- To Change Your Mind - Details Matter
ADD, ADHD Stimulant Medication Dosage: Underdose or Overdose?
ADD, ADHD Medications: Time is of the Essence
November 10, 2008ADD, ADHD Stimulant Medication Dosage: The ‘Bottom Bewitching Hours’
November 17, 2008
ADHD Medications
The Trickiest Measurement: The ‘Therapeutic Window' Bottom is Over-the-Top
Remember the ‘Top of the Window' is ranging too high in dosage, the
‘Bottom of the Window' is too little dosage. The worst thing that can
happen when you are working to carefully correct stimulant meds: an
overdose upwards because that apparent ‘bottom,' the apparent under
dose, was actually too much meds and the patient was actually coming
out of the ‘top.' Here is how that looks clinically using these 7
pointers.
- When the Med Dose is too High: it can look like the patient is no longer focused,
they are hyper, confused, and cognitively not as sharp. Every visit,
every medication review, every question in medication adjustment must
consider the possibility that these symptoms mean the drug dosage is
too high. - OverFocus Looks Like UnderFocus: This single oversight is the absolutely biggest problem with stimulant medications today:
New medications work so well the top actually appears to be
insufficient dosing. Clinically it appears as if they need more
medication. The big problem: More meds in this situation can make the
patient much worse, perhaps dangerous, certainly more unable to focus, due to that over-focusing. - Side Effects are in Evidence:
This phenomenon, actually going out the top – while looking like the
bottom – always has side effects. Side Effects are often subtle, so
inquiry must carefully review these: appetite is down, weight loss
occurs, agitation is higher, compliance appears worse. angered more
easily, sleep is disturbed significantly when no sleep problems
previously occurred. - The Patient argues that It Works Well and Can't See the Side Effects. They are so happy to have a new focus they push to have the dose up because they do, so desperately, wish to improve.
- The School Is Pleased – In A Structured Setting Side Effects Are Less Obvious.
This report often throws off the Treatment Team, because the team is
not trained to look themselves for these details, but relies to heavily
on what the teachers say, ignoring thier own personal concerns. - Peer Relationships Suffer.
People closest to the patient see odd changes and feel put off by the
pressures and new, overbearing attitude that has slowly emerged. - Malevolent Odd Actions, Never Before Experienced, Occur.
The patient becomes more destructive in odd ways. A manager who never
gossips begins to gossip. A child decides to hit his favorite pet, and
never did before. A child may start a fire in the back yard, or try to
drive the family car… ‘just for fun.' The symptoms at first seem
quite innocent but in the overall are maladaptive.
Check out the full article over at EzineArticles.com
Do review these seven tips carefully. Dropping the medication down,
even a small amount, under these circumstances will often reveal the
person who is evenly focused, who is emotionally more on track, and
performing better throughout the day. Dropping the medication down will
take them out of the ‘Top' and put them back within the best
therapeutic dosage, back in the targeted ‘Therapeutic Window.'
Bottom Line
By following simple guidelines and the metaphor of the ‘Therapeutic
Window' you will be more able to adjust dosing correctly, and
effectively – so you and yours don't feel like treatment failures. I
invite you to sign up now for the early bird special set of gifts for
my new book “Fixing the ADD Madness: A Patient's Guide to Stimulant
Medication Details,” [upper right sidebar here]-And enjoy the bonus gift on the thank you page for signing up early
— simply to express your interest in the book: a 1200 word article on
The 10 Biggest Problems With ADD/ADHD Medications, and a 17 min audio
review of the article.
12 Comments
[…] This post was mentioned on Twitter by Dr Charles Parker. Dr Charles Parker said: Overdose details: ADHD Stimulant Medication http://bit.ly/jLkrw #ADD #ADHD #Psychiatry #Brain Even more details in my new book […]
Cmpding Pharmacist:
So true, left you guys out, but work with you all the time. These notes are simply providing a simple temporary answer for a previously complex problem.
Now with the different doses we rarely suggest water titration unless just starting up.
cp
Compound Pharmacy has gained much popularity in the field of medicine. The medications are equally effective and safe for sick patients who cannot take the actual medications due to their personal allergies.
Eddie,
I think Dewey’s in Philadelphia is now closed, – they had the very best coffee and some *killer* french twist donuts back when I didn’t watch what I ate back in 1967 – I can imagine them with a protein core, yes – Cookies and Cream Spirutein comes close.
Thanks again,
cp
Thanks for the nice comments doc. We did stop the Benadryl last night. Been taking it from the start! My dau has *always* had problems sleeping. A couple of Benedryl seemed to help. What was occasional use became more regular once High School started and ADHD became more manifest (and identified.)
It just seemed natural to keep on it, since it seemed to help with the insomnia brought on by the Vyvanse.
Thanks for all your help with explanations on the *window* and just in general. Having information cuts down on worries.
We hope to get back to where we were a few weeks ago when the Vyvanse was working better. We will stay at 30 mg and let things settle out.
Now if you can tell me where to find protein bars that look and taste like donuts that would really be a help!
Happy Holidays to you and yours.
Eddie,
Gotcha on the whole thing, loved the articles over there, and just did a full post on your excellent heads up.
Thanks,
cp
Sorry for the misunderstanding. We are on the west coast. Seeing you would be great, but a challenge. We have enough of those at the moment!! Our appointment is with our family doc here at home.
Here is what prompted my comment regarding Benadryl and 2D6:
http://psy.psychiatryonline.org/cgi/content/full/44/5/430
This seemed to be similar to some of what I have read on your blog regarding Paxil and Prozac:
http://www.corepsychblog.com/2006/11/adderall_prozac.html
Probably just a coincidence, but we will move off of the Benadryl anyway…
We did seem to have *good* DOE initially. My dau was even working on school work until 9pm or so.
The problem was the persistent insomnia (hence the Benadryl). We thought we were home free for the first few weeks and now we seem to be sliding backward.
Of course this is why we are going to see our doc and try and tell her everything we can think of. We just want to get headed back in the right direction.
Eddie,
Look forward to seeing you – this is a good example for readers to see that I do the same thing their docs do: and it isn’t ‘experimentation’ -it is specific titration with specific guidelines.
This is a different approach than is customary – not the *titration process,* but the *specificity guidelines.*
Sounds like it is too little by using the DOE.
Haven’t seen an accumulation with Benadryl, – the essence of this process and message is repeatability, predictability-
Real precision takes a few more minutes,
See you soon-
cp
Additional note: I did Google ‘2D6’ and see that Benadryl has an impact here. A little beyond my understanding to sort through…
My daughter has been taking Benadryl at night as a sleep aid.
Thanks for the thoughts doc.
We have an appointment to review the meds in early Jan. We will be monitoring the lower (30 mg) Vyvanse dosage and see what that does until then.
40 mg of Vyvanse was taken at about 7 am each day and the “crash” would tend to happen in the late afternoon or early evening (3 – 5 pm). Seems to be very driven by food (or lack thereof) No lunch or snack = crash. Lunch = no crash.
Seems to get better if we can get some food in her.
Eddie,
Early AM here and gotta get to work, but I agree with your plan, does sound like side effects are creating a significant problem – and sounds like you are right on attempting to correct with breakfast.
Only problem I can’t assess with this limited information is *when* the crash/depression is occurring?
There may be some benefit to reviewing with your doc premorbid depression, and look for the possibility she is having a down regulation of serotonin. See this post:
If you use *Search* here I have several posts on depression and stim meds – and drug interactions – just don’t have time to chase them down, now. Google ‘2D6’ here. If they make sense to you, your doc and your dau then you might try a small dose of an antidepressant to smooth out the crashes at the lower stim dose.
And the final note, no disrespect, this is why I wait for two weeks before that first increase… it often takes a bit of time to settle with exactly what the problem is.
Best to you and your team,
cp
I am taking a hard look at this right now with my 16 y/o daughter. She started on 30 mg of Vyvanse at the end of Oct. This is our first ADD medication.
We went up to 40 mg after the first week, thinking we were not seeing any good effects. She did have a “bad day” on 30 mg. A “bad day” would be very irritable, moody, depressed. We thought going up would help.
Stayed at 40 mg throughout Nov with good effects. School work was good. Attitude was good. No “bad days” Although we did see side effects (appetite was down, insomnia was up). Have been getting protein at breakfast everyday (protein shakes). She did not like the cliff bars, but will take a protein shake with no complaints. The rest of the day has been little or no food. Maybe a small dinner.
Now in December the Vyvanse seems to have no positive effect. Side effects are all still here. Many “bad days”.
We thought about just stopping and trying something else, but in reading this I am thinking of asking our doc to just drop us back down to 30 mg and see how that goes. I will post our experience with that. Thoughts??