5.5 CNS Stimulants V2
CNS stimulants are a broad class of drugs that increase the activity of the central nervous system. They are mostly used for the treatment of attention-deficit hyperactivity disorders (ADHD) and as a second line treatment for narcolepsy in adults.
Other stimulants include amphetamines, caffeine, ephedrine, cocaine and khat which will not be covered (Farzam, Faizy & Saadabadi, 2023).
In this unit we will look at the use of one stimulant, methylphenidate, for the treatment of ADHD. ADHD can also be treated with non-stimulants such as atomoxetine (selective norepinephrine reuptake inhibitor (SNRI), clonidine (Alpha-2 adrenergic agonists) and guanfacine (alpha-2 agonist), which are used if stimulants are not effective.
Methylphenidate
Methylphenidate is an example of a CNS stimulant that is often used to treat ADHD. It is a first line treatment, along with amphetamine-based medications (ie. Adderall). Common methylphenidate meds are Ritalin and Concerta.
Mechanism of Action
Methylphenidate stimulates the brain and acts similar to amphetamines. This medication blocks the reuptake of the neurotransmitters norepinephrine (NE) and dopamine (DA) in presynaptic neurons while inhibiting the transport of these neurotransmitters, increasing the concentration of dopamine and NE in the synaptic cleft. This creates the classic stimulant effect within the central nervous system (CNS), primarily in the prefrontal cortex (Farzam, Faizy & Saadabadi, 2023).
Methylphenidate works well with many children, as it appears children with ADHD have an abnormality in the dopamine transporter gene (DAT-1), the D4 receptor gene and/or the D2 receptor gene. The dopaminergic effects of methylphenidate will partly overcome these alterations (DrugBank, 2026).
Indications for Use
Methylphenidate is used for ADHD and narcolepsy. Off-label uses of methylphenidate include treating fatigue in patients with cancer, refractory depression in older adults, apathy in Alzheimer disease, and enhancing cognitive performance (Verghese, Patel & Abdijadid, 2024).
Nursing Considerations
Oral administration, available in immediate release, sustained release and once-daily doses. IR and SR are taken BID or TID. The absorption is slow and peaks approximately 2 hours after ingestion. Do not crush, chew or divide extended-release capsules.
Transdermal patch (Daytrana): patches are different concentrations, and typically prescribed with the lowest concentration first. Apply on the hip and remove 9 hours later. Alternate hips each day. Following application, blood levels slowly rise and peak in 9 hours, which at this point the client removes the patch. Side effects are the same as oral formulations, with two exceptions. Erythema and pruritic at the site, and hypersensitivity reaction. If a hypersensitivity reaction occurs, then any methylphenidate product can never be used again (Rosenjack Burchum & Rosenthal, 2019; Verghese, Patel & Abdijadid, 2024).
Assessment and Monitoring:
- Blood pressure and heart rate at initial meeting and each visit.
- Weight, and self-report of anorexia or weight loss
- Growth and height in children. If child outside of normal growth curve expectations, possible discontinuation of med.
- Assess for depression, agitation, suicidality
- Monitor for signs of misuse and dependence while in therapy.
Safe with children over the age of 6. Inconclusive reports for use during pregnancy or breastfeeding.
Caution with cardiac clients: avoid with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm arrhythmias, or coronary artery disease as sudden death can occur. Blood pressure and heart rate should be monitored in all clients.
Do not give if client has glaucoma, severe hypertension, motor tics, Tourette syndrome, or a family history of Tourette syndrome or if a client has notable anxiety or agitation.
Drug Interactions
- contraindicated in clients using a monoamine oxidase inhibitor (MAOI), or use of an MAOI within the preceding 14 days.
- Additionally, a patient who is concurrently on warfarin, phenytoin, tricyclic antidepressants, or selective serotonin reuptake inhibitors should have their drug levels monitored and adjust doses as needed.
Side/Adverse Effects
The most common side effects include insomnia, headache, nervousness, weight loss and anorexia.
- CNS (dizziness, headache, tics, restlessness/akathisia),
- GI: nausea/vomiting, dry mouth, decreased appetite, weight loss, abdominal pain
- CV: tachycardia, palpitations, hypertension
- Growth retardation (reduced height, weight, and bone marrow density) is observed when prescribed to children long-term.
- Integ: excess sweating, digit ulcerations
- Decreased libido
Most side effects can be minimized with dose adjustments.
Adverse Effects:
- Serious cardiovascular events have occurred, with sudden death reported in association with CNS-stimulant treatment in pediatric clients with structural cardiac abnormalities or other serious heart problems. Sudden death, stroke, and myocardial infarction have also been reported in adults with CNS-stimulant treatment at recommended doses.
- May cause psychotic or manic symptoms in clients with no prior history
- Priapism (painful or prolonged penile erections). This is a medical emergency that requires immediate attention.
- Increases the risk of peripheral vasculopathy, such as Raynaud’s phenomenon, with signs and symptoms of fingers or toes feeling numb, cool, painful, and/or changing color from pale, to blue, to red.
Client Teaching
There are several important topics to address with clients and/or parents of minor children who will be taking Methylphenidate.
- Misuse and Dependence: Advise clients that methylphenidate is a controlled substance, and it can be misused and lead to dependence.
- Do not give methylphenidate to anyone else.
- Store methylphenidate in a safe, preferably locked, place to prevent misuse.
- Comply with laws and regulations on drug disposal. Advise clients to dispose of remaining, unused, or expired methylphenidate through a medicine take-back program if available.
- Serious Cardiovascular Risks: Advise clients that there is a serious potential cardiovascular risk, including sudden death, myocardial infarction, stroke, and hypertension. Instruct clients to contact a healthcare provider immediately if they develop symptoms such as exertional chest pain or unexplained syncope.
- Blood Pressure and Heart Rate Increases: potential increased blood pressure and heart rate with extended-release capsules. Monitor pulse and BP periodically.
- Psychiatric Risks: May cause psychotic or manic symptoms, even in clients without prior history of psychotic symptoms or mania.
- Priapism: Advise clients of the possibility of painful or prolonged penile erections and to seek immediate medical attention if this occurs.
- Circulation Problems in Fingers and Toes: Instruct clients beginning treatment with methylphenidate about the risk of peripheral vasculopathy and associated signs and symptoms: fingers or toes may feel numb, cool, painful, and/or may change color from pale, to blue, to red. Report to your prescriber any new numbness, pain, skin color change, or sensitivity to temperature in fingers or toes or any signs of unexplained wounds appearing on fingers or toes.
- Suppression of Growth: Advise parents that methylphenidate may cause slowing of growth and weight loss.
- Alcohol Effect: Advise clients to avoid alcohol while taking extended-release capsules as it can cause a rapid release of the drug.
Methylphenidate Medication Card
Now let’s take a closer look at the medication card for methylphenidate (Rosenjack Burchum & Rosenthal, 2019;Verghese, Patel & Abdijadid, 2024). Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication.
Downloadable file (.docx): Methylphenidate Medication Card CH5.5
To support your learning, you can access the Chapter 5 CNS Mood and Cognition Medication Cards. This is a downloadable and editable document to allow you to update and add content.
Clinical Reasoning and Decision-Making Activity 5.5
A 12-year-old male child has been diagnosed with ADHD after his parents and teachers became concerned with his inability to concentrate and his poor impulse control in the classroom. The physician has prescribed methylphenidate.
What topics should the nurse reinforce while educating the child and his parents about this medication?
Note: Answers to the Clinical Reasoning Activities and Critical Thinking questions can be found in the “Answer Key” sections at the end of the book.
References:
- DrugBank (2026). Methylphenidate. Methylphenidate: Uses, Interactions, Mechanism of Action | DrugBank
- Farzam, K., Faizy, R. & Saadabadi, A. (2023). CNS stimulants. National Library of Medicine. Stimulants – StatPearls – NCBI Bookshelf
- Rosenjack Burchum, J., & Rosenthal, L. (2019). Lehne’s pharmacology for nursing care (10th ed.). Elsevier: Canada
- Verghese, C., Patel, P., & Abdijadid, S. (2024). Methylphenidate. National Library of Medicine. Methylphenidate – StatPearls – NCBI Bookshelf
