Continuing Education Activity

Methylphenidate is FDA-approved for treating attention deficit hyperactivity disorder (ADHD) in children and adults and as a second-line treatment for narcolepsy in adults. Children diagnosed with ADHD should be at least six years of age or older before being started on this medication. Off-label uses of methylphenidate include treatment for fatigue in patients with cancer, refractory depression in the geriatric population, apathy in Alzheimer's disease, and enhancing cognitive performance (e.g., memory). The efficacy of methylphenidate for its off-label uses varies from limited to moderate. This activity will highlight the mechanism of action, adverse event profile/toxicity, pharmacology, monitoring, relevant interactions, and street names of methylphenidate, pertinent for interprofessional team members should they encounter a patient who requires therapy with or has potentially misused this drug.


  • Review the mechanism of action of methylphenidate.
  • Identify the approved and off-label uses of methylphenidate.
  • Summarize the contraindications and adverse events associated with methylphenidate.
  • Describe interprofessional team strategies for improving care coordination and communication to properly use methylphenidate to improve patient outcomes in the varied scenarios where it can be effective.


Methylphenidate is FDA-approved for treating attention deficit hyperactivity disorder (ADHD) in children and adults and as a second-line treatment for narcolepsy in adults.[1][2] Children diagnosed with ADHD should be at least six years of age or older before being started on this medication. The treatment of both ADHD and narcolepsy have significantly better outcomes when used concurrently with nonpharmacologic therapies (i.e., social skills training in ADHD or sleep hygiene measures in narcolepsy). 

Off-label uses of methylphenidate include treatment for fatigue in patients with cancer, refractory depression in the geriatric population, apathy in Alzheimer disease, and enhancing cognitive performance (e.g., memory).[3][4][5][6][7][8] Since it can be abused as a cognitive enhancer, it is a federally controlled Schedule II substance. The efficacy of methylphenidate for its off-label uses varies from limited to moderate. Most of these relatively newer uses are still being studied and implemented into clinical practice.

Mechanism of Action

Methylphenidate blocks the reuptake of two neurotransmitters, norepinephrine (NE) and dopamine, by presynaptic neurons. More specifically, it inhibits the transporters of these neurotransmitters, increasing the concentration of dopamine and NE in the synaptic cleft.[9] Overall, this creates its classic stimulant effect within the central nervous system (CNS), mainly in the prefrontal cortex. It chemically derives from phenethylamine and benzylpiperazine. It undergoes metabolism by the liver to ritalinic acid through a process called de-esterification via carboxylesterase CES1A1. Compared to other medications (i.e., amphetamines) that are phenethylamine derivatives, methylphenidate appears to increase the firing rate of neurons.[10] It is also a weak agonist at the 5HT1A receptor, which is an additional mechanism that contributes to the increased levels of dopamine.[11] 

With the increase in dopamine levels, methylphenidate can provide neuroprotection in certain conditions like Parkinson disease, which involves loss of dopaminergic neurons and methamphetamine abuse.[12] This effect occurs not only through its direct inhibition of the dopamine transporter but also via indirect regulation of the vesicular monoamine transporter 2. The combined interactions methylphenidate has on both of these transporters reduce the amount of dopamine that accumulates within the cytoplasm in patients with these conditions, thereby preventing the formation of reactive oxygen species that would otherwise be dangerously toxic to the brain. 


The therapeutic dosages for ADHD or narcolepsy that physicians prescribe are not harmful enough to activate the reward system within the CNS, known as the nucleus accumbens. However, excessively higher dosages taken by those who intentionally abuse the drug lead to an overexpression of deltaFosB, a transcriptional activator, in certain neurons within the striatum. This accumulation of deltaFosB in the nucleus accumbens activates a series of signaling cascades that further triggers the addiction.[13]


For medical purposes, methylphenidate is mainly given orally or, less commonly, as a transdermal patch. Multiple oral formulations are available that categorize according to how quickly the drug is released: immediate (IR), extended (XR or ER), and sustained. Two of the more unique formulations of methylphenidate are its ER sphenoidal oral drug absorption system that has a bimodal release and the osmotic (controlled) release delivery system. There are chewable tablets (either IR or ER) for children and an IR solution. The dosages range from 5 mg to 60 mg. Doses should not exceed 72 mg, the maximum dose of the ER tablet. If using the transdermal patch, then the patient must be aware of placing the patch on the opposite hip each time to achieve its full effect. Those who misuse methylphenidate for recreational purposes prefer to use either the intravenous (IV) or the intranasal route. 

Adverse Effects

Insomnia and nervousness are the most commonly reported adverse effects in patients on methylphenidate. Other frequent side effects mainly involve the CNS (dizziness, headache, tics, restlessness/akathisia), gastrointestinal (nausea/vomiting, dry mouth, decreased appetite, weight loss, abdominal pain), and cardiovascular systems (tachycardia, and palpitations). Dermatologically, patients can complain of excessive sweating and ulceration of their digits. Some patients may even develop blurry vision or decreased libido. Patients are more prone to become easily agitated, irritable, or depressed and go through mood swings/lability). While many of the common side effects can be relieved by adjusting the dosage or avoidance of an afternoon or evening dose, some require treatment emergently to prevent complications. While it rarely occurs, priapism is a medical emergency that requires immediate attention.[14] 

It is important to note that there have been reported cases of sudden death in both children and adults with a pre-existing structural cardiac abnormality. Stroke and myocardial infarction also have been observed in adults. Due to the risk of such fatal side effects, it is advisable to avoid methylphenidate in patients with a structural cardiac abnormality, cardiomyopathy, or arrhythmias.[15] 


Patients must not use methylphenidate if they are currently on monoamine oxidase inhibitors (MAOIs). There should be a minimum of at least 14 days after discontinuation of MAOIs before methylphenidate can be considered a safe treatment option to begin due to the risk of hypertensive crisis. Medical conditions that are not compatible with methylphenidate include glaucoma, severe hypertension, motor tics, and Tourette syndrome, or a family history of Tourette syndrome. If a patient is noticeably anxious, tense, or agitated, then seek alternative treatment options. However, it can be given cautiously in patients with a history of bipolar disorder or psychosis as long as physicians are wary of mania or psychotic episodes induced by the medication.[12] Any patient who develops a hypersensitive reaction to methylphenidate or an individual component of a formulation should have the medication immediately discontinued and switch to another pharmacologic agent. Children under the age of six should not be prescribed this medication as there are limited studies to prove its safety or benefit, and it could potentially cause learning impairments. 


A complete blood count with differential should be obtained periodically for those on methylphenidate. At each visit, the main vitals to note are blood pressure and heart rate, especially in patients with underlying hypertension, heart failure, a recent MI, or ventricular arrhythmia, as slight elevations can occur with methylphenidate use. If a patient complains of cardiac symptoms, such as chest pain, that worsens with exertion or has a near-syncope episode, then a full cardiac workup should be performed. Physicians should screen for symptoms of depression, agitation, aggressiveness, new-onset or pre-existing psychosis or mania, and suicidality as these can be worsened when initially starting methylphenidate. On physical exam, look for peripheral vasculitis (digital ulceration). Physicians should also monitor for signs of intravenous abuse as frank psychotic episodes can develop. Controversial evidence exists regarding the potential for methylphenidate to affect seizure threshold.[16][17] If seizures develop while being treated with methylphenidate, then the prescribing clinician should stop the drug immediately. 

In adults, patients should limit their alcohol use while taking methylphenidate as its stimulant action can mask the actual sedative effect caused by alcohol intoxication, possibly inducing severe respiratory depression. Additionally, a patient who is concurrently on warfarin, phenytoin, tricyclic antidepressants, or SSRIs should have their drug levels monitored and adjust doses as needed to achieve a therapeutic effect, primarily because methylphenidate can inhibit the metabolism of these drugs. 

In children, it is essential to evaluate their growth curve for a stable progression in height and weight since methylphenidate has demonstrated growth suppression when used on a daily, long-term basis. The medication should either be readjusted or discontinued if children are not in a healthy percentile on their growth curve.


The first step in a medication overdose is to immediately contact a poison control center for the next appropriate steps in management. Doses that exceed 60 mg of the IR (immediate-release) formulation or 120 mg of the ER (extended-release) formulation can be considered toxic. If the overdosed quantity is unknown, look for signs and symptoms such as tremors, hyperreflexia, convulsions, euphoria, confusion, hallucinations, delirium, flushing, and fever, in addition to the common adverse effects mentioned above. Supportive care with supplemental oxygen, IV fluids, and external cooling methods is the mainstay of treatment. Multiple studies have shown that benzodiazepines are an option, especially if dystonia, agitation, or convulsions are present.[14]

Enhancing Healthcare Team Outcomes

It is essential to gather a thorough history from the patient (or patient’s legal guardian) regarding their past medical history, current medications, and social history (obtain a developmental history if the patient is a child). An interprofessional healthcare team consisting of the patient’s primary care provider, psychiatrist, nurses, nurse practitioners, physician assistants, social workers, therapists, school teachers, and pharmacists should oversee the case. Communication between each member of the treatment team is crucial as medication combined with non-pharmacologic treatment measures provide the most long-term success. Evaluation of side effects requires close monitoring at each visit. If the patient is a child, it is crucial to give the patient’s legal guardian education regarding the medication and its side effects. This interprofessional approach will optimize therapeutic results while limiting adverse events. [Level 5]


Studies have shown that medication alone is not as effective as when the medication is combined with non-pharmacologic treatment measures. Patients with ADHD managed on both medication and non-pharmacologic treatments have been shown to have higher self-esteem and social functioning skills versus those untreated. There have been long-term beneficial effects shown in adults with ADHD who continue to take methylphenidate. Further long-term studies are still in progress.[18][19] 

Article Details

Article Author

Corinne Verghese

Article Editor:

Sara Abdijadid


5/4/2021 1:05:26 PM

PubMed Link:




Methylphenidate off-label use and safety., Trenque T,Herlem E,Abou Taam M,Drame M,, SpringerPlus, 2014     [PubMed PMID: 25279275]


The Medical and Economic Burden of Narcolepsy: Implications for Managed Care., Thorpy MJ,Hiller G,, American health & drug benefits, 2017 Jul     [PubMed PMID: 28975007]


Pharmacological and Nonpharmacological Treatment for Apathy in Alzheimer Disease : A systematic review across modalities, Theleritis C,Siarkos K,Katirtzoglou E,Politis A,, Journal of geriatric psychiatry and neurology, 2017 Jan     [PubMed PMID: 28248559]


A randomized, double-blind, 2-period, placebo-controlled crossover trial of a sustained-release methylphenidate in the treatment of fatigue in cancer patients., Escalante CP,Meyers C,Reuben JM,Wang X,Qiao W,Manzullo E,Alvarez RH,Morrow PK,Gonzalez-Angulo AM,Wang XS,Mendoza T,Liu W,Holmes H,Hwang J,Pisters K,Overman M,Cleeland C,, Cancer journal (Sudbury, Mass.), 2014 Jan-Feb     [PubMed PMID: 24445757]


The use of methylphenidate to relieve fatigue., Rojí R,Centeno C,, Current opinion in supportive and palliative care, 2017 Dec     [PubMed PMID: 28885263]


The problem of fatigue in patients suffering from neoplastic disease., Kolak A,Kamińska M,Wysokińska E,Surdyka D,Kieszko D,Pakieła M,Burdan F,, Contemporary oncology (Poznan, Poland), 2017     [PubMed PMID: 28947882]


Citalopram, methylphenidate, or their combination in geriatric depression: a randomized, double-blind, placebo-controlled trial., Lavretsky H,Reinlieb M,St Cyr N,Siddarth P,Ercoli LM,Senturk D,, The American journal of psychiatry, 2015 Jun     [PubMed PMID: 25677354]


Prescription Stimulants' Effects on Healthy Inhibitory Control, Working Memory, and Episodic Memory: A Meta-analysis., Ilieva IP,Hook CJ,Farah MJ,, Journal of cognitive neuroscience, 2015 Jun     [PubMed PMID: 25591060]


Methylphenidate HCl: therapy for attention deficit hyperactivity disorder., Capp PK,Pearl PL,Conlon C,, Expert review of neurotherapeutics, 2005 May     [PubMed PMID: 15938665]


Dysfunctions in dopamine systems and ADHD: evidence from animals and modeling., Viggiano D,Vallone D,Sadile A,, Neural plasticity, 2004     [PubMed PMID: 15303308]


The psychostimulant d-threo-(R,R)-methylphenidate binds as an agonist to the 5HT(1A) receptor., Markowitz JS,DeVane CL,Ramamoorthy S,Zhu HJ,, Die Pharmazie, 2009 Feb     [PubMed PMID: 19322953]


The impact of neuroscience on society: cognitive enhancement in neuropsychiatric disorders and in healthy people., Sahakian BJ,Bruhl AB,Cook J,Killikelly C,Savulich G,Piercy T,Hafizi S,Perez J,Fernandez-Egea E,Suckling J,Jones PB,, Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 2015 Sep 19     [PubMed PMID: 26240429]


Methylphenidate-induced dendritic spine formation and DeltaFosB expression in nucleus accumbens., Kim Y,Teylan MA,Baron M,Sands A,Nairn AC,Greengard P,, Proceedings of the National Academy of Sciences of the United States of America, 2009 Feb 24     [PubMed PMID: 19202072]


Overdose of drugs for attention-deficit hyperactivity disorder: clinical presentation, mechanisms of toxicity, and management., Spiller HA,Hays HL,Aleguas A Jr,, CNS drugs, 2013 Jul     [PubMed PMID: 23757186]


Liu H,Feng W,Zhang D, Association of ADHD medications with the risk of cardiovascular diseases: a meta-analysis. European child     [PubMed PMID: 30143889]


Stimulants Do Not Increase the Risk of Seizure-Related Hospitalizations in Children with Epilepsy., Liu X,Carney PR,Bussing R,Segal R,Cottler LB,Winterstein AG,, Journal of child and adolescent psychopharmacology, 2017 Oct 13     [PubMed PMID: 29028437]


Epilepsy, Attention-Deficit/Hyperactivity Disorder and Methylphenidate: Critical Examination of Guiding Evidence., Ravi M,Ickowicz A,, Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent, 2016 Winter     [PubMed PMID: 27047557]


Harpin V,Mazzone L,Raynaud JP,Kahle J,Hodgkins P, Long-Term Outcomes of ADHD: A Systematic Review of Self-Esteem and Social Function. Journal of attention disorders. 2016 Apr;     [PubMed PMID: 23698916]


Fredriksen M,Peleikis DE, Long-Term Pharmacotherapy of Adults With Attention Deficit Hyperactivity Disorder: A Literature Review and Clinical Study. Basic     [PubMed PMID: 26404187]