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"Adderall" redirects here. For amphetamine base, see amphetamine.
amphetamine mixed salts
Combination of
amphetamine aspartatepsychostimulant
amphetamine sulfatepsychostimulant
dextroamphetamine saccharatepsychostimulant
dextroamphetamine sulfatepsychostimulant
Clinical data
Trade namesAdderall
Adderall ER
Adderall XR
AHFS/Drugs.comMonograph
MedlinePlusa601234
License data
Dependence
liability		High
Routes of
administration		(Medical) Oral, (Recreational) Oral, Insufflated, Intravenous
ATC code
Legal status
Legal status
Identifiers
CAS Number
PubChem CID
DrugBank
ChemSpider
KEGG
ChEBI
ChEMBL
Chemical and physical data
3D model (JSmol)
  • NC(C)Cc1ccccc1
  • InChI=1S/C9H13N/c1-8(10)7-9-5-3-2-4-6-9/h2-6,8H,7,10H2,1H3 checkY
  • Key:KWTSXDURSIMDCE-UHFFFAOYSA-N checkY
 ☒NcheckY (what is this?)  (verify)

Amphetamine mixed salts (also known as amphetamine and dextroamphetamine mixed salts, amphetamine salt combo, or simply amphetamine salts, and sold under the brand name Adderall) is a pharmaceutical drug used in the treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy. The active ingredient contained in this medication is a mixture of the salts of amphetamine and dextroamphetamine, both of which act as stimulants. As of 2013, there is a single commercial formulation, which contains a 3:1 ratio of dextroamphetamine (the dextrorotary or "right-handed" enantiomer) to levoamphetamine (the levorotary or "left-handed" enantiomer[2]). Amphetamine mixed salts are available in immediate release and extended release formulations.

Medical use

Amphetamine mixed salts is generally used for the treatment of ADHD and narcolepsy. These are the only two conditions for which the United States Food and Drug Administration has approved its use.[3] However, it is sometimes prescribed off-label for other conditions such as depression. It has been used to treat obesity, but the American Society of Health-System Pharmacists does not recommend this use.[4] Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health.[5]

Attention deficit hyperactivity disorder

The comparative effectiveness of treatment options for children with ADHD, including different amphetamine medications, has been studied by the US Agency for Health Care Research and Quality,[6] and summarized for parents.[7] Amphetamines may improve ADHD in symptoms in children over the age of six, but there is not enough evidence to be sure.[6] Use for younger children and use for longer than a year in particular require further study.[6] Amphetamine has not been shown to improve academic outcomes in students with ADHD.[8]

Amphetamine mixed salts have also been shown to reduce ADHD in adults, but research is limited.[9]

Dosing and administration

Amphetamine mixed salts is available as immediate release form or extended-release form.[10] The extended release capsule is generally used in the morning.[11] Generic forms are available in some doses.[7]

The extended release formulation available under the brand Adderall XR is designed to provide therapeutic effect and plasma concentrations identical to taking two doses 4 hours apart.[12]

Adverse effects

Side effects of amphetamine salts include dry mouth, insomnia, tired feeling, drowsiness, dizziness, nervousness, headache and weight loss, diarrhea, as well as changes in heartbeat and blood pressure.

Chronic

A study on comparative effects between amphetamine mixed salts and methylphenidate in children who have been treated for a year or more have shown a temporary decrease in growth rate that does not affect final adult height. Change in weight was reported as slightly greater for amphetamine mixed salts and authors concluded that the result may be clinically insignificant.[13]

Studies on rats show long-term neurological and behavioral changes resulting from prenatal and early postnatal exposure to amphetamines.[14][15] Warnings from the Patient Medication Guide for Adderall include emergence of new psychotic or manic symptoms, aggression and blurred vision.[16][17] Recent studies by the FDA indicate that, in children, young adults, and adults, there is no association between serious adverse cardiovascular events (sudden death, myocardial infarction, and stroke) and the use of amphetamines or other ADHD stimulants.[18][19][20]

Contraindications, interactions, and precautions

  • MAOIs (monoamine oxidase inhibitors, e.g., phenelzine, selegiline, iproniazid, etc.) —There is a high risk of a hypertensive crisis if amphetamine is administered within two weeks after last use of an MAOI type drug. Preliminary trials of low-dose amphetamine and MAOIs being administered together are in progress. However, this is to be done only under strict supervision of the prescribing parties.
  • SSRIs (selective serotonin reuptake inhibitors, e.g., fluvoxamine, citalopram, paroxetine, etc.) — While a common combination, and although rare, the risk for serotonin syndrome exists. (Use only when directed)
  • NRIs (norepinephrine reuptake inhibitors, e.g., atomoxetine, etc.) — NRI medications and amphetamine both enhance noradrenergic activity. Possible augmentation/potentiation of effects. (Use only when directed)
  • SNRIs (selective serotonin-norepinephrine reuptake inhibitors) — See SSRIs and NRIs.
  • Bupropion  — Both bupropion and amphetamine have noradrenergic and dopaminergic activity. Bupropion is a potent CYP2D6 inhibitor. Bupropion has pro-convulsant properties that may be enhanced or cumulatively potentiated by amphetamine.[21] (Use only when directed)
  • Monoaminergic tricyclic antidepressant  — See NRIs, SNRIs, and SSRIs. Possible potentiation of serotonin-, dopamine-, and/or norepinephrine-related drug effects. The combination of monoaminergic tricyclics and amphetamine compounds has been associated with increased sympathomimetic effects. The exceptions to this class (i.e. non-monoaminergic tricyclic antidepressants) include the glutamatergic tricyclic tianeptine and sigmaergic tricyclic opipramol.
  • CYP2D6 (liver enzyme) inhibitors, e.g., Bupropion and most SSRIs such as fluoxetine, citalopram, paroxetine, etc. Some anti-psychotics such as thioridazine, haloperidol, and levomepromazine, as well as cocaine, the opioid agonist methadone, and others. It is important to determine if any medication or drug taken is a CYP2D6 inhibitor. Taking a CYP2D6-inhibiting drug along with amphetamine will lead to an elevated level of amphetamine in the system, resulting in the drug's remaining in the body for a longer period, which can lead to undesirable and possibly serious side effects.
  • Individuals with pre-existing cardiac conditions or mental illnesses.
  • Individuals with a history of drug abuse

Pregnancy

Amphetamine mixed salts is in FDA pregnancy category C.[3] Drugs assigned category C have been demonstrated to have adverse effect on fetus in animal studies, but no adequate studies on human are available.[22]

Prolonged use and withdrawal

Prolonged use of amphetamines can lead to dependence.[23] Chronic abuse of amphetamines can result in the manifestation of amphetamine psychosis;[14] occasionally this psychosis can occur at therapeutic doses during chronic therapy as a treatment emergent side effect.[24]

Most longterm users of amphetamines will experience severe, time-limited withdrawal symptoms within 24 hours of their last dose.[23] Symptoms can include dysphoric mood, irritability, anxiety, agitation, vivid or unpleasant dreams, hypersomnia or fatigue, cravings and more.[23] Thoughts of suicide have been reported.[23] This initial "crash" can last up to a week, followed generally by about two weeks of less acute withdrawal symptoms.[23] Antidepressant drugs have been studied to ease amphetamine withdrawal, but more research on their effects is needed.[23]

Commercial formulations

Historical

Rexar, a pharmaceutical company, reformulated another drug, branded as Obetrol, to exclude methamphetamine and continued to sell this new formulation under the same brand name. This new unapproved formulation was later rebranded and sold as Adderall by Richwood after it acquired Rexar resulting in FDA warning in 1994. Richwood submitted this formulation as NDA 11-522 and Adderall gained FDA approval for the treatment of attention-deficit/hyperactivity disorder therapy on February 13, 1996.[25]

Current

Amphetamine mixed salts is a psychostimulant medication used primarily for the treatment of ADHD and narcolepsy.[4]

It is a mixture of amphetamine salts consisting of equal amounts by mass of:[12]

This mixture is a dopamine releasing agent, a norepinephrine releasing agent, and can be mildly serotonergic.[14]

Amphetamine mixed salts are available in immediate release and extended release formulations. The immediate release formulation is indicated for use in ADHD and narcolepsy,.[10] The extended release formulation only approved for the treatment of ADHD.[14]

Mechanism of action

Main article: Amphetamine § Pharmacology
Main article: Dextroamphetamine mechanism of action

Amphetamine's pharmacological activity is due mainly to the release of dopamine and norepinephrine. It can also increase serotonin release, although it is disputed whether this is pharmacologically significant at therapeutic doses.[26][27][28] Dextroamphetamine (the dextrorotary enantiomer) and levoamphetamine (the levorotary enantiomer) have different pharmacological properties.[29] Dextroamphetamine is several times more potent in the central nervous system than levoamphetamine), but the two isomers have comparable activity in the peripheral nervous system.[30] The overall greater potency of dextroamphetamine to central actions suggests that this form may have a higher potential for abuse.[31]

Levoamphetamine provides mixed amphetamine salts quicker onset and longer-lasting effects than dextroamphetamine alone.[32] It has been reported that certain children have a better clinical response to levoamphetamine.[33]

Pharmacokinetics

"The mean elimination half-life for d-amphetamine is 10 hours in adults; 11 hours in adolescents aged 13–17 years and weighing less than or equal to 75 kg/165 lbs; and 9 hours in children aged 6 to 12 years. For the l-amphetamine, the mean elimination half-life in adults is 13 hours; 13 to 14 hours in adolescents; and 11 hours in children aged 6 to 12 years. On a mg/kg body weight basis children have a higher clearance than adolescents or adults."[12]

Urinary and stomach pH levels influence amphetamine excretion and absorption.[34] An acidic stomach and GI pH will decrease the absorption of amphetamine salts.[35] Plasma half life of amphetamine sulfate, a constituent of amphetamine mixed salts is dependent on pH of urinary system. For each unit of pH increase, plasma half life of amphetamine sulfate is increased by 7 hours.[36]

Detection of use

Techniques such as immunoassay may cross-react with a number of sympathomimetics drugs, so chromatographic methods specific for amphetamine should be employed to prevent false-positive results. Chiral techniques may be employed to help distinguish the source of the drug, whether obtained legally (by prescription) or illegally or possibly as a result of formation from a prodrug such as lisdexamfetamine or selegiline. Chiral separation can be used to differentiate amphetamine mixed salts use from use of another prescription form of amphetamine or from use of illicit amphetamine[37][38][39]

Abuse

Amphetamine is considered to have a high potential for misuse and a high liability for dependence and listed as Schedule II in the US,[40][41] Schedule II in the UN Convention of Psychotropic Substances and Schedule I in Canada (CSA).[42] Amphetamine mixed salts is a drug of abuse.[43] Amphetamine salts can be crushed, and snorted or dissolved in water and injected.[44] Injection into the bloodstream can be dangerous because insoluble fillers within the tablets can block small blood vessels.[44]

Recreational use of amphetamines is exceedingly dangerous, especially when used at very high doses. Research has shown that amphetamine binges in lab animals cause neurotoxicity in dopaminergic pathways, resulting in permanent but not irreversible cognitive impairments.[45] Moreover, extremely high doses of amphetamine can induce rapid muscle breakdown, repetitive or stereotyped behaviors, catecholaminergic/adrenergic storm, and coma.[46]

Performance-enhancing drug abuse

Some college and high-school students have made illicit use of amphetamine mixtures, such as Adderall, in an attempt to enhance performace during study and test-taking.[8][47] Given the students' non-recreational aims this behavior has not always been considered as problematic as other types of drug abuse, and its medical and legal consequences may be underappreciated.[8]

Amphetamine has also been abused by some professional,[48] collegiate and high school[49][dead link] athletes for stimulation. The NCAA has banned the use of stimulants such as Adderall for its collegiate athletes without a prescription and adequate records of evaluation and diagnosis of ADHD.[50]

History

Adderall is available as an instant-release (IR) and an extended-release (XR) drug. Adderall instant-release is manufactured today by Teva and Barr Pharmaceuticals. Shire Pharmaceuticals, the creator of Adderall IR, no longer produces it. However, Shire does continue to manufacture the extended-release version of Adderall ("Adderall XR"). Richwood Pharmaceuticals (later merged with Shire) introduced the Adderall brand in 1996 in the form of a multi-dose, instant-release tablet derived from an original formula of the weight management drug Obetrol. In 2006, Shire agreed to sell rights to the Adderall name for this instant-release medication to Duramed Pharmaceuticals[51] DuraMed Pharmaceuticals was acquired by Teva Pharmaceuticals in 2008 when Teva completed its acquisition of Barr Pharmaceuticals (including Barr's Duramed division).[52] Therefore, following its acquisition of Duramed, Teva is in the somewhat unusual position of manufacturing both a generic formulation of Adderall instant-release (under its Barr Division) as well as "brand name" Adderall (under its DuraMed division.)

In 2001, Shire introduced an extended-release preparation of these ingredients in a variety of dosages under the brand name "Adderall XR," on which Shire retains exclusive patent rights until the patent expires, expected in 2018.[53] Shire was unable to extend patents by evergreening and generic version of Adderall XR became available in 2009.[54] In 2009, Barr and Shire reached a settlement agreement permitting Barr to offer a generic form of the drug beginning April 1, 2009.[55]

Patent disputes

Manufacturer's claims of instant release have been disputed. A US patent granted for Adderall[56] was a pharmaceutical composition patent listing a rapid immediate-release oral dosage form. No claim of increased or smooth drug delivery was made. A study by James and colleague as published In the November 2001 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, placebo-controlled crossover study conducted among 35 children ages 5–12 indicated that patients behaved similarly to those having taken other immediate-release amphetamines. The authors found that sustained-release dexamphetamine (the main isomeric-amphetamine component of Adderall) had a longer duration of action, however D-amphetamine was less effective in the first few hours.[57]

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