- To Change Your Mind - Details Matter
ADD, ADHD Stimulant Medication Dosage: The ‘Bottom Bewitching Hours’
ADD, ADHD Stimulant Medication Dosage: Underdose or Overdose?
November 13, 2008Grumpy Outed: ADD and Depression For A Lifetime
November 27, 2008Target the Entire PM for Adequate Dosing 
Often ADD/ADHD medications aren't targeted, or dialed carefully in,
for the Entire Day, but rather set for an inadequate objective to just
"get through work or school." This problem has been with us since much
before the 1960s – is paleolithic – and simply does not address the
'bewitching hours' of 4-8 PM. The 'Therapeutic Window' is often simply
not reviewed.
New meds can cover the entire day, school and work
alone are no longer the only objectives. Family life, the evening, and
overall cognitive management throughout the day, have become important
treatment objectives with the new medication alternatives. This article
discusses some of those new options for stimulant medication titration
– and thereby adjusting the dosage correctly.
7 Tips to Find and Correct Insufficient Duration Through the Day
- Look for that longer objective:
It may sound simple, but with the new drugs we can significantly change
our PM objectives. The new drugs such as Vyvanse and Daytrana will last
13-14 hrs easily, but just take some time to ask the questions
carefully and then adjust the dosage. - DOE, 'Duration of Effectiveness,' evaluation must come up at every medication check.
If your doctor dosen't ask about it, you must think about it anyway to
encourage the discussion. It is time consuming, but if you are prepared
you will make the medical job easier. One of the main reasons it is
time consuming is because with the new stimulant medications it is more
difficult to assess. - Know The Characteristic Subsets of the PM Drop:
– These will be carefully outlined in another full article, but suffice
it to say that with the longer duration medications it is much harder
to recognize. Look for any change in focus, appetite, inattention, even
a vague feeling of decreased motivation can signal the end of the DOE. - How Vyvanse will cover 12-14 hr: Increased
carefully with 10 mg increase in the AM will add about 2-4 hrs on the
the PM bewitching hours. Studies show even in children that an object
of 13-14 hr is reasonable, but don't, repeat that, don't try to do it
all at once. Give the person time to assimilate, to get used to, the
medication, even this excellent product can be overdosed by starting
too high. Give the person about 1-2 weeks with each dosage so they can
find and report the DOE at that specific dose, then the team will be on
target. Adjusting to aggressively, too quickly, will bring more side
effects. - How Daytrana can cover 12- 14 hr: I
like both of these medications because compliance goes up with less
afternoon dosing, and there is no need to remember that PM dose. The
company does not recommend cutting the patch, but the patch can easily
be cut to target a specific clinical effectiveness through the day.
Keep the patches in the refrigerator, cut them to increase or decrease
the dose, and don't forget that you can leave them on longer in the PM
to cover evening work. Each person is different, and using PPT 'Post
Patch Time' [should be 3-4hr] will tell you if the daytime dose is
effective. If only 1 hr PPT, the dose is insufficient. - Adderall XR, Concerta, Focalin XR, Metadate CR Durations:
Of the collection of stimulant medications it is my experience that
Adderall XR is easier to adjust for about 10 hr, sometimes 12, but the
others routinely fall short. With all of these medications including
Vyvanse and Daytrana: Too little: it isn't covering the PM, too much it
is interfering with sleep. - Teach the children at the outset:
It is harder for them to know what to look for setting these PM
treatment objectives. Spending just a little time at the front end will
help them feel like part of the team.
With these tips you will be better able to make essential PM
adjustments with ADD/ADHD stimulant medications to cover the most often
overlooked part of the day, without creating sleep disturbances.
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 my new book "Fixing the ADD Madness: A
Patient's Guide to Stimulant Medication Details," at the top of this page – And enjoy the bonus gifts on the thank you page for signing up early.
See the complete series of these articles on dosing stimulant medications at EzineArticles here.
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8 Comments
I thought that this was hugely interesting Dr Parker and wanted to get your thoughts on it:
“Negative symptoms of schizophrenia (NSS), related to hypodopaminergic activity in the mesocortical pathway and prefrontal cortex, are predictive of poor outcomes and have no effective treatment. Use of dopamine-enhancing drugs (eg, psychostimulants) has been limited by potential adverse effects. This multicenter study examined lisdexamfetamine dimesylate (LDX), a d-amphetamine prodrug, as adjunctive therapy to antipsychotics in adults with clinically stable schizophrenia and predominant NSS. Outpatients with stable schizophrenia, predominant NSS, limited positive symptoms, and maintained on stable atypical antipsychotic therapy underwent a 3-week screening, 10-week open-label adjunctive LDX (20-70 mg/day), and 4-week, double-blind, randomized, placebo-controlled withdrawal. Efficacy measures included a modified Scale for the Assessment of Negative Symptoms (SANS-18) and Positive and Negative Syndrome Scale (PANSS) total and subscale scores. Ninety-two participants received open-label LDX; 69 received double-blind therapy with placebo (n=35) or LDX (n=34). At week 10 (last observation carried forward; last open-label visit), mean (95% confidence interval) change in SANS-18 scores was -12.9 (-15.0, -10.8; P<0.0001). At week 10, 52.9% of participants demonstrated a minimum of 20% reduction from baseline in SANS-18 score. Open-label LDX was also associated with significant improvement in PANSS total and subscale scores. During the double-blind/randomized-withdrawal phase, no significant differences (change from randomization baseline) were found between placebo and LDX in SANS-18 or PANSS subscale scores. In adults with clinically stable schizophrenia, open-label LDX appeared to be associated with significant improvements in negative symptoms without positive symptom worsening. Abrupt LDX discontinuation was not associated with positive or negative symptom worsening. Confirmation with larger controlled trials is warranted."
Are the negatives symptoms tattamount to ADHD or are they more pervasive? Do you ever treat your patients who suffer from Schizophrenia with Vyvanse?
J
Jamie,
No revolutionary trials here. I stick w Abilify for its 3 level dopamine improvements – and call if a day with that intervention. I personally don’t see stims a primary tx for schizo, but have augmented w stims very carefully for those who suffer w ADHD comorbidly.
cp
Jeff,
Sounds like the dose wasn’t quite right in the first place, based upon the DOE. Vyvanse, of all of them, has almost no need to adjust once dialed correctly into the ‘Window.’
Most of the others to do show a tachyphylaxis see:
http://en.wikipedia.org/wiki/Tachyphylaxis
– Sometimes we see development of ‘tolerance’ but I always, always, look for metabolic contributions that can modify the DOE – especially with Vyvanse, as it does reach steady state most of the time – barring any contributory alterations in metabolism.
Interesting question, thanks,
cp
Dr. Parker,
Thanks for posting this great information. As an experienced patient currently on Vyvanse for the last year and prior to that Adderall XR, Focalin XR and Concerta I am always interested in learning about the duration of effectiveness. There is one thing that continually frustrates me (and probably many others) about these meds. We know by the hard clinical data that any of these stimulants, such as Vyvanse or Adderall XR have a period in which the medication rises, reaches peak then starts to drop (like a bell-curve).
As a patient I can easily say that once the medication reaches the peak and starts dropping the effectiveness is pretty much over (despite that fact that there is still some level of medication in the body). My doctor says this shouldn’t happen with these once per day medications. To be fair with Vyvanse, the first couple of months I definitely got around 8-10 hours of use from it but I think that as I’ve become used to it (over a year) that I’ve reached the point with it that after it peaks (about 4-5 hours tops) it is fairly useless.
Do you have any patients with this problem or experience with this type of tolerance? I’ve come across the term “acute tolerance” but I don’t know if that applies to what I’m talking about.
Thanks!
JeffinVA
ADHD Warrior:
I have been following ADHD Warrior, and while at this moment we don’t know specifically who this masked person is, he/she is doing excellent work over at his/her site
http://adhd-treatment-options.blogspot.com/
I will be posting directly on the Warriors excellent work over there, and strongly recommend you follow – and you can keep up on Twitter as well.
Thanks for your very kind comments – a great pleasure to meet such a well informed traveler along these sometimes obscure paths.
Thanks,
Chuck
An extremely concise post on a very practical topic. Your advice is extremely detailed and focused, a real rarity among most internet sites on the topics of ADHD medications these days. I’m learning a lot by reading your blog! Thanks!
Erica,
Thanks so much for your kind remarks. The best part after finding the right med is finding the exactly right dose… precision and predictability are quite possible, if only we get ‘up close and personal’ on the titration details.
Glad this worked for you!
cp
Dr. Parker,
Okay so how about you just blew away my medulla oblongata! That was by far the most educational breakdown on this topic I’ve come across yet. It was straight to the point yet easy for the mind (well my mind anyway) to digest. 🙂 Not stuffy at all! I’d like to thank you for wanting to get to the “ROOT” and not simply sweeping dirt underneath a rug. Take care!