Introduction: Stimulant medication improves hyperactivity, inattention, and impulsivity in both pediatric and adult\r\npopulations with Attention Deficit Hyperactivity Disorder (ADHD). However, data regarding the optimal dosage in\r\nadults is still limited.\r\nCase presentation: We report the case of a 38-year-old Caucasian patient who was diagnosed with Attention\r\nDeficit Hyperactivity Disorder when he was nine years old. He then received up to 10 mg methylphenidate\r\n(RitalinW) and 20 mg sustained-release methylphenidate (Ritalin SRW) daily. When he was 13, his medication was\r\nchanged to desipramine (NorpraminW), and both RitalinW and Ritalin SRW were discontinued; and at age 18, when\r\nhe developed obsessive-compulsive symptoms, his medication was changed to clomipramine (AnafranilW) 75 mg\r\ndaily. Still suffering from inattention and hyperactivity, the patient began college when he was 19, but did not\r\nreceive stimulant medication until three years later, when RitalinW 60 mg daily was re-established. During the 14\r\nmonths that followed, he began to use RitalinW excessively, both orally and rectally, in dosages from 4800-6000 mg\r\ndaily. Four years ago, he was referred to our outpatient service, where his Attention Deficit Hyperactivity Disorder\r\nwas re-evaluated. At that point, the patientââ?¬â?¢s daily RitalinW dosage was reduced to 200 mg daily orally, but he still\r\nexperienced pronounced symptoms of, Attention Deficit Hyperactivity Disorder so this dosage was raised again.\r\nThe patientââ?¬â?¢s plasma levels consistently remained between 60ââ?¬â??187 nmol/lââ?¬â?within the recommended rangeââ?¬â?and\r\nsigns of his obsessive-compulsive symptoms diminished with fluoxetine 40 mg daily. Finally, on a dosage of 378\r\nmg extended-release methylphenidate (ConcertaW), his symptoms of Attention Deficit Hyperactivity Disorder have\r\nimproved dramatically and no further use of methylphenidate has been recorded during the 24 months preceding\r\nthis report.\r\nConclusions: Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in this adult patient, who also\r\nmanifested a co-occurring obsessive compulsive disorder, dramatically improved only after application of a\r\nhigher-than-normal dose of methylphenidate. We therefore suggest that clinicians consider these findings in\r\nrelation to their adherence to current therapeutic guidelines.
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