stimulants like amphetamines and methylphenidate and is said to have fewer side effects than them. Liver toxicity Rarely, pemoline is implicated in causing hepatotoxicity. Because of this, the FDA recommended that regular liver tests be performed in those treated with it. Since being introduced, it has been linked with at least 21 cases of liver failure, of which 13 resulted in liver replacement or death. Approximately 1–2% of patients taking the drug show elevated levels of liver transaminase enzymes, a marker for liver toxicity, though serious cases are rare. Over 200,000 children with ADHD were prescribed pemoline in the United States and Canada alone during the approximate 25 years that it was available, plus a smaller number of adults prescribed it for other indications (and not including prescriptions in the rest of the world). As such, the number of liver failure cases was statistically not that large. However the reactions proved idiosyncratic and unpredictable, with patients sometimes taking the drug with no issue for months or even years, before suddenly developing severe liver toxicity. There was no clear exposure–toxicity relationship, and no characteristic liver pathology findings. Some patients showed as little as one week between first appearance of jaundice and complete liver failure, and some of the patients that developed liver failure had not showed elevated liver transaminase levels when tested previously. On the other hand, there are no cases of liver failure associated with pemoline in Japan, although it is used at lower doses and is only prescribed for the niche indication of narcolepsy in this country. Overdose Overdose of pemoline may present with choreoathetosis symptoms. Interactions Other stimulants and monoamine oxidase inhibitors are contraindicated with pemoline. Pharmacology Pharmacodynamics The pharmacodynamics of pemoline are poorly understood and its precise mechanism of action hasn't been definitively determined. However, pemoline has similar activity and effects to those of other psychostimulants, and in animals the medication appears to act as a dopamine reuptake inhibitor and releasing agent. By increasing dopamine levels in the brain, it functions as an indirect agonist of dopamine receptors. In contrast to most other stimulants, pemoline appears to produce no significant central or peripheral noradrenergic effects. As a result, it has minimal or no cardiovascular or sympathomimetic effects. Pemoline is described as a selective dopamine reuptake inhibitor that only weakly stimulates dopamine release. While drugs like dextroamphetamine and methylphenidate are classified as schedule II and have considerable misuse