- To Change Your Mind - Details Matter
Vyvanse Dosing for ADHD: Finding the Safe Top of the Window
ADHD: Vyvanse – The Therapeutic Window Mystery
June 11, 2009Vyvanse for ADHD: The Complete Story on CorePsych Radio
June 18, 2009
- ADHD Medications: The Frustration of Ultrarapid Metabolizers
Vyvanse Dosing and Ultrarapid Metabolizers: Titration Matters With Vyvanse.
Cookie cutter medicine in psych treatment is on its way out folks – from SPECT reports to simply adjusting the dosage of ADHD medications in the office, the public knows, as do many of the informed docs, that one size, one label, one basal ganglia platitude, one description of one mood, does not fit all. – And using only one dosing strategy for ADHD medications doesn't cut it for most people. Biomedical details matter. Metabolism matters.
Functional complexity is the reason we are missing the treatment boat so often. The brain and body too often are not in the medication picture.
Each person deserves a customized approach that will individualize their care. So much of psych medicine now is throwing psychiatric medication at a superficial diagnosis, or even a cookie cutter SPECT report without understanding the patient. Remember SPECT, while helpful, is not directly representative of cellular physiology – it's a sophisticated biomarker, and often doesn't compute with current DSM4 codes, as brain function is almost completely ignored in the current code book.
Questions Abound For ADHD Medications
This brief ADHD medication question and comment on a recent post deserves more attention due to the prevalence of the questions regarding customizing the upper dosage of Vyvanse [video here at CorePsych]- and the science behind why finding the best dose may not be that easy with some.
Vyvanse Dosing Question from Daisy:
The first week on Vyvanse, everything was so clear and seemed so right, it’s hard to explain, but my brain was with me all the time. I wasn’t off daydreaming. I had never felt that good, but then it went away after a week. So, we raised the dose, but that never seemed to work again. I’m on 70 mg, I was on 30 mg that first week, so I assumed when it stopped working it was because I needed to work my way up to the appropriate dose. So, we worked up, I think there was only one or two steps in between, up to 70mg where, I am now. My dr stopped, because he says this is the highest dose, and my symptoms are just as bad as they are off the medication.
This is my 4th medicine change, I was on this first, when we got up to 70 mg, with no noticeable improvement, he took me off of this and tried, that barrel shaped one, that can’t be crushed, I can’t remember the name off-hand. That didn’t make me feel any better, then we tried Adderall XR and again no change. At this point he said those were my only options and to give up at this point, so I asked to go back on Vyvanse, and I tell him it works OK, so he doesn’t take me off of it and leave me with nothing, as he was going to do before and I thought I could play with the dosing on my own, to see if I can get it to work again. I want that week back, that week of feeling clear headed and coherent. Of knowing what was going on around me and understanding people when they talk to me.
The Problem of Ultrarapid Metabolism – My Answer
Without a few more details this sounds at first like you were right: a good example of too much too fast – too rapid a titration, not leaving about 1-2 weeks near the top dose before increasing to the next, and, as you point out, no appropriate slow steps in between. With adults I rarely go faster than 10 mg increase every 1-2 weeks, watching carefully for that expected 2 hr increase in DOE in the PM with that carefully adjusted dose – and I fully admit I am very conservative. The only problem with that process in my office is the patient’s becoming impatient, as I rarely create a drug excess with that protocol.
Many docs feel the same way yours does, as they stay only with the package insert. He is simply following the ‘insert rules’ as Vyvanse is a controlled product, and just as I have almost no experience writing for antibiotics – and simply won’t write for them – he is simply doing a good job following guidelines.
My possible contribution to this conundrum is a mix of common sense and experience over the time that Vyvanse has been out – with a dose of clear science about the CYP 450 genetic polymorphisms of 2D6 [see the many posts here – just type 2D6 into SEARCH].
1. Common sense: Adults already often go over 30 mg Adderall XR [roughly = 70 mg Vyvanse] regularly – and can be titrated based upon watching carefully for the DOE as outlined in this post. If your medical person goes very slowly they will not have a problem, and I don’t recommend that you ‘play with the dose’ – even tho your doc may not be working with you at this moment – do stay tuned with your medical team with your actions, or you very likely will loose [justifiably so] their medical support.
2. Experience: I do go up past 70 mg in dose at times, and have heard whilst in CA last week that some have not only gone up to 400mg, but have recommended simply ‘going to the top’ without careful titration, a practice I completely dismiss as dangerous. I always steer completely away from an answer to the question of ‘just what is your top dose?’ because that discussion drives practitioners away from the essential practice of careful titration into cookie cutter medicine – a point with which I am completely philosophically at odds… don’t get me started!
3. The genetics: about 1.5% of folks are 2D6 [the AMP pathway] ultrarapid metabolizers [UMs] as reported in many books such as Drug Interactions in Clinical Practice leaving practitioners with a challenging few that just can't correct their ADHD on average doses, as they burn up the effectiveness just too fast. These individuals are often unhappy and disappointed, often with long unsuccessful trials of meds. For these folks only someone completely comfortable with those higher [notice I didn't say ‘highest'] doses of medications [using the predictable, careful titration strategies outlined in multiple posts here at CorePsych and at http://www.squidoo.com/vyvanse is recommended.
Vyvanse Dosing Best bet: talk these issues over with your doc, and see if he is comfortable with a little increase – if not perhaps they can suggest someone more experienced in your community to walk carefully down that path with you. Do shoot for the 12 hr duration [DOE] as noted frequently in these blog posts. [Video on Vyvanse and DOE}
Interesting and common problem – just talked to some of the docs in CA last week about this very issue – thanks for sharing it with our readers.
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Vyvanse Dosing: Therapeutic Window Video – 3:22 min
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I hope these details encourage improved accuracy!
cp
Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
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59 Comments
Dr. Parker– I contacted you once before. Gastric bypass 15 years ago. I am prescribed 70 mg of Vyvanse. Also, I am taking 75 mg of bupropin (Wellbutron) without any real relief. The duration of the medication is a short window. I have not asked my doctor to suggest perhaps adding a medication such as Adderall (immediate release) because he will think I am drug seeking. He seems utterly incapable of understanding that providing extended release medication has little effect. I do not know what I can do. Without insurance I have few options. Would taking Vyvanse with peanut butter for example increase duration of the Vyvanse making it efficacious? It has gotten to the point where I am abusing the Vyvanse and spend times in what feels like despair. I read on ADHD forums of many gastric bypass patients using Vyvanse with small (20 mg) doses of Adderall) to augment the short duration time of the Vyvanse. Is this unreasonable? I appreciate any advice. Your website has been truly helpful. You are a considerate man and the type of insightful and understanding physician so few are these days.
Larry – Thanks for your kind remarks.
1. You need to change physicians for your stimulant adjustment process. Many untrained docs simply don’t get it, and with the NYTimes streaming counterproductive, hysterical trash on a regular basis physicians see the politics moving against them, and lawsuits increasingly possible. The middle ground is increasingly hard to find even if you know what you’re doing. Recommendation: Search for a psychiatrist with ADHD understanding and interest.
2. If you are limited in doc choices and your doc is worried about possible addiction perhaps they will go to Vyvanse 2x/day?
3. Ask your doc to look at my vids – these especially: On DOE – http://corepsych.com/doe | On PM Drop – http://corepsych.com/drop | On Dosage – http://corepsych.com/basic-3
cp
Larry – PS: You absolutely need biomedical testing or else you will be chasing your metabolic tail around the woods for years to come. You don’t have to use my services, you just have to get it done – test links on this PDF: http://corepsych.com/tests14 – Especially recommended the top three: Walsh, OATS, IgG with IgG being the most important first investment.
cp
[…] Vyvanse And Therapeutic Window […]
Dr. Charles Parker,
My name is Joe Moslemian and I am a twenty-one-year-old male. I was driven to seek testing for ADHD due to my lack of performance at my university last year because of my inability to focus, start tasks, finish tasks, block out even the slightest sounds, and my constant inability to sit still or shut my brain off (to name a few reasons I can think of off the top of my head right now). Throughout high school and my freshman year of college at a community college I managed to get by with slightly above average grades. However, after coming to a university I began to struggle with school like never before.
My grades were still slightly above average, but achieving this took drastically more effort and time than I had ever had to put in before. While this is expected at a university, the effort, time, and frustration involved with struggling to focus became unreasonable; I knew that I was capable of achieving much more and the frustration of not meeting my potential only further interfered with my ability to focus.
At first I began to feel a little depressed due to my under-performance because I started thinking that I would not be able to succeed and I felt as though I was falling behind. This initialized a domino effect because feeling depressed only further inhibited my ability to concentrate and my motivation to get things done, or even start them, which negatively affected my performance at school; the more I struggled at school, the more depressed I became.
After years of suspecting that I had ADHD and trying to avoid seeking help because I am a very stubborn person and I felt that seeking help was weak, I finally decided to get tested for the condition. After half a dozen appointments and hours of extensive testing with a psychologist through my university, I received confirmation that I do in fact have inattentive ADHD.
My psychologist told me that it is not uncommon for people that get diagnosed with ADHD later in life to be of the inattentive type because they are not distracting to anyone but themselves so while I was younger others didn’t pick up on it (for example, teachers in grade school); she also said the same thing about people with a high IQ because they can compensate for their ADHD with intelligence (after taking an official IQ test with her my results placed me in the 94th percentile). I personally feel as though IQ tests need to be taken with a grain of salt because everyone’s brains operate differently and it seems impossible to standardize a test for intelligence. That being said, even though I am not the most confident person, I know that I am highly intelligent and the frustration of not meeting my potential only further interfered with my ability to focus.
After receiving my results I went to a doctor through the university. After talking with him he became convinced that my depression was causing my ADHD symptoms and he refused to prescribe me a medication that adequately addressed ADHD and prescribed me Zoloft, insisting that treating my depression would alleviate my symptoms. Reluctantly I decided to give it a shot but after a few days I developed a rash and after reading online that it could be a serious side effect I stopped taking the medicine and gave up seeking ADHD medication.
As time went by I continued to become more and more depressed and after turning twenty-one I found that drinking calmed my brain down immensely and I honestly felt like I could concentrate better with a few drink than when I was sober. I soon after, in my mind, became dependent on alcohol which only made everything even worse. Finally, I couldn’t take it anymore and I went back to see my doctor through the university and again he insisted on treating me for depression. At times it seemed as if he was trying to convince me how I felt rather than listen to me. What he failed, or simply refused, to understand was that my depression was secondary, caused by my ADHD. Once again, thinking that maybe I was wrong because he’s the doctor and I’m just a college student, I reluctantly tried another antidepressant. After about a few weeks I felt better, but I still had all of the same ADHD problems – I wasn’t surprised.
Fed up, I decided to seek a help outside of my university because it seemed like my doctor was basically instructed by the university not to give out stimulants no matter what. I understand the reasoning behind that with students abusing drugs, but it makes life a lot harder for people that actually need such medication. After showing my new doctor my diagnosis and discussing all my symptoms with him and taking a test with him he wrote me a prescription for 30mg of Vyvanse four days ago.
On the first day I felt it the most. I focused better, didn’t procrastinate, and I honestly felt better than I can ever remember. Not only were my symptoms a little better, but I felt as if a huge weight had been lifted off my shoulders because instead of feeling hopeless after failing to receive proper help for ADHD for over eight months, I finally felt hopeful again, and I still do now. Although the symptoms were not fixed as much as I would have like them to be, it was an improvement. However, after day one the pill has not seemed to help me focus much. I do still feel positive and significantly better emotionally and mentally, and I do have a much easier time getting tasks started, I just don’t feel as if my concentration is much better, if at all, anymore and my brain still seems to be in a million places. Side effects have been almost nonexistent; I only have noticed a slight pain in my chest from time to time as if there is slight pressure on it.
I think that I need a stronger dose, and I thought so from the beginning because I knew I have a high metabolism and tolerance to things in general, but my doctor said to start on 30mg until I see him again on the fourth of September, which I am okay with me because I want to do this the right way and I trust my new doctor. Given that I won’t see my doctor in more than another week and that the medication definitely seems to be at too low of a dose I decided to search Google to find out how to find the right dosage and I came to your page. You seem very intelligent and like you know a great amount about stimulant medications and ADHD and that is why I am writing you.
Your video was helpful for advice on how to find the correct dose, but just to make sure I have a good understanding I would like to know where you think I should go from here. I feel as though 30mg is far below what I need and that a 10mg increase won’t be enough, but at the same time I also don’t know how much a 10mg increase can help, and that is where your knowledge will be very helpful. Do you think that it would be wise to increase more than 10mg? If so, how much more? Also, based on everything I have shared with you, do you believe that out of all the stimulant options, Vyvanse is the best place to start? Finally, about the slight chest pain every now and then that I mentioned, do you know if that is normal and whether or not it is something that is typically prevalent when someone first starts but then subsides as the body becomes used to the medication? Any information and help that you could send my way would be much appreciated. I would like to go to my next appointment with a second opinion in my back pocket so that I can make the best decision possible.
Thank you,
Joe Moslemian
Joe,
When anyone with ADHD treatment training personally witnesses the suffering you’ve experienced with those who don’t know about this condition the temptation is definitely there to offer specific treatment suggestions. However, even with your considerable notes it’s not reasonable for me to offer you a “second opinion” for you personally, but I can confirm guidelines that do work for most. I hope these are helpful – are all outlined in far more detail in my book at: http://adhdmedicationrules.com
1. Untreated depression can create significant challenges with ADHD. Watch for the PM drop phenomenon in this playlist to help confirm comorbid depression and anxiety: http://corepsych.com/drop
2. Get firm in your mind your Duration of Effectiveness [DOE] as no matter the dose that DOE will help an informed doc get your dose right: http://corepsych.com/doe
3. With Vyvanse recognition of DOE take awhile because your target [“hyperactive” and “inattentive”] are often too vague and imprecise for the best understanding. Look within yourself [metacognition] for when your brain function diminishes in this ADHD Meds Tutorial: http://bit.ly/medtutr
4. Share these videos with your doc so he can understand these issues and you both can communicate more effectively.
Two additional 1.5 hour video webinar/interviews will help on Why these problems and How to address them recorded at TotallyADD – and another live program at 6 EST Wed Oct 29 – for this last in a series on exactly What To Do for Treatment Failure.
1. Why Use Precision With ADHD: http://corepsych.com/totallyadd-why-video
2. How To Apply Neuroscience Principles: http://www.corepsych.com/totallyadd-how-video
3. What To Do For ADHD Treatment Failure: To Register – Here Oct 29, Wed: http://corepsych.com/totallyadd, now available at: http://corepsych.com/totallyadd-what-video
Your dosage activities will become more clear as you progress. It will often take some time to actually live with and recognize your personal objectives.
Hope this helps,
cp
See the updated link on the TotallyADD What Video in the comment above, just added.
cp
[…] Polymorphisms of CYP450 2D6 make that interaction more unpredictable – and deniable. […]
Hey I’ve just started 40mg vyvanse it doesn’t feel like I’m getting more focused like I can feel it a little but nothing for anything really important. I’ve always had low energy along with lack of focus and was wondering if the improvement in energy is because I had so low to begin with. Like I was legally disabled so like I could barely move and I guess if forgot what its like to live. I also have a very high metabolism like I’m one of those twiggy Asian guys who can eat 4000+ cal a month and not gain weight, I tried it not fun. I was wondering if that can affect how long it lasts because in the afternoon I feel nothing but energy feels like my focus is back to unmedicated but I still have more energy than when not medicated. Thanks for your time
andrew
Andrew,
It matters not if you’re either on the thin or fat side – either end quite often heralds a metabolic problem. Your brief discussion here hints at that problem with tiredness and hopes that the stim meds will give you energy. See the energy drop in the PM here: #6 http://youtu.be/q79GS1X4U1U
You have two different issues: Focus and Energy. They are often related, but often do not arise from the same source therefore treatment w stimulants misses the other metabolic, adrenal source.
Even better take a look at the entire playlist to get the picture: http://www.corepsych.com/stimulantdropinfo
Best,
cp
Thanks again for your responses. im caurious as to why my pain goes away, but the mental effects don’t stay. interestingly today, and yesterday, I took a spoon full off peanutbutter before taking my Adderall ir, and the mental effect lasted longer, I guess cause the peantubuter kept the meds in my system longer.
thanks again for your help and how can I get consultaion from you.
-Russ
Thanks Russ,
Detail for everything to connect: http://corepsych.com/services
Talk soon,
cp
Dr Parker,
I am 42 and recently diagnosed with inattentive add.
I started out with welbutrin, and it immediately made me angry, stopped taking it after 2 days, was then switched to Adderall ir, currently 30mg in morning 9am, then 15mg noon and 15mg at 3 pm.
basically I feel like i’m on a roller coaster all day of Adderall helping then not then helping then not and various side effects some times not remembering and not retaining what I have just read or done. basically very inconsistent. Seems like positive effect of medicine only last about an hour, regarless of dosage, when meds wear off I get a lot of anxiety,i may get maybe and hour of effective time per taking my doses. I had gastric by pass surgery nine years ago, could the gastric by pass surgery be affecting my absorption
of my medication?
Thank You
Russ
Russ,
A very big YES to that one. – And quite likely, seen with remarkable frequency in our offices, food sensitivity preceded the obesity issue – it simply remains – yet to be addressed.
Best!
cp
I had Roux-En-Y Gastric Bypass type surgery. I have inattentive adhd (lots of procrastination, thinking not acting,and very distracted by sounds).
so what would be a good med for me that wouldn’t absorb so quickly, would Vyvanse be better? I have had glimpses of hope with Adderall ir, but this daily roller coaster is becoming too much to bare, all I wanted was clarity and focus.
Thanks,
Russ
Russ,
Don’t worry about the absorption on Vyvanse w bypass, we never see it as a problem clinically – nor do we see the oft cautioned problems with Effexor XR and other time release meds. I understand the concerns, just don’t see those problems with careful dosing and respect for slowed metabolic rates so often seen w bypass.
cp
Thank you Dr Parker,
Just to clarify are you saying I should be ok taking Vyvanse instead of Adderall ir? I have relly come to the conclusion that the Adderall ir if im lucky is lasting as far as the mental effects for not more than an hour, and after that hour I get very unfocused, start to for get things and have trouble staying on any one task for mor than a few moments, and find it difficult to complete any tascks, and anxiety then kicks in because im not getting done what I need to get done. but the physical plusses of Adderall seem to stay in my system all day, it wakes me up out of my sleep tirednedss feeling with in 15 minutes of taking it, and I wont feel sleppy or tired all day, and I use to have pain in my legss all day, that pain now stays away all day despite the mental effecs roller coastering. i’m having a reall hard time having clear enough thoughts to type this out right now (only and hour and a half after taking my last dose of 15mg Adderall).
your book is very good by the way, but I wish you had it in audio format, being add and all.
thanks,
Russ
Thanks Russ,
Audio format coming out this fall, if all things come together as I expect.
You, unfortunately, are, from the limited perspective of these few sentences, suffering w the condition many have w stim meds post bypass: metabolic challenges and very likely associated neurotransmitter imbalances following malabsorption, secondary to chronic immune challenges for years. Without examining you, without looking at your lab work, it’s only speculation. But the reason to speculate is clear: if I’m right it’s correctable, and you can fix your Therapeutic Window, and improve your response to stim meds.
I am clearly not making a specific recommendation on which med. As I’ve often said: Vyvanse is my favorite for many reasons, but because it’s my favorite doesn’t bring it up to the level that I can make a recommendation to anyone without an evaluation. That would go over into the category of nonsense.
Your pain syndrome seals the deal on the strong likelihood of an underlying metabolic condition – we see odd pain syndromes often in chronic inflammatory conditions.
cp
I am 36 years old, and I’ve been diagnosed with depression and ADD at age 15. I’ve taken several medications for the aforementioned issues. I am currently taking 225 mg of wellbutrin and 90 mg of Adderall xr. I have built tolerance I believe to the Adderall and it stopped working at that dose. I have tried several psychiatrists to help me address this issue to no avail. I have tried other medications for add but this one is the one that my body adjusts to better. Unfortunately, as you know this dose is high , and I haven’t had any luck getting a doctor who could increase a bit or give me another solution. I am also on ambien 15 mg. Am I asking for something is not plausible that is a higher dose than 90 mg of adderall. This is frustrating , I feel handicapped.
David,
Without knowing you at all I’m going to float a theory, not based on specific facts, but based upon my extensive experience in these matters. The most likely issue: not that you are on too little, but that you are on too much. If you feel that it doesn’t work now for about 2-3 hrs, has a stiff, good window for 3-4 hr around noon and then drops off again that is most likely the problem = out the top, not the bottom. This problem is spelled out in my book in considerable detail and in this specific Out The Top Of The Window article: http://ezinearticles.com/?ADD-ADHD-Medication-Treatment—7-Tips-to-Find-the-Most-Challenging-Pattern-of-Inadequate-Dosage&id=1685104
cp
Thanks for your reply Dr. Parker.
I have tried that that is taking breaks of time between doses. The problem is that I can’t take the last dose that late because it will give me insomnia.
David
David,
No, I never recommend a break, but rather superimpose it to prevent excessive duration, or lower the dose w your doc.
cp
Dear Dr. Parker,
I am 28, current BMI 18.3, diagnosed with ADHD (with a capital H) when i was a teenager. I have been on Ritalin, 5 mg every 4 hrs (great grades, got into a great university, but Ritalin made me increasingly anxious (on ANY dose) then Stattera (did nothing) than DL-amphetamin (a comparable low dose, just as the ritalin) which was fine for work, but increased my anxiety and made me lethargic with a tendency for procastination in the long run. after a longer medication break i have just started vyvanse, because my social anxiety got too much and i need to get things done otherwise my life will fall apart. We are using water titration to find the right dose, after 30 mg i was “spaced out” and too relaxed, i was almost “paralysed” – procrastination galore, but i could not sleep(but at least i was not anxious!!!)and it lasted for 16 hrs. I am a normal healthy person – but could it be that 10 mg are enough? and 15 are too much already? my doctor says the 10 mg dose might be too low to really work and its just a placebo effect… but i felt best on 10 mg…(DOE around 12 hrs)
Thank you very much in advance!
Best regards
Lucy,
No matter how healthy you are two issues:
1. You either have a genetic 2D6 pipeline challenge with too narrow a path [~7% of the Caucasian population] causing backup and need for smaller dosage, or
2. You have a metabolic challenge even tho you appear healthy. See this YouTube video playlist to clarify possible problems with ADHD, immunity, gut, and brain which very frequently compromise metabolic rates.
I disagree w your doc and agree w you. Dosage always must be determined by patient experience not independent medical expectations. Expectations are helpful, but not the reality.
As my mentor, from Science and Sanity, Alfred Korzybski always said: The map is not the territory.
cp
thank you so much dr parker! although i burn calories (esp sugar) like mad (i eat more than my boyfriend, but i am a lot thinner and fitter) the metabolic challenge of some sort must be the case. Although i am fine with glutein (had that tested just to be sure).
I took 15 mg Vyvanse y-day and i had problems sleeping (max 4hrs) took another 15 this morning and i was irritable, over emotional but did not get ANYTHING done at work…
I’ll am very tired now (BST, I’m in the Uk) and will hopefully get some sleep and start with the 10 mg tomorrow. Keep your fingers x’d for me, as i have the suspicion vyvanse could be “the one”
Ps: ordered your book on amazon! I think you are doing great much needed work in the ADHD field!
Lucy,
Vyvanse is most likely to work, but, quite honestly, I expect that you will prove refractory to any stimulant, because it’s likely that you have some IgG problem and that it simply has not been successfully identified. In my office the order of frequency is 1. milk/casein 2. eggs, 3. and gluten is a slow third. IgG testing hard to find in the UK, but worth the chase. Discover and fix that one and you’ll be moving on down the road.
cp
Dr. Parker,
I have been taking vvanse for about 4 months. Initially it helped immensely with my focus and it still does. I have Hashimoto’s thyroiditis and take Armour Thyroid for that and am on Zoloft. In the last 4 weeks, i have been unable to sleep and I have developed drop foot. I have a lot of stress in my life, but I am wondering if A. the drop foot could be a result of the Vyvanse, my Dr. does not think so. The sleeplessness was not a problem when i first started and i am trying everything. My Dr. told me to try Kavinace Ultra Pm. It seemed to work for the first night, but now I am back to not sleeping. I take 40 mg of Vyvanse in the morning. I started with 70 but was bouncing of the walls.
So, I guess I am asking what to do about the sleep and the if Vyvanse could be the problem with the numbness in my leg and foot.
Thanks so much for you answer in advance!
Shannon,
Two perspectives:
1. First Dosage assessment [you could still be on too much]. Continue to assess with your doc that DOE. See this video playlist to get that straight if you need some help with that one:
http://www.youtube.com/playlist?list=PL321-bGRTfd9xcGzJtPGu6neFvnLVo2LO
2. Then review this video playlist on ADHD Gut and Mind, as with Hashimoto’s you very likely have gut issues, and they need careful, separate evaluation, measurement:
http://www.youtube.com/playlist?list=PL321-bGRTfd8aFE_AhB43UnsRTiYAo6me
Hope this helps,
cp
Cheryl,
Wellbutrin can block the pathway for Dex, only moderate, but if the person is s slow burner that moderate blockage of 2D6 could spell the difference. With the other symptoms is sounds much like you have an associated metabolic imbalance that would require further investigation in careful interview and history.
cp
Not a problem from anything in my experience or reading.
cp
I have a problem with the comment under point number 1- “or you very likely will loose [justifiably so] their medical support”. From what Daisy shared, she doesn’t HAVE medical support! Her doctor sounds like he thinks treating ADHD is optional. Would he treat other medical conditions the same way? The fact that she FEARS he may withdraw helping her with any meds tells me this doc is way over his head and shouldn’t be dabbling in this treatment. He is NOT justified in withdrawing his “support”. He should be asking himself why she feels it is necessary to take her treatment into her own hands in the first place- and then refer her to someone who is more exprienced in this area.
Cheryl,
Interesting problem indeed – seen every day in our offices. The societal problem of disdain for stimulants is so pervasive that the implication often arises that those with ADHD are closet addicts, and, following that line of non-science, anyone trying to help them get stimulants is acting as a perpetrator of evil, drug addiction and against the code of “do no harm.” Pretty crazy, but undeniably pervasive.
Parallel to that view is the simple problem of dis-ease with the meds period. Many have no clue about stimulant meds, fear societal or med board reprisals, and just want to keep their jobs.
I do agree with your doc in the sense that oftentimes if I don’t even know a little what to do with a med that’s not on my formulary. I also frequently don’t have specific referrals in mind in their specific locality. It’s a bind that does loop back to the patient to keep looking.
cp
On this Cheryl, and completely agree. I keep thinking we should have a certification course for ADHD med management, but don’t expect it in this lifetime…
cp
Colin,
I think, it’s late now, I answered this on another posting… bottom line, hang tough, get to the pharmacy the tide is turning!
cp
Star,
Right on the same track… the therapeutic window is alive and well in every med check with every practitioner in our offices. Look for 12 hr DOE no matter the dose, and watch the details at the end of the day cognitively to see when your dose burns out.
cp
[…] This post was mentioned on Twitter by Dr Charles Parker, Mungo. Mungo said: RT @drcharlesparker: #Vyvanse Dosage for ADHD: Finding the Safe Top of the Window http://t.co/UszkyE4 via @AddThis […]
AN UPDATE & A FEW QUESTIONS
(5 to be precise; although some include sub-questions. I counted them after writing this!)
1st question: is there a need to wean off of any of the stimulant meds before switching to a new one? Obviously I know that with the new, you start low and slow again. Does how slow depend on the stimulant?
Other questions are interspersed below…
(After writing all this, I just counted them — there are 4 more questions, basically one per section).
Update:
Per drs orders, I am now taking adderall w/o the vyvanse to be able to see more clearly its effects. Although initially I was opposed to this, I can definitely say that it is easier to see the differences! I had thought that the vyvanse plus 20 IR wasn’t making much of a difference (at least the morning dose), so when I took the 30 mg IR by itself I was expecting that it would be about right. Nope! It was way too much. I had not been tired before, and shortly after I was completely tired and unable to do anything at all! It was awful. I then slept and worked on not dwelling on my negative thoughts for the next 6 hours. After that, I felt normal for me again. Then I took 10 mg because I did not want to repeat! It also occurred to me that day that the adderall plus the vyvanse previously had likely been too much. Even though I didn’t think I’d noticed any changes, upon reflecting, I had been irritable all week. External events, that normally, although probably distracting would not be aggravating, were.
Onset for adderall has been about 25-30 minutes. It’s been 20 mg and I’ve felt good, but also able to concentrate, be less restless, and not have so many thoughts swirling in my mind. DOE has pretty much been exactly 4 hrs as far as I can tell, which I believe is within typical range? (I know you cite 6, but every where else I see 4 – why is that?)
Another question: that first night after taking the 10 mg (which did not have much benefit) leading into about the 5th hour, I was pretty tired. By the 6th hour I was fine. Why is that? Similarly on another day, the 20 mg second dose of the day, I felt tired for that first hour or so (which again is the 5th hour of the first dose and the onset of the second one). I’m confident that the aspect of up/down is part of these shorter acting stimulants, but what I don’t understand is why I feel tired when it’s coming off and then fine afterwards, even if I don’t take any more medicine (like in the evening). Then again, this regimen is pretty new.
On a side note, we would not be sticking with the IR as a general rule…it’s what I have currently filled and is serving as a sort of test before deciding to switch to XR I guess. Isn’t there one other amphetemine formulation besides Adderall and Vyvanse? I can’t recall off the top of my head.
Suppose I wind up taking 20 mg adderall IR 3 times a day (or 4 at the most depending on when I started it) and it works well….what would be the normal switch if going to adderall XR? Because 20 mg adderall 3x is 60 and 4 is 80, but I didn’t think XR came in those doses. Is that how it works or no?
I do have your book on adhd meds, thank goodness – that’s how I knew that the first 30 of adderall was too much and subsequently figured out the other problem too. But it doesn’t answer these questions, most of which seem to me to be pretty straightforward!
So my 5 questions (extracted from the paragraphs) are:
1) Is there a need to wean off of any of the stimulant meds before switching to a new one? Does how slow when starting a new one depend on the stimulant?
2) Typical DOE range for Adderall IR is 4-5 hrs? I know you cite 6, but every where else I see 4 – why is that?
3) Why was I tired roughly the 5th hour into the dose when I had not been previously? The 6th hour I was good.
4) Isn’t there one other amphetemine formulation besides Adderall and Vyvanse?
5) What’s the switch from Adderall IR to Adderall XR if someone is taking 20 mg IR 3 or 4 times daily?
Every now and then I want to completely give all this med stuff up because it’s frustrating and takes a while, but right when I’m about to do that, I see a glimpse of how things can be and so I just try again.
Thanks for your assistance asap. This website and the information is invaluable!
jm,
1. No
2. Adderall IR = 4-6 hr, dialed in carefully max is 6 for some.
3. Please, for your own sake, put the magnifying glass down on the table. Microscopic analysis can make you goo-goo. Look for patterns over time. Answer: Getting used to the med.
4. 80 IR = ~ 20 XR two times a day… no other long lasting formulation.
5. See 4. Each person is different, you and your doc will figure it out. You have now graduated to the ‘informed consumer’ crowd ;-).
cp
Thanks. I appreciated and smiled at your advice for #3 – I am very analytical with everything, and many times too much so; but sometimes it’s hard to know when I’m doing it too much and when it’s just being careful or precise. If it’s all I can think about, then I know it’s too much and I just do my best to change those thoughts!
I haven’t gotten to the xr yet, but the last few days on the adderall have been really good. Almost every objective has improved dramatically (the others I just haven’t had the opportunity to observe yet due to circumstances). Overall I’m even sleeping better. Which, I don’t know if that makes sense, but I’m definitely doing and feeling better rested in the mornings. It can be difficult to remember to take it each time, 4 times a day, but that’s the advantage of the xr…I just hope that if/when we go to that, I would have a similar response. Is the onset for adderall xr still about 25-30 minutes?
It’s been consistently good for this amount of time and that is just so new for me that I almost don’t want to believe it or get my hopes up. I’m waiting for it to just not have these benefits. I also haven’t had any side effects that I’m aware of. Sometimes I think it’s just that I slept better or wonder if it’s the placebo effect..but at the same time, I’ve tried before and not succeeded. Now I’m trying, and I am succeeding for the most part. I still have to work on the stuff though, of course! I wouldn’t want that differently. I’m almost want to know what would happen if I didn’t take it for a day or two or three to see what would happen — if my willpower and recent successes would keep me going and have the same effect.
It’s funny (odd, funny) that despite all this and despite everything I’ve read (which is a lot) about adhd, medications, therapy/coaching, et cetera I still have my doubts about the diagnosis for myself – not because I don’t want it though. I guess that doesn’t really matter, as long as I do what I can to function better. It’s nice to be able to function better.
I have to go….or I’ll be late! I just wanted to finish this real quick (gotta work on that!)
Thanks again for sharing your expertise!
Have a great day,
jm
jm,
Your diagnostic issues are not unlike thousand of other folks wondering about the current codes describing ADHD appearances unrelated to careful thinking about real brain function. I think you read my book on Medication Rules wherein I work hard to answer compelling diagnostic and treatment issues often overlooked.
cp
Dr. Parker,
I’m a 28 yr old female who’d thought about an evaluation for ADHD etc. for several years but never had actually followed through on it until a few months ago – mostly because I’ve always managed and been successful. But some relatives and others close to me told me to go to a psychiatrist. It took them 3-4 weeks of convincing me I should go before I even considered making an appointment. I did not go with the idea of being evaluated specifically for adhd though, said as little as I could about it, and answered the questions on as low of a scale as possible yet still being honest. I’m somewhat knowledgeable in the area and had debated this many times.
I own a copy of your e-book on adhd medication and have read it several times; I’ve also read/watched almost all of the information posted on your site.
I have some questions regarding the top of the window and effectiveness in general. I started with 30 mg Vyvanse, noticed a difference with project avoidance but not other differences. It took about an hour to an hour and a half to set in, from what I could tell. Increased dose weekly by 10 mg; all with no other changes. No side effects either during this time. I went to 70 mg and was physically and mentally less impulsive/hyperactive (most notably when I was really making an effort to do only one thing that was quiet & not involving the computer – thus able to focus better) with still less project avoidance. That lasted for at least 3-4 days, maybe as much as a full week and then went away. Time of onset stayed the same – roughly an hour to an hour and a half. DOE from time of taking it was 10 hours, sometimes 11.
Objectives I was looking for to change but still did not notice even with the 70 were: remembering what/how to say things, remembering where I put things, being able to stop doing something when I need to and have already reminded myself several times, being able to listen in conversations more easily, being less confused with overload of information or choosing what to do first (even when I already have a list broken into steps). If any of these are not specific enough objectives or reasonable to expect changes with medication, please tell me. There are other issues too, but I don’t know how to state them clearly.
I’m wondering about the top of the window because I had read in one of your comments to someone else that the long onset could indicate that they were on too much. Is that only true if onset changes as you increase?
I’m also wondering again about the top of the window (or basically just getting it right) because now what I am taking is: 70 mg vyvanse and 20 mg adderall ir together in the morning, and another 20 mg adderall in the afternoon. This is very new to me; I didn’t notice any drop off with the adderall and I’m not sure about the onset. I’m supposed to take it in the afternoon, but haven’t yet because I’d gotten sick and was trying to rest up that afternoon. The next day I was trying to sleep all day and drink water so I didn’t take either…but normally, I would stick to what the dr says.
I have yet to be on this regimen (70 mg vyvanse + 20 mg adderall 2x) for any length of time, but should I expect to see those other changes with my objectives? Should I just do exactly this regimen for a week or so to see and then maybe change? I was thinking to do 10 mg adderall 2x instead of 20 at first, or 20 mg in am with vyvanse and only 10 in afternoon…I just don’t want to be on too much. With taking the adderall, would I maybe need less of the vyvanse? I keep thinking of all these possibilities and I’ m not sure what I should actually do. I’m making careful notes about when I take these medicines, other medicines I’m taking (i.e. antibiotic for being sick), breakfast, and notice of symptoms as best I can. I was glad to not have to switch from vyvanse all together, because it was helping in at least one regard and I had no negative side effects. I just want to be sure about not doing too much and basically knowing when I’ve found what’s right.
Two other quick questions — how long for onset with adderall ir typically? And, can I use that typical time or should I add to it since I was longer with vyvanse? I know DOE for adderall ranges from 4-6 hours. As far as the necessity of a protein breakfast: I do make sure I get it and I’ve been taking the medicine right along with it or shortly after I’ve started eating, but I was wondering how much protein is enough? Some of the things I’ve done include: 1-2 C. reg. oatmeal with 1/4 to 1/2 C peanut butter mixed in and a little honey (I’ll usually eat half and save the rest for the next day), a cereal w/ @ least 2-3 g protein per serving plus either spoonful of peanut butter or handful of nuts both with milk, one day I didn’t have anything so I just ate a half piece of chicken breast.
I’m thinking about maybe waking up earlier than I need to, having an easy protein thing – like a shake, taking the adderall, and going back to bed for a bit. Then when I actually get up, get ready, eat something (either w/ or w/o much protein), and take the vyvanse on my way to work or right before I leave. The mornings have always been so hard for me (at least since adolescence)- even when I get enough sleep I rarely feel rested. When I do feel rested, it can still be hard! I have always been one of those people who really needs sleep (childhood and on) and a lot of it. If I’m healthy (no cold/other illness), exercising, and eating…9 hours is what I aim for, although 8 is just fine. 7 or less I can manage for a few days at a time, but then I really struggle with everything a lot more. Anything less than 6, I’m miserable later in the day or I get sick.
Anyways, I got sidetracked. If you can let me know about the objectives, the vyvanse and adderall, and how much protein is enough I would really appreciate it. Thanks so much!!
Jm,
Thanks for your interesting review, your deepening appreciation of the How-Stims-Work, and these questions. Honestly I could do a much better job talking to you in person, because I am quite certain you are missing something – I just don’t have a clue what it is.
1. Late onset is atypical at low doses unless the dose is too low. That late onset with increased doses is the tip off to too much.
2. I just don’t see a need to augment with Adderall if the diagnosis, the comorbid conditions and the underlying metabolic issues are straight.
3. No definitive answer on the protein, we simply see folks doing better with AM dose of 10-20 Gm.
4. Adderall, like the Vyvanse, should onset in 30-45 min.
Do consider these possibilities:
1. You are one of those 5-7% of Caucasians or 3% of the African Americans who simply can’t take AMP products [genetic polymorphism of 2D6].
2. You have an additional metabolic problem quietly grinding away at your liver metabolic rate: IBS, Constipation, Substance abuse etc?
3. You could simply be a very fast burner, and after these latter considerations simply need to go up to the the 12 hr DOE on Vyvanse.
cp
Thanks for your help.
I suppose it’s possible that there’s another metabolic issue, but what would that mean in terms of finding a solution with the meds? As far as I know there’s no history of IBS etc in my family, and although yes, sometimes I do have digestive difficulties — but never any problem that was a big deal or consistent day to day. I have no known allergies.
The adderall was supposed to help in the morning; from what I’ve read the Vyvanse typically takes an hour or so to be effective (although for me it was a bit longer even at the lowest dose). You mentioned that late onset with increased doses indicated too much, is that just in general? My onset has never changed and I’ve noticed no difference with the adderall.
I guess I will just keep trying….part of me wants to stay with this class of meds because I’ve had no side effects at all, but at the same time, the benefit has just been a little. One other quick question, even if there is a comorbid condition – let’s say dysthemia – wouldn’t the adhd still need the treatment? I’m just throwing that out there, but there’s no diagnosis and I don’t struggle very much with the thoughts/feelings aspect due to therapy.
What about my treatment objectives?
Thanks!
jm,
You bet, cormobidity needs its own game plan separate and distinct from ADHD. Treatment objectives will be difficult to assess when you aren’t in the Window, either out the top or below the bottom. You just can’t assess the accuracy when the target is so completely missed.
cp
Thanks again for your quick reply!
That makes sense about the accuracy.
Did you answer my question about what it means as far as the meds even if there is some other underlying metabolic problem? (I don’t REALLY think there is though).
By target you mean the window right? What I was wondering about more was the reasonableness of the objectives I listed–are those things that can be improved with this type of medication and is it reasonable to look for it as doses increase or medications change?
Absolutely for the comorbidity (if it’s even there) – but since the adhd seems to be more prevalent and more of a struggle, I guess that’s the reason for starting there.
Thanks again.
jm
jm,
Yes, this CorePsych Blog post does a decent job of breaking down liver, gut and metabolism. Yes, the target it the window, objectively defined by specific office questions regarding brain function.
cp
Dr. Parker,
Have you had patients become diabetic after using vyvanse? Do Adhd medications increase blood glucose levels? I am confused…do I stop vyvanse? My Dr. called and scheduled a glucose tolerance test due to labs indicating high numbers. Never had this problem until after using vyvanse. Any thought are appreciated.
Thanks,
ry
Robin,
Diabetes is not downstream from Vyvanse, but does indicate comorbid metabolic challenges that, if not corrected, can make the ADHD refractory to treatment.
cp
It doesn’t sound as though Robin has been diagnosed with diabetes, but rather that her/his doctor noticed an atypically high sugar level after routine blood work. Robin states clearly that he/she didn’t have this issue previously. Talking about comorbidity completely ignores the facts that Robin presented.
I started taking Vyvanse about a year and a half ago. Before Vyvanse, I’d never had a single blood test come back with a blood glucose level that was remotely out of the norm. I recently had two blood tests (one at my annual physical; another several weeks before when I visited my MD after a spate of headaches), and both revealed glucose levels that, while still normal, were noticeably higher than my usual levels; enough so that my PCP–who’s also an endocrinologist–commented on it. Does that mean Vyvanse is the culprit? Of course not. But it’s certainly possible and worth consideration. In fact, Duke U is launching a study to examine this very issue.
No one can definitively state at this point whether Vyvanse has an adverse effect on blood sugar. It’s only been on the market for a few years now. Oftentimes, additional side effects don’t manifest until the initial patient population has been on a drug for a significant period of time. So no person can make a statement that “diabetes is not downstream from Vyvanse.”
Tom,
Interesting reply, and not on my radar at the moment – thanks for weighing in! One additional point on your same vein is worthy of consideration: I have seen significant dietary changes with stimulants in general, in the unanticipated hyperglycemic direction. Often we see some decreased appetite, but sometimes it does swing the other way… and with neurotransmitter testing [as with a person just seen in the office yesterday] her neurotransmitter PEA was off the chart to start with, only aggravated by the stimulant to become more dysregulated with sugar cravings. – Have also seen this phenomenon with SSRIs.
Thanks for your feedback, good points for consideration.
cp
Dr. Parker,
My 15 yr old son has been on Vyvanse for a few months at his request due to the longer duration. He seems to be less moody and his grades have improved but some days are just better than others. On the “good” days he’s more motivated, gets things done more effectively and is just plain happier. On the “off” days he still gets work done but he doesn’t take much initiative and he doesn’t have the joy that he does on the “good” days. He is pleased with Vyvanse as compared with the Adderall. He does try to eat a protein breakfast but he skipped breakfast this morning yet it was still a “good” day. Thanks for your insights.
Susan
Susan,
Thanks for the comment, I have to redo the video here, had some problems with the previous, but this needs to be explicated more specifically,
So many other ideas that could help: Good multivitamin, Zinc supplement, Omega 3 FA bout 2-3 Gm, all shotgun, but might trim him up just a bit. If the next tweak doesn’t do it, check out the details for investigation on the Neuroscience page,
Best,
cp
Why don’t MDs combine stimulant types? I have tried Concerta, Ritalin IR, and Vyvanse.
Each type (methyl. v. amph) affected me very differently! Both positively, both helped with major ADD symptoms, but completely different ones: methyl. with internal processing and obsessiveness; Vyvanse with doing tasks, maintaining focus, and getting my brain ‘up to speed’ for quick activities like driving. Neither on its own really ‘cuts it.’
I don’t think it’s a dose-level issue, as my doc is willing to go notably above FDA regs, with careful consideration and monitoring.
My MD believes my ADD underlies other comorbid concerns, but won’t consider combining stimulants. I trust her, but I don’t really understand why!
Why don’t MDs combine the two? (I wish they would! )
Thank you,
B-Philadelphia
Brian,
Be careful with mixing, I do recommend against it for the following reasons:
1. Not commonly appreciated, but seen in the lit and from comments on the road [never have done it myself because of my reading]: AMP products are 2D6 substrates, and MPH products [not ‘methyl,’ another subject all together] block 2D6, creating the possibility of a challenging drug-drug interaction.
2. In the lit they both have similar actions qualitatively, blocking the reuptake of DA and NE, but also qualitatively differ in effect. Statistically speaking, the absolute best effect size with stimulant meds is Vyvanse, by far.
3. I suspect the differences may occur with you, as often they do with others: breakfast, food on taking the meds, DOE [titration imprecision], sleep, even foods eaten – especially with the immediate release/mechanical release products. [Vyvanse, the only prodrug {with no immediate release features}, shows only slight variations with food, but can occur with some.]
4. Speculation: Neurotransmitter imbalances, a step deeper in the stream of med adjustments, may be encouraged by either set of drugs because they do have different methods of action.
She’s completely correct – you just need a bit more attention to the details.
Be well,
cp
[…] My Reply Do look very carefully at your duration, your DOE as discussed in this post on Vyvanse dosing, and assess if it has crept up to the 14 hr range. While not always the accurate barometer [having […]
I think Dr. Parker is one of the most rational doctors I’ve known save my own, and one would be well to heed his advice. I too have gone through the gambit of ADD medications, save Desoxyn, which though is on occasion the right medication for an individuals brain is far too disorienting for most.
The barrel shaped pill Daisy was Concerta, the most ineffective, if least risky towards abuse by far, of the stimulant medications (in my experience.) I spent five years on Adderall XR, from 30 up to 90mg over that time period, and for me, it was the perfect (if one can call any medication with the side effects stimulants can cause perfect) fit for my brain chemistry. My doctor was always willing to listen to me, and never afraid of throwing the PDR out the window if reality spoke louder than paper, so increasing my dosage within reason was fine by him. Then I turned 25, lost my father’s insurance, and could no longer afford Adderall XR, and instead switched over to Vyvanse which offers a 12 month free 30 pill fill PAP card. I started off at 60mg with Vyvanse, and I am 100% with you on how it changed my life. I was normal for about 1 week (after three days of feeling little to nothing), and had never felt such peace. It faded as quickly as it came though.
Being a prodrug, it functions a bit more like an anti-depressant than the typical stimulant medication – it has to build up a bit in your system, and then should ideally stay at a constant level at all times. Like those happy pills, which make the clouds part for a while, eventually the normality resumes and one finds themselves no longer finding the treatment obvious. I went up to 70mg for a week. Nil once more. Because Vyvanse is so new, the ceiling dose of 70mg preempted the logic of making a single capsule of greater strength (I have no doubt this will change over time, as most of the doctors I know of take it to 100mg before settling into worry over protocol). I, however, was now in a position of having to get one RX for free, and pay for one as well anyway, as I required more than 30 pills monthly. I went to 100mg, then 120, albeit with greater periods in between… finally I was on 140mg, and, again, 2 70mgs a day was the most I could take unless I wanted to pay 350+ out of pocket for the one medication (and I am on a number of them).
Always fascinated by psycho pharmacology, I did a lot of reading and thinking, and came up with a solution: I asked to be put on 70mg of Vyvanse once each morning, and another 60mg of immediate release generic Adderall to be taken 20mg at a time from noon until 60pm as I needed it. The Adderall was $22 for 90 20s, the Vyvanse free, and while the latter kept me at a steady level of normal at all times, the former gave me the remaining relief and yet without the peaks and valleys typical of 4 hour dosages – much reduced by the constant 70mg “steady” underneath.
I will no doubt need up to 75-90mg of Adderall eventually, but any good doctor who has no reason to fear abuse (because dependence with amphetamine is inevitable, but completely different in nature from addiction) should know the brain is different for all, and the stimulant is always fast on the growth of tolerance, and the combo means having to do what is best for the patient, putting out of mind the decrees set by the FDA (which most likely makes such decisions never having been on or been close to someone on any of the medications they decide about for you.)
Most key in what the good doctor said Daisy (I won’t approach CYP 450, though it is relatively new to me and voraciously fascinating in most all ways, effecting (pardon my hazy stab here) 60-70% of what goes through your pathways to the perhaps 10-15% the next most influencing CYPs (shrug) will.) Read his lips and mine, do not press the desire for an addictive medication without documentation and a fair understanding of the science behind why it needs to be pressed. Doctors other than the rare Dr. Parker and my own, come in about 3 flavors: Overly flippant, overly cautious, and addiction “specialist.” Your doctor, may simply be too cautious, but that he removed you from medication completely (malpractice in my opinion), I fear he may be #3. These are the doctors who will deny severe panic prone patients Klonopin, and when the seizure hits get an injunction to hold you for 72 hours figuring heroin was the cause of the grand-mal.
Get a new doctor. Sadist or not, if you do not feel you are being respected in your concerns, he/she is the wrong one to be going to anyway. You have to build trust for both your sake as well as the Psychiatrist, because if he feels he can trust you, he won’t fear you’re trying to get high when you need a 3 day fill of .5 Xanax because your friend died, but trust you need the respite, while you will get that respite without having to seek alternate means.
Last thing: It’s been shown many a time that an addictive medication given under the care of a doctor greatly lowers the chance a patient will self medicate and truly ruin their lives. Get help if you feel you need it, because if you know there is something wrong, there is something wrong – no MD can make it go away because of incompetence.
Best of luck Daisy,
and Dr. Parker, thank you for helping instead of hurting. You are one of the true good doctors, I feel your heart in it.
Gordon,
Thanks for the kind remarks – it does appear that you are following DOE guidelines, and doing the very best that can be done with the entire universe of money, ADHD, medication durations and drug interactions. No prob with Adderall and Vyvanse, as you likely know, AMP with AMP is no problem… AMP with MPH is a problem, as MPH does moderately block that 2D6 pipeline.
About the other docs – having spoken to hundreds of them I can affirm that only a very few are flippant, some very reasonable folks are overly cautious [simply based upon insufficient clinical experience], and some addiction folk are simply anti-biology on any level. On the other hand you have docs like Patrick Carnes PhD, an international addiction specialist [yes, not an MD], who is very biologically oriented and very well informed about brain function.
My overall impression and the reason for these postings: the medical dialog about these ADHD/stimulant matters is in sad disrepair – and apparently worsening with the attitude fostered by some that discussing these medications with pharma reps is out of the question – some of the most esteemed medical training facilities refuse to speak to pharma while pharma pays most of their research. The obvious dichotomy: let’s look at the numbers and not participate in the dialogue about patients – we’ll loose our objectivity!
Sounds like you have a very thoughtful doc who is working well with you, – and, who knows, some docs may come around just thinking carefully about this dialogue [and the science] and the Daisy folks out there.
Thanks,
cp
My grandson is 7 and has started taking 30mg Vyvanse once daily for ADHD, poor social skills, and aggressions towards his younger siblings. We have noticed some positive changes, but he also has some negative ones. On the positive side, his attention span is definitely longer and he isn’t as aggressive with his younger brothers, but on the negative side, he becomes fixated on things…like his homework to the exclusion of anything else. (He with do his entire week’s homework in one afternoon). Then, when you try to interrupt him to eat or do something else, he becomes very upset and cries. He has also started to self-abuse himself by picking at his cuticles until they bleed. This is something he has never done before. Obviously we are worried about the injuries and possible infections. Does this mean he is under-dosed, over-dosed, or that Vyvanse is simply the wrong drug for him? He is about 3 years smaller than the other kids his age and he also weighs at least 1/2 or more as much.
We are very worried about him. Any suggestions?
Carol,
The top of the window, like the bottom is filled with subtlety – so this reply is based only upon an educated guess based upon my own experience of watching these details closely for years:
1. The dose clearly could be too much. The hyperfocus is often a clue that he’s out the top of the window regardless of the dose, his size or similar variables. Lowering w your doc would be a reasonable next step.
2. Some of the other issues sound like he isn’t metabolizing it correctly, like it’s accumulating and he suffers from the Roving Therapeutic Window as seen in this Dosing Video Playlist at my channel on YouTube.
3. If he isn’t metabolizing correctly these are some other thoughts RE: Videos on Metabolism, Gut and Brain.
Hope this helps,
cp