through dopamine re-uptake blockade while amoxapine has central dopamine antagonist properties.

In theory, the therapeutic effects of either agent may be reduced. Minor The effects of gastrointestinal pH alterations on the absorption of extended-release methylphenidate Ritalin LA have not been studied. Per the manufacturer of extended-release methylphenidate, the modified release characteristics are pH-dependent. It is possible that the administration of proton pump inhibitors PPIs or other acid suppressants could alter the release of extended-release methylphenidate, resulting in reduced or increased absorption.

Patients receiving a PPI should be monitored for adverse effects and reduced therapeutic efficacy of extended-release methylphenidate. Severe Amphetamines and methylphenidate should not be coadministered.

These drugs represent duplicate treatments for certain conditions. Nervousness, irritability, insomnia, palpitations, arrhythmias, seizures, or other serious stimulant-related adverse effects may occur. Angiotensin II receptor antagonists: Moderate Methylphenidate can reduce the hypotensive effect of antihypertensive agents such as angiotensin II receptor antagonists. Moderate Methylphenidate can reduce the hypotensive effect of antihypertensive agents such as angiotensin-converting enzyme inhibitors.

Moderate Increased dopaminergic effects may occur during coadministration of methylphenidate, an inhibitor of dopamine reuptake, and dopamine agonists such as pergolide, pramipexole, apomorphine, and ropinirole. Dopaminergic side effects, such as nausea, loss of appetite, weight loss, insomnia, tremor, nervousness, or changes in mood or behavior, are possible.

Moderate Atypical antipsychotics and methylphenidate may interact pharmacodynamically to diminish the therapeutic effects of either agent through opposing effects on dopamine. Methylphenidate blocks central dopamine reuptake, which has the potential to exacerbate psychosis, and antipsychotics, which are central dopamine antagonists, may diminish the effectiveness of methylphenidate. Major The use of armodafinil with other psychostimulants, including methylphenidate, has not been studied.

Patients receiving combination therapy of armodafinil with other psychostimulants should be closely observed for signs of nervousness, irritability, insomnia, arrhythmias, or other stimulant-related side effects. Major Use methylphenidate cautiously in patients receiving atomoxetine, a selective norepinephrine reuptake inhibitor. If coadministration is necessary, monitor patients closely for tachycardia and hypertension. Although coadministration of methylphenidate and atomoxetine did not increase the cardiovascular effects seen with administration of methylphenidate alone during clinical trials, concurrent use of sympathomimetic agents may result in an increased risk of noradrenergic effects.

Also monitor for appropriate clinical response and for any unusual changes in moods or behavior. Moderate Theoretically, concurrent use of methylene blue and methylphenidate may increase the risk of serotonin syndrome. Although a causal relationship has not been established, suppression of growth i. Therefore, patients requiring long-term therapy should be carefully monitored.

Ritalin should not be used for severe depression of either exogenous or endogenous origin. Clinical experience suggests that in psychotic children, administration of Ritalin may exacerbate symptoms of behavior disturbance and thought disorder. Ritalin should not be used for the prevention or treatment of normal fatigue states. Taking this medication late in the day may cause trouble sleeping insomnia.

Do not break, crush, or chew this medication. Doing so can release all of the drug at once, increasing the risk of side effects. Swallow the capsules whole. If you have trouble swallowing the capsule, you may open the capsule and carefully sprinkle its contents on a spoonful of cool applesauce.

Swallow all of the mixture right away without chewing it. Then drink a glass of cool liquid to make sure you have swallowed all of the dose. Do not prepare the mixture ahead of time. Take this medication regularly to get the most benefit from it. To help you remember, take it at the same time each day. The dosage is based on your medical condition and response to treatment. Your doctor may direct you to gradually increase or decrease your dose.

Also, if you have used it for a long time, do not suddenly stop using this drug without consulting your doctor. This medication may cause withdrawal reactions, especially if it has been used regularly for a long time or in high doses. To prevent withdrawal reactions, your doctor may reduce your dose gradually. Consult your doctor or pharmacist for more details, and report any withdrawal reactions right away.

When used for a long time, this medication may not work as well. Talk with your doctor if this medication stops working well. Though it helps many people, this medication may sometimes cause addiction. Take this medication exactly as prescribed to lower the risk of addiction. Although some children benefit greatly from doses greater than these, benefit from use of either the lowest and highest ends of the dose range is uncommon. Delivery rate varies depending on patch size.

Conversions for psychostimulants are always approximations, especially when one is converting between stimulants, such as methylphenidate and dextroamphetamine. Different forms of the same drug have slightly different pharmacokinetics, and patients often have different responses to them.

FDA-recommended conversions between short-acting and long-acting LA preparations of the same drug are based on attempts to match serum-concentration curves and not clinical-performance curves. In clinical practice, ratios for converting among medications vary by ADHD ADD manifestations, adverse effects, comorbidities, and the patients' metabolism.

Common approximations are described below. Individual patients vary; therefore, close follow-up, and possibly titration, is initially necessary. For example, Ritalin 10 mg q4h is converted to Ritalin LA 20 mg q8h.

For a few patients, effects last only hours with the LA preparations, although effects last 3. However, a short effect from one 8-hour preparation does not always mean another 8-hour preparation has the same problem.

The half-life of MAS widely varies among individuals. Some patients do better with a lower second dose and, thus, may benefit from an IR and XR morning combination. Dexedrine Spansule seems to have the greatest interpatient variance when converting the IR form to the CR form.

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