THERAPEUTICS

Brands

• Focalin
• Focalin XR
• see index for additional brand names

Generic?

• Yes

Class

• Stimulant

Commonly Prescribed For

• (bold for FDA approved)
• Attention deficit hyperactivity disorder (ADHD) in children ages 6–17 (Focalin, Focalin XR) and in adults (Focalin XR)
• Narcolepsy
• Treatment-resistant depression

How The Drug Works

• Increases norepinephrine and especially dopamine actions by blocking their reuptake
• Enhancement of dopamine and norepinephrine actions in certain brain regions (e.g., dorsolateral prefrontal cortex) may improve attention, concentration, executive function, and wakefulness
• Enhancement of dopamine actions in other brain regions (e.g., basal ganglia) may improve hyperactivity
• Enhancement of dopamine and norepinephrine in yet other brain regions (e.g., medial prefrontal cortex, hypothalamus) may improve depression, fatigue, and sleepiness

How Long Until It Works

• Some immediate effects can be seen with first dosing
• Can take several weeks to attain maximum therapeutic benefit

If It Works (for ADHD)

• The goal of treatment of ADHD is reduction of symptoms of inattentiveness, motor hyperactivity, and/or impulsiveness that disrupt social, school, and/or occupational functioning
• Continue treatment until all symptoms are under control or improvement is stable and then continue treatment indefinitely as long as improvement persists
• Reevaluate the need for treatment periodically
• Treatment for ADHD begun in childhood may need to be continued into adolescence and adulthood if continued benefit is documented

If It Doesn’t Work (for ADHD)

• Consider adjusting dose or switching to a formulation of d,l-methylphenidate or to another agent
• Consider behavioral therapy
• Consider the presence of noncompliance and counsel patient and parents
• Consider evaluation for another diagnosis or for a comorbid condition (e.g., bipolar disorder, substance abuse, medical illness, etc.)
• Some ADHD patients and some depressed patients may experience lack of consistent efficacy due to activation of latent or underlying bipolar disorder, and require either augmenting with a mood stabilizer or switching to a mood stabilizer

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Best to attempt other monotherapies prior to augmenting
• For the expert, can combine immediate release formulation of d-methylphenidate with a sustained release formulation of d-methylphenidate for ADHD
• For the expert, can combine with modafinil or atomoxetine for ADHD
• For the expert, can occasionally combine with atypical antipsychotics in highly treatment-resistant cases of bipolar disorder or ADHD
• For the expert, can combine with antidepressants to boost antidepressant efficacy in highly treatment-resistant cases of depression while carefully monitoring patient

Tests

• Blood pressure should be monitored regularly
• In children, monitor weight and height
• Periodic complete blood cell and platelet counts may be considered during prolonged therapy (rare leukopenia and/or anemia)