Methylphenidate Sandoz

Methylphenidate HCl.

Each tablet contains 18 mg of methylphenidate hydrochloride.
Excipient(s) with known effect: contains 6.31 mg of lactose monohydrate.
Each tablet contains 36 mg of methylphenidate hydrochloride.
Excipient(s) with known effect: contains 8.43 mg of lactose monohydrate.
Excipients/Inactive ingredients: Drug layer: Polyethylene oxide, succinic acid, povidone (K 25), butylhydroxytoluene, stearic acid.
Push layer: Polyethylene oxide, sodium chloride, povidone (K 25), butylhydroxytoluene, iron oxide red (E 172), stearic acid.
Membrane layer: Cellulose acetate, poloxamer 188.
Drug coat: Hypromellose, succinic acid.
Film coat: Film coating mixture consisting of: Lactose monohydrate, hypromellose, titanium dioxide (E 171), macrogol 4000.
In addition in 18 mg prolonged release tablets: Iron oxide yellow (E 172).
In addition in 54 mg prolonged release tablets: Iron oxide red (E 172), iron oxide yellow (E 172).

Pharmacotherapeutic Group: Psychoanaleptics, psychostimulants and nootropics, centrally acting sympathomimetics. ATC Code: N06BA04.
Pharmacology: Pharmacodynamics: Methylphenidate HCl is a mild central nervous system (CNS) stimulant. The mode of therapeutic action in Attention Deficit Hyperactivity Disorder (ADHD) is not known. Methylphenidate is thought to block the reuptake of noradrenaline and dopamine into the presynaptic neurone and increase the release of these monoamines into the extraneuronal space. Methylphenidate is a racemic mixture comprised of the d- and l-isomers. The d-isomer is more pharmacologically active than the l-isomer.
In the pivotal clinical studies, Methylphenidate Prolonged-release tablets was assessed in 321 patients already stabilised with immediate release preparations (IR) of methylphenidate and in 95 patients not previously treated with IR preparations of methylphenidate.
Clinical studies showed that the effects of Methylphenidate Prolonged-release tablets were maintained until 12 hours after dosing when the product was taken once daily in the morning.
Pharmacokinetics: Absorption: Methylphenidate is readily absorbed. Following oral administration of Methylphenidate Prolonged-release tablets to adults the drug overcoat dissolves, providing an initial maximum drug concentration at about 1 to 2 hours. The methylphenidate contained in the two internal drug layers is gradually released over the next several hours. Peak plasma concentrations are achieved at about 6 to 8 hours, after which plasma levels of methylphenidate gradually decrease. Methylphenidate Prolonged-release tablets taken once daily minimises the fluctuations between peak and trough concentrations associated with immediate-release methylphenidate three times daily. The extent of absorption of Methylphenidate Prolonged-release tablets once daily is generally comparable to conventional immediate release preparations.
Following the administration of Methylphenidate Prolonged-release tablets 18 mg once daily in 36 adults, the mean pharmacokinetic parameters were: C_max 3.7 ± 1.0 (ng/mL), T_max 6.8 ± 1.8 (h), AUC_inf 41.8 ± 13.9 (ng.h/mL), and t_½ 3.5 ± 0.4 (h).
No differences in the pharmacokinetics of Methylphenidate Prolonged-release tablets were noted following single and repeated once daily dosing, indicating no significant drug accumulation. The AUC and t_1/2 following 17 repeated once daily dosing are similar to those following the first dose of Methylphenidate Prolonged-release tablets 18 mg.
Linearity: Following administration of Methylphenidate Prolonged-release tablets in single doses of 18, 36, and 54 mg/day to adults, C_max and AUC_(0-inf) of methylphenidate were proportional to dose.
Distribution: Plasma methylphenidate concentrations in adults decline biexponentially following oral administration. The half-life of methylphenidate in adults following oral administration of Methylphenidate Prolonged-release tablets was approximately 3.5 h. The rate of protein binding of methylphenidate and of its metabolites is approximately 15%. The apparent volume of distribution of methylphenidate is approximately 13 litres/kg.
Biotransformation: In humans, methylphenidate is metabolised primarily by de-esterification to alpha-phenyl-piperidine acetic acid (PPA, approximately 50 fold the level of the unchanged substance) which has little or no pharmacologic activity. In adults the metabolism of Methylphenidate Prolonged-release tablets once daily as evaluated by metabolism to PPA is similar to that of methylphenidate three times daily. The metabolism of single and repeated once daily doses of Methylphenidate Prolonged-release tablets is similar.
Elimination: The elimination half-life of methylphenidate in adults following administration of Methylphenidate Prolonged-release tablets was approximately 3.5 hours. After oral administration, about 90% of the dose is excreted in urine and 1 to 3% in faeces, as metabolites within 48 to 96 hours. Small quantities of unchanged methylphenidate are recovered in urine (less than 1%). The main urinary metabolite is alpha-phenyl-piperidine acetic acid (60-90%).
After oral dosing of radiolabelled methylphenidate in humans, about 90% of the radioactivity was recovered in urine. The main urinary metabolite was PPA, accounting for approximately 80% of the dose.
Food Effects: In patients, there were no differences in either the pharmacokinetics or the pharmacodynamic performance of Methylphenidate Prolonged-release tablets when administered after a high fat breakfast on an empty stomach.
Special Populations: Gender: In healthy adults, the mean dose-adjusted AUC_(0-inf) values for Methylphenidate Prolonged-release tablets were 36.7 ng.h/mL in men and 37.1 ng.h/mL in women, with no differences noted between the two groups.
Race: In healthy adults receiving Methylphenidate prolonged release tablets, dose-adjusted AUC_(0-inf) was consistent across ethnic groups; however, the sample size may have been insufficient to detect ethnic variations in pharmacokinetics.
Age: The pharmacokinetics of Methylphenidate Prolonged-release tablets has not been studied in children younger than 6 years of age. In children 7-12 years of age, the pharmacokinetics of Methylphenidate Prolonged-release tablets after 18, 36 and 54 mg were (mean±SD): C_max 6.0±1.3, 11.3±2.6, and 15.0±3.8 ng/mL, respectively, T_max 9.4±0.02, 8.1±1.1, 9.1±2.5 h, respectively, and AUC_0-11.5 50.4±7.8, 87.7±18.2, 121.5±37.3 ng.h/mL, respectively.
Renal Insufficiency: There is no experience with the use of Methylphenidate Prolonged-release tablets in patients with renal insufficiency. After oral administration of radiolabelled methylphenidate in humans, methylphenidate was extensively metabolised and approximately 80% of the radioactivity was excreted in the urine in the form of PPA. Since renal clearance is not an important route of methylphenidate clearance, renal insufficiency is expected to have little effect on the pharmacokinetics of Methylphenidate prolonged release tablets.
Hepatic Insufficiency: There is no experience with the use of Methylphenidate Prolonged-release tablets in patients with hepatic insufficiency.
Toxicology: Preclinical safety data: Carcinogenicity: In life-time rat and mouse carcinogenicity studies, increased numbers of malignant liver tumours were noted in male mice only. The significance of this finding to humans is unknown.
Methylphenidate did not affect reproductive performance or fertility at low multiples of the therapeutic clinical dose.
Pregnancy-embryonal/foetal development: Methylphenidate is not considered to be teratogenic in rats and rabbits. Foetal toxicity (i.e. total litter loss) and maternal toxicity was noted in rats at maternally toxic doses.

Attention-Deficit/Hyperactivity Disorder (ADHD): Methylphenidate Prolonged-release tablets is indicated as part of a comprehensive treatment programme for Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents aged 6-17 years of age and adults aged 18-65 years when remedial measures alone prove insufficient. Treatment must be under the supervision of a specialist in childhood behavioural disorders. Diagnosis should be made according to DSM-IV criteria or the guidelines in ICD-10 and should be based on a complete history and evaluation of the patient. Diagnosis cannot be made solely on the presence of one or more symptoms.
The specific aetiology of this syndrome is unknown, and there is no single diagnostic test. Adequate diagnosis requires the use of medical and specialised psychological, educational, and social resources.
A comprehensive treatment programme typically included psychological, educational and social measures as well as pharmacotherapy and is aimed at stabilising patients with a behavioural syndrome characterised by symptoms which may include chronic history of short attention span, distractibility, emotional lability, impulsivity, moderate to severe hyperactivity, minor neurological signs and abnormal EEG. Learning may or may not be impaired.
Methylphenidate Prolonged-release tablets treatment is not indicated in all patients with ADHD and the decision to use the drug must be based on a very thorough assessment of the severity and chronicity of the patients' symptoms in relation to the patients' age.
Appropriate educational placement is essential, and psychosocial intervention is generally necessary. Where remedial measures alone prove insufficient, the decision to prescribe a stimulant must be based on rigorous assessment of the severity of the patients' symptoms. The use of methylphenidate should always be used in this way according to the licensed indication and according to prescribing/diagnostic guidelines.

Treatment must be initiated under the supervision of a specialist in childhood, adolescent and adult behavioural disorders.
Method of administration: Methylphenidate Prolonged-release tablets must be swallowed whole with the aid of liquids, and must not be chewed, divided, or crushed (see Precautions).
Methylphenidate Prolonged-release tablets may be administered with or without food (see Pharmacology: Pharmacokinetics under Actions).
Methylphenidate Prolonged-release tablets are taken once daily in the morning.
Pre-treatment screening: Prior to prescribing, it is necessary to conduct a baseline evaluation of a patient's cardiovascular status including blood pressure and heart rate. A comprehensive history should document concomitant medications, past and present co-morbid medical and psychiatric disorders or symptoms, family history of sudden cardiac/unexplained death and accurate recording of pre-treatment height and weight on a growth chart (see Contraindications and Precautions).
Ongoing monitoring: Growth, psychiatric and cardiovascular status should be continuously monitored (see Precautions).
Blood pressure and pulse should be recorded on a centile chart at each adjustment of dose and then at least every 6 months;
Height, weight and appetite should be recorded at least 6 monthly with maintenance of a growth chart;
Development of de novo or worsening of pre-existing psychiatric disorders should be monitored at every adjustment of dose and then at least every 6 months and at every visit.
Patients should be monitored for the risk of diversion, misuse and abuse of methylphenidate.
Dose titration: Careful dose titration is necessary at the start of treatment with Methylphenidate prolonged release tablets. Dose titration should be started at the lowest possible dose.
Other strengths of this medicinal product and other methylphenidate-containing products may be available.
Dosage may be adjusted in 18 mg increments. In general, dosage adjustment may proceed at approximately weekly intervals.
The maximum daily dosage of Methylphenidate Prolonged-release tablets is 54 mg in children, 72 mg in adolescent and 108 mg in Adult.
Patients New to Methylphenidate: Clinical experience with Methylphenidate Prolonged-release tablets is limited in these patients (see Pharmacology: Pharmacodynamics under Actions). Methylphenidate Prolonged-release tablets may not be indicated in all patients with ADHD syndrome. Lower doses of short-acting methylphenidate formulations may be considered sufficient to treat patients new to methylphenidate. Careful dose titration by the physician in charge is required in order to avoid unnecessarily high doses of methylphenidate. The recommended starting dose of Methylphenidate Prolonged-release tablets for patients who are not currently taking methylphenidate, or for patients who are on stimulants other than methylphenidate, is 18 mg once daily.
Patients Currently Using Methylphenidate: The recommended dose of Methylphenidate Prolonged-release tablets for patients who are currently taking methylphenidate three times daily at doses of 15 to 45 mg/day is provided in Table 1. Dosing recommendations are based on current dose regimen and clinical judgment. (See Table 1.)

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If improvement is not observed after appropriate dosage adjustment over a one-month period, the drug should be discontinued.
Long-term (more than 12 months) use in children and adolescents: The safety and efficacy of long-term use of methylphenidate has not been systematically evaluated in controlled trials. Methylphenidate treatment should not and need not, be indefinite. Methylphenidate treatment is usually discontinued during or after puberty. The physician who elects to use methylphenidate for extended periods (over 12 months) in children and adolescents with ADHD should periodically re-evaluate the long-term usefulness of the drug for the individual patient with trial periods off medication to assess the patient's functioning without pharmacotherapy. It is recommended that methylphenidate is de-challenged at least once yearly to assess the child's condition (preferable during times of school holidays). Improvement may be sustained when the drug is either temporarily or permanently discontinued.
Dose reduction and discontinuation: Treatment must be stopped if the symptoms do not improve after appropriate dosage adjustment over a one month period. If paradoxical aggravation of symptoms or other serious adverse events occur, the dosage should be reduced or discontinued.
Elderly (Older than 65 years): Methylphenidate should not be used in the elderly. Safety and efficacy has not been established in this age group.
Children under 6 years of age: Methylphenidate should not be used in children under the age of 6 years. Safety and efficacy in this age group has not been established.

When treating patients with overdose, allowances must be made for the delayed release of methylphenidate from this formulation.
Signs and Symptoms: Acute overdose, mainly due to overstimulation of the central and sympathetic nervous systems vomiting, agitation, tremors, hyperreflexia, muscle twitching, convulsions (may be followed by coma), euphoria, confusion, hallucinations, delirium, sweating, flushing, headache, hyperpyrexia, tachycardia, palpitations, cardiac arrhythmias, hypertension, mydriasis, dryness of mucous membranes and rhabomyolysis.
Treatment: There is no specific antidote to methylphenidate overdosage.
Treatment consists of appropriate supportive measures.
The patient must be protected against self-injury and against external stimuli that would aggravate overstimulation already present. If the signs and symptoms are not too severe and the patient is conscious, gastric contents may be evacuated by induction of vomiting or gastric lavage. Before performing gastric lavage, control agitation and seizures if present and protect the airway. Other measures to detoxify the gut include administration of activated charcoal and a cathartic. In the presence of severe intoxication a carefully titrated dose of a benzodiazepine be given before performing gastric lavage.
Intensive care must be provided to maintain adequate circulation and respiratory exchange; external cooling procedures may be required for hyperpyrexia.
Efficacy of peritoneal dialysis or extracorporeal haemodialysis for overdose of methylphenidate has not been established.

Hypersensitivity to the active substance or to any of the excipients listed in Description; glaucoma; phaeochromocytoma; during treatment with non-selective, irreversible monoamine oxidase (MAO) inhibitors, or within a minimum of 14 days of discontinuation those drugs, due to risk of hypertensive crisis (see Interactions); hyperthyroidism or thyrotoxicosis; diagnosis or history of severe depression, anorexia nervosa/anorexic disorder, suicidal tendencies, psychotic symptoms, severe mood disorders, mania, schizophrenia, psychopathic/borderline personality disorder.
Diagnosis or history of severe and episodic (Type I) Bipolar (affective) Disorder (that is not well-controlled).
Pre-existing cardiovascular disorders including severe hypertension, heart failure, arterial occlusive disease, angina, haemodynamically significant congenital heart disease, cardiomyopathies, myocardial infarction, potentially life-threatening arrhythmias and channelopathies (disorders caused by the dysfunction of ion channels).
Pre-existing cerebrovascular disorders cerebral aneurysm, vascular abnormalities including vasculitis or stroke.

Methylphenidate treatment is not indicated in all patients with ADHD and the decision to use the drug must be based on a very thorough assessment of the severity and chronicity of the patients' symptoms in relation to the patients' age.
Long-term use (more than 12 months) in children and adolescents: The safety and efficacy of long-term use of methylphenidate has not been systematically evaluated in controlled trials. Methylphenidate treatment should not and need not, be indefinite. Methylphenidate treatment is usually discontinued during or after puberty. Patients on long-term therapy (i.e. over 12 months) must have careful ongoing monitoring according to the guidance in Dosage & Administration and Precautions for cardiovascular status, growth, appetite, development of de novo or worsening of pre-existing psychiatric disorders. Psychiatric disorders to monitor for are described below, and include (but are not limited to) motor or vocal tics, aggressive or hostile behaviour, agitation, anxiety, depression, psychosis, mania, delusions, irritability, lack of spontaneity, withdrawal and excessive perseveration.
The physician who elects to use methylphenidate for extended periods (over 12 months) in children and adolescents with ADHD should periodically re-evaluate the long-term usefulness of the drug for the individual patient with trial periods off medication to assess the patient's functioning without pharmacotherapy. It is recommended that methylphenidate is de-challenged at least once yearly to assess the child's condition (preferably during times of school holidays). Improvement may be sustained when the drug is either temporarily or permanently discontinued.
Cardiovascular status: Patients who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden cardiac or unexplained death or malignant arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further specialist cardiac evaluation if initial findings suggest such history or disease. Patients who develop symptoms such as palpitations, exertional chest pain, unexplained syncope, dyspnoea or other symptoms suggestive of cardiac disease during methylphenidate treatment should undergo a prompt specialist cardiac evaluation.
Analyses of data from clinical trials of methylphenidate in children and adolescents with ADHD showed that patients using methylphenidate may commonly experience changes in diastolic and systolic blood pressure of over 10 mmHg relative to controls. The short- and long-term clinical consequences of these cardiovascular effects in children and adolescents are not known, but the possibility of clinical complications cannot be excluded as a result of the effects observed in the clinical trial data. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate. See Contraindications for conditions in which methylphenidate treatment in contraindicated.
Cardiovascular status should be carefully monitored. Blood pressure and pulse should be recorded on a centile chart at each adjustment of dose and then at least every 6 months.
The use of methylphenidate is contraindicated in certain pre-existing cardiovascular disorders unless specialist paediatric cardiac advice has been obtained (see Contraindications).
Sudden death and pre-existing structural cardiac abnormalities or other serious cardiac disorders: Sudden death has been reported in association with the use of stimulants of the central nervous system at usual doses in children, some of whom had structural cardiac abnormalities or other serious heart problems. Although some serious heart problems alone may carry an increased risk of sudden death, stimulant products are not recommended in children or adolescents with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant medicine.
Misuse and Cardiovascular Events: Misuse of stimulants of the central nervous system may be associated with sudden death and other serious cardiovascular adverse events.
Cerebrovascular disorders: See Contraindications for cerebrovascular conditions in which methylphenidate treatment is contraindicated. Patients with additional risk factors (such as a history of cardiovascular disease, concomitant medications that elevate blood pressure) should be assessed at every visit for neurological signs and symptoms after initiating treatment with methylphenidate.
Cerebral vasculitis appears to be a very rare idiosyncratic reaction to methylphenidate exposure. There is little evidence to suggest that patients at higher risk can be identified and the initial onset of symptoms may be the first indication of an underlying clinical problem. Early diagnosis, based on a high index of suspicion, may allow the prompt withdrawal of methylphenidate and early treatment. The diagnosis should therefore be considered in any patient who develops new neurological symptoms that are consistent with cerebral ischemia during methylphenidate therapy. These symptoms could include severe headache, numbness, weakness, paralysis, and impairment of coordination, vision, speech, language or memory.
Treatment with methylphenidate is not contraindicated in patients with hemiplegic cerebral palsy.
Psychiatric disorders: Co-morbidity of psychiatric disorders in ADHD is common and should be taken into account when prescribing stimulant products. In the case of emergent psychiatric symptoms or exacerbation of pre-existing psychiatric disorders, methylphenidate should not be given unless the benefits outweigh the risks to the patient.
Development or worsening of psychiatric disorders should be monitored at every adjustment of dose, then at least every 6 months, and at every visit; discontinuation of treatment may be appropriate.
Exacerbation of pre-existing psychotic or manic symptoms: In psychotic patients, administration of methylphenidate may exacerbate symptoms of behavioural disturbance and thought disorder.
Emergence of new psychotic or manic symptoms: Treatment-emergent psychotic symptoms (visual/tactile/auditory hallucinations and delusions) or mania in children and adolescents without prior history of psychotic illness or mania can be caused by methylphenidate at usual doses. If manic or psychotic symptoms occur, consideration should be given to a possible causal role for methylphenidate, and discontinuation of treatment may be appropriate.
Aggressive or hostile behaviour: The emergence or worsening of aggression or hostility can be caused by treatment with stimulants. Patients treated with methylphenidate should be closely monitored for the emergence or worsening of aggressive behaviour or hostility at treatment initiation, at every dose adjustment and then at least every 6 months and every visit. Physicians should evaluate the need for adjustment of the treatment regimen in patients experiencing behaviour changes bearing in mind that upwards or downwards titration may be appropriate. Treatment interruption can be considered.
Suicidal tendency: Patients with emergent suicidal ideation or behaviour during treatment for ADHD should be evaluated immediately by their physician. Consideration should be given to the exacerbation of an underlying psychiatric condition and to a possible causal role of methylphenidate treatment. Treatment of an underlying psychiatric condition may be necessary and consideration should be given to a possible discontinuation of methylphenidate.
Tics: Methylphenidate is associated with the onset or exacerbation of motor and verbal tics. Worsening of Tourette's syndrome has also been reported. Family history should be assessed and clinical evaluation for tics or Tourette's syndrome in children should precede use of methylphenidate. Patients should be regularly monitored for the emergence or worsening of tics during treatment with methylphenidate. Monitoring should be at every adjustment of dose and then at least every 6 months or every visit.
Serotonin syndrome: Serotonin syndrome has been reported following co-administration of methylphenidate with serotonergic drugs such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). The concomitant use of methylphenidate and serotonergic drugs is not recommended as this may lead to the development of serotonin syndrome. The symptoms of serotonin syndrome may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Prompt recognition of these symptoms is important so that treatment with methylphenidate and serotonergic drugs can be immediately discontinued and appropriate treatment instituted (see Interactions).
Priapism: Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products in both pediatric and adult patients. Priapism generally developed after some time on the drug, often subsequent to an increase in dose. Priapism has also been reported during a period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention.
Anxiety, agitation or tension: Methylphenidate is associated with the worsening of pre-existing anxiety, agitation or tension. Clinical evaluation for anxiety, agitation or tension should precede use of methylphenidate and patients should be regularly monitored for the emergence or worsening of these symptoms during treatment, at every adjustment of dose and then at least every 6 month or every visit.
Forms of bipolar disorder: Particular care should be taken in using methylphenidate to treat ADHD in patients with comorbid bipolar disorder (including untreated Type I Bipolar Disorder or other forms of bipolar disorder) because of concern for possible precipitation of a mixed/manic episode in such patients. Prior to initiating treatment with methylphenidate, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. Close ongoing monitoring is essential in these patients (see 'Psychiatric Disorders' in the previous text and Dosage & Administration). Patients should be monitored for symptoms at every adjustment of dose, then at least every 6 months and at every visit.
Growth: Moderately reduced weight gain and growth retardation have been reported with the long-term use of methylphenidate in children.
The effects of methylphenidate on final height and final weight are currently unknown and being studied.
Growth should be monitored during methylphenidate treatment: height, weight and appetite should be recorded at least 6 monthly with maintenance of a growth chart. Patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.
Seizures: Methylphenidate should be used with caution in patients with epilepsy. Methylphenidate may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and rarely in patients without a history of convulsions and no EEG abnormalities. If seizure frequency increases or new-onset seizures occur, methylphenidate should be discontinued.
Abuse, misuse and diversion: Patients should be carefully monitored for the risk of diversion, misuse and abuse of methylphenidate.
Methylphenidate should be used with caution in patients with known drug or alcohol dependency because of a potential for abuse, misuse or diversion.
Chronic abuse of methylphenidate can lead to marked tolerance and psychological dependence with varying degrees of abnormal behaviour. Frank psychotic episodes can occur, especially in response to parenteral abuse.
Patient age, the presence of risk factors for substance use disorder (such as co-morbid oppositional-defiant or conduct disorder and bipolar disorder), previous or current substance abuse should all be taken into account when deciding on a course of treatment for ADHD. Caution is called for in emotionally unstable patients, such as those with a history of drug or alcohol dependence, because such patients may increase the dosage on their own initiative.
For some high-risk substance abuse patients, methylphenidate or other stimulants may not be suitable and nonstimulant treatment should be considered.
Withdrawal: Careful supervision is required during drug withdrawal, since this may unmask depression as well as chronic over-activity. Some patients may require long-term follow up.
Careful supervision is required during withdrawal from abusive use since severe depression may occur.
Fatigue: Methylphenidate should not be used for the prevention or treatment of normal fatigue states.
Excipients: Galactose intolerance: This medicinal product contains lactose: patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Choice of methylphenidate formulation: The choice of formulation of methylphenidate-containing product will have to be decided by the treating specialist on an individual basis and depends on the intended duration of effect.
Drug screening: This product contains methylphenidate which may induce a false positive laboratory test for amphetamines, particularly with immunoassay screen test.
Haematological effects: The long-term safety of treatment with methylphenidate is not fully known. In the event of leukopenia, thrombocytopenia, anaemia or other alterations, including those indicative of serious renal or hepatic disorders, discontinuation of treatment should be considered.
Potential for gastrointestinal obstruction: Because the Methylphenidate prolonged release tablet is nondeformable and does not appreciably change in shape in the gastrointestinal (GI) tract, it should not ordinarily be administered to patients with pre-existing severe GI narrowing (pathologic or iatrogenic) or in patients with dysphagia or significant difficulty in swallowing tablets. There have been rare reports of obstructive symptoms in patients with known strictures in association with the ingestion of drugs in nondeformable prolonged-release formulations.
Due to the prolonged-release design of the tablet, Methylphenidate Prolonged-release tablets should only be used in patients who are able to swallow the tablet whole. Patients should be informed that Methylphenidate Prolonged-release tablets must be swallowed whole with the aid of liquids. Tablets should not be chewed, divided, or crushed. The medication is contained within a nonabsorbable shell designed to release the drug at a controlled rate. The tablet shell is eliminated from the body; patients should not be concerned if they occasionally notice in their stool something that looks like a tablet.
Effects on ability to drive and use machines: Methylphenidate can cause dizziness, drowsiness and visual disturbances including difficulties with accommodation, diplopia and blurred vision. It may have a moderate influence on the ability to drive and use machines. Patients should be warned of these possible effects and advised that if affected, they should avoid potentially hazardous activities such as driving or operating machinery.
Renal or hepatic insufficiency: There is no experience with the use of methylphenidate in patients with renal or hepatic insufficiency.
Use in Children under 6 years of age: Methylphenidate should not be used in children under the age of 6 years. Safety and efficacy in this age group has not been established.
Use in the Elderly (Older than 65 years): Methylphenidate should not be used in the elderly. Safety and efficacy has not been established in this age group.

Use in Pregnancy: There is a limited amount of data from the use of methylphenidate in pregnant women.
Cases of neonatal cardiorespiratory toxicity, specifically foetal tachycardia and respiratory distress have been reported in spontaneous case reports.
Studies in animals have only shown evidence of reproductive toxicity at maternally toxic doses (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Methylphenidate is not recommended for use during pregnancy unless a clinical decision is made that postponing treatment may pose a greater risk to the pregnancy.
Animal data: Methylphenidate is considered to be possibly teratogenic in rabbits. Spina bifida with malrotated hind limbs was observed in two separate litters at a dose of 200 mg/kg/day. Exposure (AUC) at this dose was approximately 5.1 times higher than the extrapolated exposure at the maximum recommended human dose (MRHD). Exposure at the next lower dose, wherein no spina bifida was found, was 0.7 times the extrapolated exposure at MRHD. A second study was conducted with a high dose of 300 mg/kg, which was considered maternally toxic. No spina bifida was seen in 12 litters (92 fetuses) surviving. Exposure (AUC) at 300 mg/kg was 7.5 times the extrapolated exposure at MRHD.
Methylphenidate is not teratogenic in rats. Development fetal toxicity was noted at a high dose of 75 mg/kg (20.9 times higher than the exposure (AUC) at MRHD) and consisted of an increase of the instance of fetuses with delayed ossification of the skull and hyoid bones as well as fetuses with short supernumerary ribs.
When methylphenidate was administered to rats throughout pregnancy and lactation at doses of up to 45 mg/kg/day (about 26-fold higher than the MRHD on a mg/kg basis), offspring body weight gain was decreased at the highest dose, but no other effects on postnatal development were observed.
Use in Lactation: Methylphenidate has been found in the breast-milk of a woman treated with methylphenidate.
There is one case report of an infant who experienced an unspecified decrease in weight during the period of exposure but recovered and gained weight after the mother discontinued treatment with methylphenidate. A risk to the suckling child cannot be excluded.
A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from methylphenidate therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.
Females and males reproductive potential: There are no data to support special recommendation in women of child-bearing potential.
Infertility: No human data on the effect of methylphenidate on fertility are available. Methylphenidate did not impair fertility in male or female mice.

Table 2 shows all adverse drug reactions (ADRs) observed during clinical trials and post-market spontaneous reports with Methylphenidate Prolonged-release tablets and those, which have been reported with other methylphenidate hydrochloride formulations. If the ADRs with Methylphenidate Prolonged-release tablets and the methylphenidate formulation frequencies were different, the highest frequency of both databases was used.
Frequency estimate: Very common (≥1/10); common (≥1/100 to < 1/10); uncommon (≥1/1000 to < 1/100); rare (≥1/10,000 to <1/1000); very rare (<1/10,000); not known (cannot be estimated from the available data). (See Table 2.)

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*see Precautions.
Adverse drug reactions from spontaneous reports and literature (frequency not known).
Reproductive system and breast disorders: Priapism.

Pharmacokinetic Interaction: It is not known how methylphenidate may effect plasma concentrations of concomitantly administered drugs. Therefore, caution is recommended at combining methylphenidate with other drugs, especially those with a narrow therapeutic window.
Methylphenidate is not metabolised by cytochrome P450 to a clinically relevant extent. Inducers or inhibitors of cytochrome P450 are not expected to have any relevant impact on methylphenidate pharmacokinetics.
Conversely, the d- and l- enantiomers in methylphenidate did not relevantly inhibit cytochrome P450 1A2, 2C8, 2C9, 2C19, 2D6, 2E1 or 3A.
However, there are reports indication that methylphenidate may inhibit the metabolism of coumarin anticoagulants, anticonvulsants (eg, phenobarbital, phenytoin, primidone), and some antidepressants (tricyclics and selective serotonin reuptake inhibitors). When starting or stopping treatment with methylphenidate, it may be necessary to adjust the dosage of these drugs already being taken and establish drug plasma concentrations (or for coumarin, coagulation times).
Pharmacodynamic Interactions: Anti-hypertensive drugs: Methylphenidate may decrease the effectiveness of drugs used to treat hypertension.
Use with drugs that elevate blood pressure blood pressure: Caution is advised in patients being treated with methylphenidate with any other drug that can also elevate blood pressure (see also sections on cardiovascular and cerebrovascular conditions in Precautions).
Because of possible hypertensive crisis, methylphenidate is contraindicated in patients being treated (currently or within the preceding 2 weeks) with non-selective, irreversible MAO-inhibitors (see Contraindications).
Use with alcohol: Alcohol may exacerbate the adverse CNS effect of psychoactive drugs, including methylphenidate. It is therefore advisable for patients to abstain from alcohol during treatment.
Use with halogenated anaesthetics: There is a risk of sudden blood pressure increase during surgery. If surgery is planned, methylphenidate treatment should not be used on the day of surgery.
Use with centrally acting alpha-2 agonists (e.g. clonidine): Serious adverse events, including sudden death, have been reported in concomitant use with clonidine. The safety of using methylphenidate in combination with clonidine or other centrally acting alpha-2 agonists has not been systematically evaluated.
Use with dopaminergic drugs: Caution is recommended when administering methylphenidate with dopaminergic drugs, including antipsychotics. Because a predominant action of methylphenidate is to increase extracelluar dopamine levels, methylphenidate may be associated with pharmacodynamic interactions when co-administered with direct and indirect dopamine agonists (including DOPA and tricyclic antidepressants) or with dopamine antagonists including antipsychotics.
Use with serotonergic drugs: The concomitant use of methylphenidate and serotonergic drugs is not recommended as this may lead to the development of serotonin syndrome (see Precautions). Methylphenidate has been shown to increase extracellular serotonin and norepinephrine and appears to have weak potency in binding serotonin transporter.

Special precautions for disposal and other handling: No special requirements.
Incompatibilities: Not applicable.

Do not store above 25°C.
Shelf-Life: The tablets can be stored for 6 months in de HDPE bottles after the first opening.

Other CNS Drugs & Agents for ADHD

N06BA04 - methylphenidate ; Belongs to the class of centrally-acting sympathomimetics. Used as CNS stimulant.

P2