- To Change Your Mind - Details Matter
ADD, ADHD Medications: Time is of the Essence
Gluten/Celiac, Migraine, & ADD/ADHD Connections 1
November 8, 2008ADD, ADHD Stimulant Medication Dosage: Underdose or Overdose?
November 13, 2008
Image via Wikipedia Notes For The Bottom Of The Therapeutic Window
If we don't dose medications correctly based upon expected pharmacology, we simply are simply not paying attention to the details. Time is of the essence, and must be measured, just as would measure a land and tide fix if sailing off the New England Coast.
- The Meds Don't Work Long Enough: The Duration of Effectiveness [DOE] is not adequate: Each stimulant drug, each family of stimulant drugs has its own expected DOE. This DOE is not discussed in the literature as a measuring tool,
but it is common knowledge with any who watch carefully for drug action
and duration through the day. - If you know both the drug's expected duration and take a fix on your own metabolism, it's like knowing exactly where you are on the map sailing off the New
England Coast. Each measurement will give you a specific fix for that
geography, and that tide. - All stimulant medications have an expected, less than 24 hr duration.
This is an obvious point, but overlooked so often as an essential tool.
If meds last less than 24 hr, then how long should each last? - Dialing in the specific duration is essential to get the best action out of each specific med. [AMP=Amphetamine Family, MPH=Methylphenidate Family]
- Vyvanse [AMP] and Daytrana [MPH patch] both win the DOE race with 12-14 hr expected
- Adderall XR [AMP] is next with 10 hr DOE – sometimes can get 12, but often 12 DOE is too much
- Concerta
[MPH] and Focalin [MPH] both run 8-10 hr if dialed in effectively –
some studies show longer, my experience is more than 10 with either of
these is too much – see other articles on the ‘Top of the Window' - Metadate CR [MPH] and Ritalin LA [MPH] are both right at 8 hr, rarely longer, with side effects if pushing the dose higher
- The Immediate Release Stimulants, the tablets with no extended time
expected, last only a portion of the day with Adderall IR [AMP]
[Immediate Release Tabs] lasting about 5-6 hr, Ritalin IR [MPH] is 4
hour max duration.
Simply knowing these expected Durations of Effectiveness make the medications much more predictable.
ADD and ADHD medications have a geography, a coast line, that is rugged and must be navigated correctly. If you run aground you are on the rocks.
I just added an article on these details over at EzineArticles.com, click on the link here on the right hand side of this post for updates.
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8 Comments
I’m not sure if this is the right place for this but I recently switched from vyvanse 60 mg to adderall xr 25 mg due to change in my health insurance. I have noticed that 30 minutes after taking my medication I become so tired I must take a nap for about an hour. I wake up starving. The main symptom of my add is panic and inability to perform tasks because of constant overthrowing of everything. Although the adderall does help with my panic and anxiety, I find it does nothing for my focus. It has only been 3 days but the vyvanse helped from day 1 and changed my life. I’m not sure if this is something you have seen in other adult adhd patients an would appreciate any insight. My doctor does not Harwich experience with adult adhd by is very open to any information I can provide. I am a 35 year old female. Thank you so much for all you have done for our community.
heide,
The adderall adds a norepinephrine piece not present in Vyvanse. That NE might be the cause of the odd symptoms. Yes we see this from time to time. Use the DOE as documented in this video series to make sure the dose is correct, as it might be a bit too high, hard to tell from that one side effect > http://bit.ly/dosevids
cp
[…] Details from 2008 with some-more specifics: http://www.corepsychblog.com/2008/11/add-adhd-medications-time-is-of-the-esse… […]
[…] Details from 2008 with some-more specifics: http://www.corepsychblog.com/2008/11/add-adhd-medications-time-is-of-the-esse… […]
Thank you G,
Appreciate your being there!
cp
Jackie,
Thanks for your kind comment, I am also looking forward to sending out the book, as I do think it will tighten up the way we do the stim meds.
Excellent question on the Well. and Stratt. and the short answer is simply: yes! BTW, watch for drug interaction with Stratt and Well thru my old favorite 2D6… A large dose of Well. [2D6 inhibitor] can seriously back up Stratt – and I have seen kids nodding off at school with an OD of Stratt secondary to that interaction.
I do apply these DOE principles to every psych med, but am only at this moment covering the stimulants — In addition I will be covering in the book how different meds effect the DOE of the stimulants through interactions, so the DOE is not always ‘only’ stimulant related. The stimulants are the best way to open that DOE door simply because they are so doggone obvious.
This DOE thing is so overlooked, and so completely essential to med management – and a great place to start the discussion of metabolism and meds, and the necessary customized approach to every patient med interaction.
The other meds with longer ~ 24 hr half lives are not as obviously relevant, but can hint at dosage patterns… e.g. I have seen Effexor drop off in the PM when the overall dose was too low, even tho it is expected to work.
Depression and antidepressants can provide odd swings, as can the oft discussed metabolic challenges, even, as you likely know, breakfast, or pasta last night. The variables are many, and the reason to get those swings timed out is that we can become more predictable in out outcomes as we remove/explore all the contributory variables.
I have regularly seen folks on Adderall XR who took the med with orange juice in the AM – hyper all morning, and right on after noon, after the release of the second bead. It’s not commonly appreciated that orange juice interferes with the absorption of the first AM bead, so no effect.
Metabolism and metabolic rates are influenced by ‘many factors’ and will provide a regular ‘field day’ for discussion in future posts and books.
Some of the swings you are talking about, just speculating, not for a recommendation per se, for your daughter could be a comorbid depression, no breakfast, carb only breakfast… etc.
Thanks for that excellent question – thinking about these additional aspects will help more folks drive home the necessity of precise dosing strategies.
If any readers appreciate this discussion please chime in here, and be sure to forward this note to interested friends on the easy email link at the bottom of this post.
cp
Thanks Dr. Parker!
Gina
Hi Dr. Parker,
As always, your posts are so insightful and I cannot wait for your book to come out!
My question is, for those who cannot handle the traditional stimulants of either the AMP or MPH class and are therefore on the meds Strattera and/or Wellbutrin XL, would your same therapeutic window and DOE approaches similarly apply?
For my teen daughter, who is currently doing pretty well on both these meds, I have been trying to apply your insights in evaluating a couple problems she is experiencing — specifically, a wired/antisocial/stressed feeling smack in the middle of the day and DOE that is less than the 24-hours that these meds are designed to provide, making it difficult for her to function for several hours in the early morning.
So, do your same rules apply, or are there other/additional rules for these meds? Thanks!