What adjustments do you make for patients with ADHD who report their long-acting stimulant wears off too quickly?

There are essentially 3 options: 1) administer the medication later in the morning; 2) add a short-acting booster dose; 3) switch to a similar formulation with a longer duration of action. I typically discuss these options with patients/families and make individualized decisions depending on the particular circumstances, such as daily schedule, age, activities, prior stimulant trials, cost/coverage, and tolerability. I have some young kids who wake up extra early due to parent work schedules, but don't start school until much later, and do okay with morning routine. If such a patient is taking the medication unnecessarily early, I recommend option 1. For younger kids who might only need a longer duration of action on some days (e.g., for af...

• Adjust the dose to the maximum potential
• Add a booster
• Change the form
• Add NRI like atomoxetine
• Adjust timing if allowable

I also counsel patients that citrus juices and high-dose vitamin C (ascorbic acid) should be avoided around the time of morning stimulant dosing because they act as gastrointestinal acidifying agents that lower the absorption of amphetamines, and as urinary acidifying agents that increase renal excretion — both mechanisms reduce blood levels and efficacy of the medication, including duration of action. Conversely, if their medication isn't wearing off soon enough and interfering with their sleep, they can have orange juice with dinner to help expedite its clearance.