Problems with ADD: Stimulants2

Correct dosing strategies: now two additional sides of the therapeutic box – from titration using duration of effectiveness with stimulants on a daily basis [those two sides], to adjusting the dose [titration] over time.

These two additional problems we often find overlooked with titration: the top and the bottom of the therapeutic window: for more predictable results.

Now we have four sides to the box: AM and PM two sides, too much and too little. AM to PM because the half life is less than 24 hrs [the DOE in the previous post].  If they take the stimulant it can work from 7AM to 4PM, the total duration is 9 hr DOE: 9

So just what are we talking about with the other sides, the top and bottom of this imaginary box?

Once you see this box you can use it everyday with your patients, your family, and finding the right dosage makes more sense.

The top of the box: the real boundary of too much meds, the bottom: real boundary of this just isn't working at all.

All this stimulant dosage stuff can come down to these two clinical activities, these two effects, these four sides, four box measurements.

1. Too short or too long in duration during the day
2. Too much or too little all day.

So we know what not enough on the bottom of the window looks like: nothing happens. Nothing. That's easy, we all know when that happens. Basic.

But the tough one to measure, the one that is a serious problem with dosage of stimulant meds: when it's too much. There are two ways to see if the stimulant meds are too much.

1. They are lasting more than 12 hr in the DOE. -Not always true, nothing is categorical, but often if they last more than 12 hr in an expected 10-12 hr DOE they are on too much. Back off.
2. And they are out the top of the window –with Ritalin family (Concerta, Ritalin LA,  Metadate, Focalin, Methylphenidate) products appear stoned and out of it, overdosed –with Amphetamines (Adderall, Dexedrine, Mixed Amphetamine Salts) jittery, jumpy, overfocused and mercurial.

Often when they are on too much they become moody, can't eat, can't sleep, and yet may have moments when they are really much better. They have moments of focus and clarity. But mostly they are emotionally very cranky, can become suicidally depressed if they had a depression. Labile is the word.

A big problem with the top: Some think it is the bottom and add more meds…. Big problem.

More next post: how many then jump to the bipolar diagnosis: correctly and incorrectly.