- To Change Your Mind - Details Matter
ADHD: Vyvanse – The Therapeutic Window Mystery
ADHD: Vyvanse and Duration – DOE Simplified
June 9, 2009Vyvanse Dosing for ADHD: Finding the Safe Top of the Window
June 17, 2009
Chose The Correct Dosage
Overlooked: Vyvanse Titration
Vyvanse provides many interesting features for ADHD treatment – but this important dosage challenge is often missed. Don't adjust medications by the “buzz,” but rather the clear treatment objectives.
Take a quick look at this video, it can help you find and understand the important Top of The Therapeutic Window with Vyvanse – the ‘forgiving amphetamine.' I reviewed the Vyvanse titration process [duration – DOE] this previous video, so do check that one out, but watch for this uncommon and subtle presentation previously described in this article on the Top of The Therapeutic Window.
Top of the Window – Heavy Nuance
———————
Remember This:
The top can look like the bottom with Vyvanse, more than the other stimulants, – because it's more forgiving.
Please take a look and tell me what you think, it's often quite obvious and quite subtle at the same time.
Key Points here to review and amplify:
- Onset of action was appropriate in time at first, about 30-45 min after taking it
- Increased dose caused apparent improvement, but later the effect onset comes around 10 AM, – 3 hr after taking it
- Intensity high for about 4-6hr then drops off early afternoon
- They don't feel the ‘jittery' side effect one experiences on too much Adderall, but they feel very irritable, anger easily and can become suddenly quite depressed
- Others become burdened by their emotional travails as they never experienced this intense emotionalism previously
- They aren't eating correctly – often no breakfast
- They aren't sleeping adequately
- They can't focus, and feel that they need more stimulants and antidepressants
- Some wag calls them bipolar, serious, and – it becomes the diagnosis de jure
- They distance themselves from their progress and regress in their program, smoke, drink, etc.
- They can become suicidal over their dismay at the regression.
- SPECT Imaging does not show signs of ‘diffuse cortical hyperperfusion' – [euphemistically yet emphatically labeled ‘Ring of Fire' by Amen – a designation frowned upon by experienced nuclear medicine folk]- but rather signs of diffuse cortical hypoperfusion.
- This same observation applies to Adderall XR and Adderall IR, but is much easier to recognize.
Yes, you can stop it altogether, abruptly if the presentation is more acute – but I find that simply cutting the dose in half can create a foundation for a careful recalibration – take more time.
Additional Homework
Review these 2 video playlists to dig further into details that matter regarding treatment objectives:
The Dosage Strategy Playlist: http://bit.ly/dosevids
How to Learn from The PM Stimulant Drop: http://bit.ly/7PMdrops
Drop us a comment if you do think of more features on this puzzle.
cp
Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
Complimentary 23 Special Report: Predictable Solutions For ADHD Medications
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84 Comments
Hello Dr. Parker, i realize this a very old thread but I hope you get to see my post. I was on fast release dexedrine 10-15mg a day. Any time I took my 5mg booster I would get a headache, be able to fall asleep around 10-11pm but be wide awake at 2am.
My Dr switched me to Vyvanse now and I am in the middle of trying to figure out a good dose.
-10mg definitely wears off by noon, at that time I feel incredibly hungry and a headache follows. Experienced exhaustion and deep sleep that night.
-20mg seems to push the same patten to about 4-5pm. Experienced exhaustion and deep sleep that night.
-30mg felt a little too much once it kicked in but I was able to stay motivated all day BUT same thing that used to happen with dexedrine happened, I could fall asleep but wide awake at 2am.
I read online I should avoid coffee and acidic foods and to take tums on an empty stomach and take vyvanse immediately after. Breakfast only an hour later. Does this make sense to you?
Thank you.
J.
Juliana,
You’re demonstrating the phenomenon of a narrow therapeutic window, and clear metabolic slowing through one of a number of pathways. Increasing Vyvanse from only 10-20 mg in a well balanced metabolic body = about 2 hr additional burn rated [DOE] not 4-5 hr more. Very typical of the narrow therapeutic window phenomenon. Video here: http://corepsych.com/tw Tests for metabolic listed w video explanations here: http://corepsych.com/tests Hope this helps – we can interpret these tests long distance.
cp
Thank you so much for this. It does make so much sense. I’m a nursing student currently working towards my BSN and my class at the moment is actually pharmacology (how ironic?). I am curious to know if my insurance would cover the testing. I will call the office to find out those details. My goal is to make it as effective as possible and even not use it if I can balance my metabolism and fix my ADD.
For the meantime should I stick with the short acting meds or vyvanse you think?
Thanks again.
Juliana,
As a medical professional, you will find considerable insight in pursuing these tests, in addition to your own progress. Do write to Libby to see what’s available thru your insurance. Best bet is the first two, that’s why they are at the top. See the vids and you’ll understand why I say that. In the meantime on your question of ‘which:’ Vyvanse is great for most people unless they are significantly troubled by metabolic challenges, then immediate release is less challenging to adjust.
cp
“Increased dose caused apparent improvement, but later the effect onset comes around 10 AM, – 3 hr after taking it”
I dont understand how too big of a dose with Vyvanse pharmacokinetics would work like this. Shouldnt patients be faster inside the therapeutic window with a larger dose (even if that dose is supratherapeutic AKA too much)?
I understand why a patient would go over the top of therapeutic window 3 hr after taking it with Vyvanse, but getting the effect onset at that time? What dont I see?
pkiiski,
The short and simple answer: they’re toxic with an amount that continues in the body until the next day. That first 2-3 hr they go out the top of the Therapeutic Window, then drop out later and fall back down into the window as time marches on.
cp
So like a rapidly accelerating space rocket that goes through the atmosphere of Earth in a very short time, Vyvanse shoots over the therapeutic window to toxic level for several hours.
Yes, makes perfect sense now. Ty!
Dear Dr Parker,
Thanks so much for this article. 30mg of Vyvanse cured my impulsivity but not attention improvement. Now on 60mg… Both leave me with headache, low energy, focus that comes and goes (more often ‘goes’) and lack of motivation.
Any tips greatly appreciated.
Ann
PS: I am an extreme late night chronotype and after taking Vyvanse at 7.30 (kicks in around 10), I only feel OK at 10pm (as in happy to study, clean my room)
self-medicating behaviors (
Ann,
Two quick thots:
1. You must take a look at this video on serotonin and dopamine balance – I think that’s part of your problem: http://corepsych.com/balance – likely need a trim w some kind of SSRI even though you’re not a crybaby. Hint: “motivation.”
2. I’ll now place a strong bet on the next issue: metabolic disarray. See this video playlist to describe how gastrointestinal issues can supervene: http://corepsych.com/gi Hint: chronotype and odd metabolic presentation.
Hope this helps,
cp
I’m 49. Been on Vyvanse about a year. Titrated up to 70 mg. Really concerned lately about afternoon tiredness and lack of motivation. Take it around 8am and go back to sleep. Wake up about an hour later. Start my day with small breakfast and need a soda to get going. Feel chatty and normal for about 5-6 hours then need a nap or just sit on the iPad for 3-4 more hours. Definitely not happy with it not lasting 12 hours. House is a mess, nothing is getting done, and I’m wanting to fall asleep on the days I keep my grandkids.
If I have nowhere to go and it’s not a day with the grands, I’ll sleep later and waste time on the iPad until I look at the clock at 3:00 and realize I need to get moving. Not the Vyvanse I knew in the earlier days.
Michelle,
Highly likely, more likely than not, that you suffer with a low grade chronic energy related medical condition. At CorePsych I have multiple measurement systems in place to jump on this, including a full on workup for other possible challenges including thyroid issues etc. Download and take a look at this pdf for more details: http://corepsych.com/tests14
We consult out of town all the time, but to write prescriptions you would need to come to Va Beach – see these details: http://corepsych.com/services for both phone and on-site.
Then take a look at these complimentary videos [especially number 6], as some of these might relate to your question: http://corepsych.com/stimulantdropinfo
Hope this helps! Best for the Holidays,
cp
That’s EXACTLY what I do too Michelle, and I’m 45! Thanks for posting!
[…] Vyvanse Odd Toxic Reaction – Top of The Therapeutic Window […]
Dr. Parker,
I am fascinated by all of the information you have shared with us. I have been struggling for the last two year to find a medication that works. I was first started on Adderall 10 mg dose and later a 20mg dose 2x a day. That seemed to work for the few months I took it. I later moved and was off of medication for a while as I started new school and looked for a new doctor. I was then started on Adderall again, which did not work, and then later Concerta to no avail. My physicians decided to try me on Vyvanse. At the lowest dosage I had no effect. Later I was upped to 50 and later to 70mg as I was still feeling no change. However at all dosage with all of the stimulants I can always feel the physiologic side effects (dry mouth, increased heart rate, and sweating) which were rather bothersome. When I took the medicine (we ended up keeping me on 50mg since 50 & 70 were having the same effect) I would feel nothing for the first 1-2 hrs then from hours 2-5 I would feel a surge of clarity and then it would begin to decrease after that. By the 7th or 8th hour there was no clarity left and I would begin to crash and By hour 10, my body would feel as if it had been run over by a truck, completely fatigued. My grades on Vyvanse had improved compared to when I had changed to Concerta but the physiological effects (sympathetic stimulation), fatigue, and later uncontrollable acne breakouts were too annoying and I decided to see what other options were available.
I was started on Nuvigil and that seemed to be working but the headache side effect was not one I was able to get used to. At this point my psychiatrist told me that I may be one of the subset of ADHD patients that was not as responsive to medication. She suggested we try Straterra. This medicine initially seemed to give me nocturnal anxiety attacks but that went away within a few days. I was able to wake up in the morning much more easily, but sometimes it seemed like I was getting less sleep and not as deep sleep. After a while even the ability to wake up had tapered off and I am currently titrating up to 60mg Straterra. I do not really feel any more clear or focused than usual and I’m not sure if it is my anxiety or the drugs that are affecting my ability to fall asleep and get quality sleep (I take it before bed). I am not sure if this drug is one that can potentially work for me but there are other options of when/how to take it.
I like the clarity that the stimulant medications gave me, especially the Vyvanse, but not the side effects although I can tolerate them if need be. And it seems as though Straterra has a good reputation for being an effective medication as well. I feel like I would respond ideally to a Vyvanse (or straterra) that re-newed their effects every 3-4 hours, but I do not know if this is physiologically possible.
I have been having trouble finding a medicine that works and am not sure how to go about figuring out the best one for me. From reading through your posts I understand this can be a lengthy, ever changing process and I now know that “cognitive anxiety” is the title to give to one of my long-standing symptoms. But I am not sure how to proceed or if there are other medications that can be tried.
Sarah,
Your pervasive med failures are quite likely accompanied by metabolic challenges. Oddly enough it sounds like you have a very narrow Therapeutic Window, and on Vyvanse that late onset 2 hr after taking is almost always associated with too much not too little, and a gummed up liver. When good docs give appropriate meds and the patient just bounces off everything the problem is always metabolic and requires more precise testing… with any psych meds. See IgG, see my videos on Mind, Gut, IgG, Wheat and Milk etc. Also look at the dosage videos on this list of playlists at this channel: http://youtube.com/drcharlesparker for much more info.
cp
Dr. Parker,
I was recently told about something called GeneSight but did not find this mentioned on your site althought it seems to be in support of much of the things you tell us about cyp2D metabolizers, etc. This is the website, not sure if you have ever heard of it. http://assurexhealth.com/products/
Over the past few weeks I have been watching many of your videos and reading through your sight as well as trying to do some additional research. I also tried the “mouth to south” test that you have recommended. It seems like I fall outside the 18-24 hour range. Based on some of your videos and what I have read I am not surprised that some of my medication issues may be related to GI sensitivities. In fact, I have always had what I thought was a resistance to most medications (such as pain pills) aside from antibiotics.
I have been struggling for years to figure out a solution to GI problems I experience from bloating to gas, etc. You mention in a series of your videos about IgG sensitivity/allergy as being a potential problem some of us may have that may be overlooked. I tried to search your site and the web, but am not sure how to receive IgG testing or what my next steps should be. For instance should I make an appointment to see a GI specialist or some other specialist? I am not sure.
Thank you,
Sarah
Sarah,
There are several companies involved with genetic testing: Genomind, Genelex [excellent reference page], Genova with this useful pdf.
Interestingly most of these companies fail to document the important Amphetamine path as a substrate thru 2D6 which I learned about from Stephen Stahl in 1996, and have lectured about nationally since that time.
Details From Genelex:
Some 7-14% of Caucasians are poor metabolizerss (PM) and lack functional CYP2D6. The genetic basis for poor metabolizers is now well defined. The four most common mutant alleles are CYP2D6*3, CYP2D6*4, CYP2D6*5, and CYP2D6*6 and account for 93-97% of the PM phenotypes in the Caucasian population. Individuals who are homozygous for PM alleles do not display CYP2D6 enzyme activity, nor do any those who carry combinations of these alleles. Additional alleles CYP2D6*6-8, *11-16, *19-20 and *38 are also associated with lack of enzyme activity identified with bufarulol, dexromethorphan, debrisoquine or sparteine. However, these alleles are rare. Some 35% of Caucasians are intermediate metabolizers (IM) with a combination of one functional CYP2D6 and one mutant CYP2D6 allele.
The combination of genetic polymorphisms and IgG challenges with subsequent aberrations in receptor site efficiency is well documented as predictive of treatment failure.
cp
In addition: the average doc has no idea about IgG at this time, finds it either suspicious or “unproven,” and is clearly not aware of the pervasive world literature on these matters. I suggest you find a provider who can, as we can at CorePsych, send you testing and interpret it for you to discover the underlying problems.
cp
Dr. Parker,
I am a 50yo female, who after too many years of letting acute ADHD, undiagnosed, dictate my life, am trying to get help. Was tested and diagnosed and put on Adderall 20mg am/pm. I mentioned to my doctor that I have a tremendous tolerance for any type of drug I have taken and needed three to four times what a “normal” dosage would be for it to be effective also when I was in the hospital for a broken leg from a car accident the morphine they insisted on giving me was ineffective and I was treated like a drug addict and lastly the epidural I was given at childbirth lasted about ten minutes. Oh and I have had dentists call me a liar when I tell them I can still feel the pain from the drill after several doses of novocain.
I was willing to give 20mg a try, being someone who prefers not to take drugs. Sadly, at 20 mg 2x day I could not feel any difference. After two weeks the Dr. put me on 40mg am and 30mg pm. At 40mg I had a few minor side effects of taking something, however no mental clarity and it wore off quickly. Next visit he took a saliva swab.
The results were not surprising to me, I am CYP2D6 UM (ultrarapid metabolizer) (Genotype: *1/*2xN)
My doctor has no experience with this and I will be patient while we work on a solution. I was searching for some insight when I came upon your site, you talk a little about this, like here you talk about the opposite, people who are PM or IM, and I am looking for suggestions from experience with UM. Is it effective to take a med that slows the metabolization along with Adderall or is there an ADHD medication that takes different pathways to achieve the desired affect that would avoid the CYP2D6? Is it possibly effective to take a low dose every hour? I really would like to avoid adding medications, however your explanation of why this is sometimes necessary was helpful.
I am very thankful for any thoughts or suggestions?
Sincerely,
Not feeling very hopeful at the moment.
Debra,
When serious metabolic issues prevail we consider several tests. See this pdf list with links to review a video and look at research to consider next steps. Honestly, I would strongly recommend OATS as described in the video – not asserting that you have yeast issues, just that it covers so much territory. -> http://www.corepsych.com/tests14
cp
I will certainly request the OATS test. I seems the results will have a number of clarifications that would be helpful in my treatment.
Thank you for your input and all the information you offer on your site.
Debra,
That one is really instructive and loaded w great info. Good idea, hard to miss w that one.
cp
Debra,
Thanks, best wishes on your next discovery steps!
cp
Thank you so much for this knowledge. I was at 50mg Vyvanse, and it wasnt working quite right and wearing off around 4pm. Went in to see psychiatrist and he upped morning dose to 60mg and added booster(vyvanse) 20mg at noon. After a week of being on 80mg in total and thinking I was going crazy I came across this site this morning. I was still all over the place from the 60mg Vyvanse but didn’t take the 20mg at noon. It’s now 2:30 and I don’t feel like I’m on an emotional roller coaster. I feel less angry. And I don’t feel depressed and like I don’t want to do anything. I have been on Vyvanse for a year and I never would have thought to think the medication being too high could do this to me. So called pharmacy and they are going to call and get me back down to 50mg with booster. Again thank you for the information
Jessica
Jessica,
That’s exactly what to do… going up only 10mg [good judgement] should have taken you only 2 hr further thru the day. That 20 mg at noon, not my style. To be out the top on 60 does indicate that you very likely have a metabolic slowing problem… so don’t throw in the towel if this next adjustment doesn’t work as expected over time. You very likely will have a Roving Therapeutic Window – but who knows, it may be just the ticket.
Hang tough, it does work if you measure and think about it. Look for a vid coming out soon – specifically on Vyvanse Titration.
Thank you,
cp
I am female 54 been on 40mg of vyvanse for three years but my blood pressure is thru the roof. I have a very negative family history of heart diease. My dr wants to put me on a beta blocker to help the bp. Today I decided to stop the vyvanse cold turkey. doc said that is fine too. Ugh…I take the med for the buzz and the feeling to have a quality life but it does not really help my ADHD. Or maybe it does and I forgot how. I am really relient on the vyvance for the pick me up. Tried stopping it last summer and stayed in my room most of the time. I had no desire to socialize. Vyvanse did make me look bipolar and act way different than I really am.
Joan,
Everything you report here about Vyvanse leads me to several conclusions:
1. Your treatment targets are unclear for you, so you watch the buzz as a means of dosage measure – an inaccurate objective. See this video playlist to help clarify objectives: http://bit.ly/medstutorial
2. Your dosage strategy appears to be taking you out the top of the Therapeutic Window as in this posting. See this video playlist to tighten on dosing: http://bit.ly/dosevids
3. It sounds like you are missing 1/2 of your diagnosis thus ensuring that you and your med team will likely use stimulants to correct most symptoms vs the correctly differentiating the serotonin objectives and strategies: See this video series to learn from your med problems: http://bit.ly/7PMdrops
A little homework can turn the tide and help answer your questions.
cp
Thank you so kindly. I have been reading and listening to your material. Fascinating! My 16 boy has ADD …we don’t seek counseling for him because the meds don’t work for me nor did counseling (my regular DO doc gives me the Vyvanse)I cannot see them work for him. He has executive functioning and written expression issues along with awkwardness in socializing. I am discouraged because I don’t see help for us. We are in the Chicago area…NW subs. Wish we had a knowledgable doc like you…you could save us. Do you have reputable colleagues in the area? Also, I am on thyroid meds,,,,the generic Synthroid. I always feel awful on it…I have asked if I could get off but my doc says my blood work looks normal with it. Maybe thyroid med and vyvanse not good together? Maybe why vyvanse worked short term. You are right I was looking for the buzz factor to see if it were working. I cannot even tell if it worked but liked the buzz. Now that my bp is averaging 170/95 on the med I am afraid to take it. Today is day 2 of no vyvanse…i am getting anxious and my appetite is out of control. I will continue to learn from your material but I have a problem expressing and retaining…that anxiety that gets in the way. Both types anxiety…thinking and thinking but shut down and unable to act. I am praying, too, and hoping someone can finally help me so I can help my beautiful boy.
Joan,
We can, and do, consult long distance everyday, so take a look at http://corepsych.com/services wherein w can provide, thru Desiree, a Brief Chat [see the protocol there]. Thru a consult there we can work w a doc in Chi-town [Park Ridge?] – but we can figure that out when we talk. Counseling doesn’t work as well w/o the meds balanced. Take a look at the GI videos and do the Transit Time Test – then we can discuss by phone.
Talk soon,
cp
Thank you…I will take the transit CORN test I saw that in an earlier video you were in with Mr Copper. Interesting! I just downloaded your book on my kindle looking forward to reading it. Park Ridge is not too far away but not close. Anyone in Lake Zurich or Barringtin area? Seeing my doctor again today at three to let her know my second day w/o vyvanse and BP is spiking. I am scared. Maybe I better take the beta blocker she prescribed two days ago. I was hoping to just sacrifice not taking the vyvanse so I don’t need a BP drug. Maybe I will need a BP drug even w/o vyvanse.
I will schedule a chat with you after I complete the transit test and read the GI videos. BTW…I was Dx with IBS years ago. I have extremely high cholesterol/triglycerides and stopped taking Liptor years ago because I think it is dangerous and overprescribed. I am pretty sure I have food allergies…I always feel sickly. When I follow the Adkins diet most gut symptoms diminish and so do my high lipids. But the diet doesnt seem realistic. Maybe I am allergic to dairy as well. Have no idea. But never feel well.
This is a big question from me…Does synthroid interfere with vyvanse?? Wish I could find a good thyroid doc who takes appropriate testing for it. I convinced a doc many years ago to put me on the meds since I was having symptoms but not apparent on blood work. Been feeling sick for years. My weight shot up soon after taking synthroid…now I am stuck on the med and feel worse.
Thank you so much Dr Parker. Have a blessed day.
Joan,
Thanks for your kind remarks!
1. No, Synthroid not a problem w Vyvanse. Synthroid, just as Vyvanse, can fix those thyroid symptoms, but if you have an underlying food allergy you can shoot blanks w meds for many more years. Wise to test with whomever. IgG issues effect thyroid directly. See this book Why Do I Still Have Thyroid Symptoms? Reviewed at this link: http://astore.amazon.com/cpbks-20/detail/1600376703
2. That cholesterol, etc, all likely downstream from IgG problems.
3. Meds almost never work correctly w all of that background noise.
My first serious girlfriend lived in Park Ridge – dated her in high school while I attended Culver Military Academy. Super family, great times there and in Chicago.
You’re on the Path to self discovery,
cp
Sounds like possibly low serotonin levels as well but I’m not a doctor, just a patient who is fascinated with this stuff! (lol).
You’ve come to the right place, Dr Parker makes so much sense that it is quite ridiculous that mainstream medicine hasn’t caught on!
Mike,
Thanks – and you don’t have to be a doc to understand the process. It’s my feeling that a dissatisfied public will ultimately encourage the important next level of dialogue.
cp
My child has been on Vyvanse for two days after being on adderall xr for about 8 months. Adderall work up until about 3 weeks ago. Within these two days the teacher and I noticed a change in just the first two hours. Then is was like a switch and he went back to running, etc. The teacher comment today was “I thought thank goodness we found something to work” but was disappointed when after two hours it failed. Does it take a while to get into your system? What could be making this happen?
Annie,
Multiple issues on why it works then doesn’t. Sometimes Vyvanse works even when Adderall doesn’t, reasons unexplained. By far the more explainable, most recognized and most correctable reason: associated metabolic challenges with the Roving Therapeutic Window.
cp
Hello Dr. Parker,
I was recently diagnosed with ADHD as well. My doctor told me to start with 20mg of Vyvanse. The first day, it seemed to work, but I realized that it was only a placebo after taking the same dosage the next day and not feeling anything. Since my doctor was on vacation at the moment, I was not able to speak with him and took 40mg of Vyvanse the third day at 8:00 am after speaking with my cousin, who has been a long term user of the drug. After an hour, the drug started working. I noticed that my concentration improved and that I was able to access my short term memory faster, which helped me complete my work at a faster rate and the quality of my work was better, since I stayed focused only on work. Everyone around me saw that my mind was sharper and that I seemed more intelligent and I sort of felt that way since I could access my thoughts faster and clearer than before and I was able to analyze and do tasks involving logic at a faster rate, since nothing was blocking or distracting my mind (I know that Vyvanse does not make you smarter). I also noticed that I felt anxious, but unlike other times, this was over nothing.
However, this anxiety did not interfere with my work and almost disappeared while I worked. When I did not work, I noticed this feeling increased and all I wanted to do was another assignment. Things that I would rather do than work, such as watching tv, going on a run, etc. no longer interested me because all I wanted to do was work. The drug wore off at around 6:30 pm and I became more like myself again, but at night I went to asleep during my regular bed time and could not fall asleep for another hour.
On the fourth day, which is today, I took 40mg once again at 8:00 am, with seven hours instead of eight this time, and I experienced the same feeling, but the drug wore off by 2:00 pm and afterwards my thoughts were cloudy and I felt irritated and no longer wanted to do anything with work. Today, I did two hours of math from 9-11 am and then took a break for two hours before doing more math, during which I could not think clearly and was not focused. Afterwards, at 3:30 pm, I took a break for two more hours, since my cousin told me to take breaks between assignments so I would not be overwhelmed, and then did another practice essay for the exam. I found that it was harder to write an essay than when I was on the drug and after only two paragraphs I could not do anymore writing due to exhaustion and have not done any work since. My mind feels cloudy and I feel restless. I also have had a slight suppression in my appetite these last two days.
Are these pauses from work what causes the drug to wear away? I have been taking the pill when I wake up and then I proceed to eat breakfast a half hour later, should I do the opposite? Is my dosage incorrect, or should I modify the way I ingest the pill? (e.g. 20mg in the morning and 20 mg in the afternoon/ mixing the 40mg pill in water instead of swallowing it)
Unfortunately, I cannot consult my doctor until later this week, but I have a major exam tomorrow. I was planning on taking the same dosage at 10:00 am tomorrow due to the fact that my exam begins at 1:00 pm and was thinking about doing an essay prompt beforehand while under the drug, to prepare for my exam.
What do you think I should do?
Thank you for your help!
Alex,
Sorry, inappropriate for me to guess out here on the Internet, hope you understand. Too many variables… but does sound like you are on the right track. Use your intuition and check back w you doc. Catch the Therapeutic Window as best you can.
cp
Hello Doctor,
I was recently diagnose with ADHD and started on 30mg of Vyvanse. I am a 30 year old female. I take the Vyvanse in the morning around 7 am but by the time I am at work at around 9:00 am, I am so anxious I can’t do anything. Right now, I am in my office and am supposed to be seeing clients but I am too anxious. My chest feels tight. I feel like my heart is racing. I have had this same problem every day that I’ve taken the vyvanse. It is about 11:30am right now and based on my experiences over the past few days, by about 12:30, the anxiety will decrease enough that I can go about my day and do my work. I am thinking of titrating down to 20mg tomorrow. Thank you!
April,
Sorry a bit late, definitely would consider that Vyvanse is too much. I always start w the too much theory when in doubt. Look at the Water Titration Strategy here, talk w your doc as it has recently been approved, after 6 years, by the FDA.
cp
Hey Doc!
I’ve been prescribed 50mg vyvanse for over 8 months, however it doesn’t seem to last me very long. My DR prescribed me 10mg Dexmethylphenidate for the afternoons to combat the issue. I’ve noticed that the dex makes me extremely anxious, as where I am in a profession where I need to stay calm (Fire Fighter/ Paramedic). I discussed this with my Dr, and asked him if there are any alternatives. His response ultimately was writing my a script of 60mg vyvanse. What would you recommend me doing?
Conner,
If Vyvanse doesn’t last 10-12 hr in DOE, your doc, in my opinion was on the right track. However, there are many other variables and it simply doesn’t work as expected every time. I don’t recommend chasing an amphetamine product with a methylphenidate product as more often than not they interact negatively. Best to use an immediate release adderall or small amount of Dexedrine as a PM coverage – to stay in the same family of meds, as that process most often works best.
If the 60 Vyvanse works better, that is the easiest and best solution.
cp
Hello Dr. Parker,
Im from Germany and i have a question for you. Im taking 70 mg of Vyanse and my doctor and i are thinking on combining it with a antidepressant.
The question is, which antidepressants are allowed to be use in conbination with Vyanse??. I read that some of them could cause a Serotin Syndrom in combination with Vyanse.
Looking forward to your answer
Greetings
Andres Faba
Andrea –
Several reasonable drugs listed in the last paragraph here: http://www.corepsych.com/2009/12/intuniv-for-adhd-avoid-drug-interactions/
Do watch this score card, and more notes are here: http://www.corepsych.com/2013/07/adhd-depression-the-kelsey-score/
Hope this helps!
cp
Hello Dr. Parker,
Thank you for the information you’ve provided. I’ve been taking Vyvanse on and off for about three years now and would like to get your perspective on my DOE and symptoms, if possible.
I’m 34 years old, married with three children, and I am a lawyer. The medication has worked wonders for me in terms of keeping up with both at work and at home. Without it, I am a total wreck. While in college, law school, and the early years of practice, I self-medicated with a combination of alcohol and caffeine and did quite well, although I was very unfocused.
I reached the point where I was having severe panic attacks and fialed to meet several deadlines at work. I lost my high-paying job at a private litigation firm and am currently working in a lower-stress, (but less satisfying and lower-paying job) as a result.
Right before I was terminated in 2010, I finally got up the nerve to visit a psychiatrist. He promptly diagnosed me with ADD and some form of depression/anxiety disorder. Since then, I have taken some form of anti-depressant/anti-anxiety/add med, except for when I became pregnant with my third child. I stopped while I was pregnant and nursing him, and I restarted the medication again about three months ago.
I was initially on Adderall and Well Butrin, which together caused several negative side effects such as increased anxiety, to the point where the doctor began prescribing 2.5 mg Xanax as needed for panic attacks. Then I was moved to a combo of Vyvanse and Citalopram. When Citalopram was no longer effective, I was moved to Vyvanse and Zoloft. Prior to my pregnancy, I was on 70 mg of Vyvanse and 100 mg of Zoloft, which worked well. I was also given either Dexadrine IR or Adderall IR to take when the medication wore off, which I found consistently happened around 3:30 pm, if I took the Vyvanse at 8:00 a.m. or so. I would take one or two of the IR tablets to get me through the late afternoon and evening, and then I would crash. I have never had any problems sleeping on this medication, and didn’t question the regime or ask whether the doctor should others increase or lower my dose. I just figured that for whateve reason the Vyvanse didn’t last as long as it should and that I could just deal with it by taking the IR at the end of the day, and would just have to deal with the crash.
My doctor also advised me to take a break on the weekends. This has been hard for me, since I’m technically “working” all weekend running a household with three small children, and frequently need to take care of bills and other items that need my attention. To assist me with accomplishing things on the weekend, my doctor suggested I take an IR tablet when I needed to accomplish something, which has been only moderately successful. The problem is that it lasts for just a few hours and the crash and extreme irritability after the IR wears off is way too pronounced for it to be of any benefit to me.
The regime I’m on now is largely the same (Zoloft and Vyvanse), but instead of 70mg, I’m on 60 mg. If I take the pill at about 8:00 a.m., focus and mood are great until about 12:30 p.m. Then I get this sudden extreme sleepiness, fatigue, and completely lose focus. Sometimes, it is accompanied by my heart pounding and beating quite fast (this does not happen any other time). About an hour and a half later, I will feel moderately focused again for a short time. And by 6:00, the focus is gone. This makes it very difficult for me to do things like get dinner on the table, get the kids ready for bed, and complete other household tasks.
The confusing thing is that sometimes around 8:30 pm or 9:00pm I’ll feel a resurgence in focus that lasts for one to two hours. This happens usually when I do NOT take an IR tablet to get me through the end of the day.
I don’t know what to do and I’m not sure that I trust my doctor’s point of view. When I called to tell him about the problem I was having, he suggested I take Dexadrine IR three times a day along with the 60 mgs Vyvanse. I took this for a few weeks but it only made me have increased anxiety and irritability and didn’t do much for focus. He then said that I could either try 80 mg once a day or 40 mg twice a day, and he ultimately wrote me a prescription for the 40mg twice a day.
I haven’t filled the prescription yet and I’m still taking the 60mgs once a day, sometimes adding in the IR at the end of the day, and I’m losing valuable time when the Vyvanse stops working midday. Can you offer any insight? Do you agree with his recommendations or do you suggest I ask him about altering the dose in a different way? If you agree with the 40mg twice a day, when would I take it? The doctor suggested I would take it sometime in the early afternoon when I feel it dropping off, but your article suggests taking it around 11:00 a.m.
On another note, I had to start taking Losartan HCTZ for elevated blood pressure that I seem to have only while taking the Vyvanse. While both the psychiatrist and cardiologist I visited think this is not a big deal because I am otherwise healthy and not overweight, I am a kind of uncomfortable with it (and also with the fact that sometimes it causes my heard to pound and beat fast). I wonder if it will do me more harm in the long run and put me at risk for heart problems. The benefits of Vyvanse are so great in terms of my quality of life that I would very much like to continue treating my ADD with it or with something similar. Is there a non-stimulant or other stimulant medication you prescribe to your patients that is comparatively effective and doesn’t have the blood pressure or heart adrenaline problems? My doctor seems to think that nothing else will work for me since I’ve had such good results on the Vyvanse.
Finally, do you know any doctors in the Washington, D.C. area that specialize in ADD? While I appreciate everything my Doctor has done in diagnosing and treating my ADD, I’m not sure that it’s the right fit for me and I want to see someone with a bit more specific expertise.
Very sorry for the length of my message–and I am very much looking forward to hearing from you!
Mrs,
Yours are problems we see far too frequently, and while I do understand what your doc is doing I also, simultaneously do think there are some ineffective recommendations.
Brief notes:
1. Do the Vyvanse at 40 mg 2x/day just as described in the article as you discussed.
2. Watch the PM DOE so that your sleep is not compromised.
3. The energy flip in the pm w/o the Adderall is likely due to metabolic issues which aren’t apparent because you take care of yourself.
Consider a phone consult w me, fill out the forms and we can test you for additional challenges, ask you some additional questions and figure out what to do next. If that works out we can follow you in person if you pop down for a summer stop in VB as we see many folks at CorePsych from DC having worked up there for years. Yes, making business, but – more importantly – directly addressing the causes of your refractory problems which are likely beyond a quick comment here.
cp
Dear Dr. Parker,
I’m so pleased with the formal information that you have made available to the general public. I found this website by google “Vyvanse half dose”, and happen to click on website and enter the world of logical, informative, useful, information about ADHD.
I have asked my son’s doctor about lowing the dose of Vyvanse cause the effects on my son was cause to be concern, loss appreciate, sleep, anger, frustrations. crying spells, these side effects were worst, vs. when he wasn’t on medication. I asked, “if there is anyway of splitting the 20mg dose, his reply said, “no because they would be no way of measuring it, lets try another one’.” But I don’t want to try another one, I think his anxiety would become worst on other stimulants. That’s when it gets scary for parents and him too.
We are starting back on vyvanse 2 weeks before school starts, with half dose of 20mg with the water titration method.
I plan to be aware of duration times and top of the window. In case I need to up the dose to 15mg. can you give me some directions on water titration recipe? Grateful for all you do. Fran V
Fran,
Thanks, appreciate your kind remarks, glad you found me. Stay tuned for a serious blogging experience this fall to get on the map with my book. Those planned 91 short posts will detail brief outtakes on info from neurotransmitters to glial cells and immunity – profoundly important details too many are missing – sign up for the blog to get them.
To answer: This next step is really easy after the first one: divide the 20 mg into 4 oz of water, and just give 3 oz = 15mg, save the 5 for the next day, or toss it, depending on cost-to-toss. Best,
cp
Michele,
The problem with any evaluation, either testing or clinical inquiry, is that the reading can appear as too little and still be too much – been there done that. Too much = decreased concentration.
cp
Michele,
My quick take, complete speculation, is that she is on the wrong dose, that it has been cranked too high and she is overdosed.
cp
Angie,
Good question! Both Cymbalta and Wellbutrin create a ‘moderate’ inhibition of 2D6 and the two together are likely creating your Vyvanse challenges. An antidepressant that doesn’t block 2D6 such as Effexor, Lexapro, Celexa, etc would likely work better if your doc is willing to give one of those a trial.
cp
Franco,
I disagree with the way your doc is suggesting titration should take place. No, I’m not a control freak, I simply know it takes a good while to appreciate the downturn on Vyvanse… it’s just so well released.
Do go down on the blog to Ezine Articles: I have many there on the window, and my new book hits that subject in great detail – the Med Rules book.
Hope this helps, you’ll get it if you stay with it!
cp
Thank you for sharing your research.
I am in my 30s, and I was just diagnosed with ADD a few weeks ago, when I had severe problems with attention and concentration at work. After a lengthy session, my internist started me on Vyvanse. She gave me a script for 20mg and 30mg of Vyvanse. She told me to
start with the 30’s, then, using a combination of 30’s and 20’s,
increase the dose by 10mg every three or four work days, continuing
whatever dose I was on Friday over the weekends. She told me that when I
think I’ve reached “nirvana,” I should try going up one more dose, then
if I’m overfocused, I’ll know it’s too much, and I should settle on the
dose right before that, but if that feels fine, I should continue.
The problem is, I am very unobseravant/unaware when it comes to what is
going on with my mind/body. 30s felt okay.
Since this is my first experience with ADD meds, they gave me a nice
little boost in the morning (I set an alarm for 30 mins before I need to
get up at 7:30 and take my meds and go back to bed until my second
alarm tells me to get up), and I was very productive the first weekend.
I think, though, that the novelty wore off quickly, and now I’m more
altert in the AM but not as peppy as at first, and on the 30s I fell asleep at home after work by 7pm. I went up to 40, and
though I overdid it one day by having coffee (I know, what was I
thinking?), the side effects weren’t too bad. I’ve been thirsty with
decreased appetite, and my leg will shake up and down if I put my foot
on the floor at my desk. I immediately noticed that I was able to focus
on my work. While I did feel tired around 6 or 7, if I powered through
it, I could stay up to midnight or so, since I’ve always been a night
owl. Vyvanse seems to come and go so subtly, I can’t really tell a difference at DOE in the doses above 40mg, other than the fact that I don’t pass out as soon as I get home.
While I feel like the duration is fine, I still haven’t gotten to the
point where I feel overfocused, so now I’m up to 70mg. I
don’t feel much difference in my concentration, and I actually feel like
my leg shakes less on this dose. However, I have had a headache both
days on 70s, starting in the morning. This could be due to the fact
that starting the 70s coincided with starting my period, though I don’t
think I usually have headaches on my period (I said I was bad at
noticing these things, plus I’m on seasonal birth control, so I only
have a period 4 times a year).
So, I’m wondering if 70 is too high and that’s why I’m having the
headache. Also, I felt fine on 50 and 60 though oddly 70 makes my leg
less jumpy. Does that mean I should have stuck with those doses? Or
can side effects at lower doses mean they’re not high enough? Or is headache such a mild side effect I should stick it out? What I’ve
read on your site seems to say that you should use the minimum effective
dose, so if I can concentrate on my work at 50 or 60 mg, I should stick
with that, and they seemed to imply that you find the dose by timing how
long it feels like the meds last, though again I can’t really tell when
the Vyvanse wears off. But my doctor seemed to imply that she wants me
on the highest dose before I become an ogre who will bite your head off
if you interrupt me. I don’t want to keep going until I reach 140 and
have some toxic reaction. My doctor has ADD herself, so maybe she’s
describing her experience and my body chemistry is different. I just
don’t know how this stuff is supposed to make me feel, since I’ve never
taken any other meds like adderall or anything. I’ve never had to work
out dosage of anything myself, so this is confusing.
Could you please give me some advice as to how to determine when the side effects are noticeable enough to constitute popping out of the top of the window and how to find the right dose? I understand the DOE concept, but I don’t know how to find it!
BTW, I’m also taking Cymbalta and a beta blocker, if that helps.
My son is on 10 mg..as I wanted to start him off slow and titrate up. I am seeing the problems of what you are mentioning above but the video is removed. I really want to do whats right for him because this is the first time he is on meds. The med makes him more subdued as opposed to his natural hyperactive self. When it wears off, he is double the amount hyper, it is almost like he is manic. now, today the medicine wore off and he was tired and in bed relatively earlier. When the medicine leaves his system, is there always the same effect because the difference is night and day of the extreme hyperness he had when the medicine was gone. But today, tired.My question is …is this not adhd but another mood disorder. Can you tell from a difference in how he reacts when the med starts to wear off. I was hoping to get a happy productive in control response to vyvanese. Isnt that what most people experience.I am getting a tired and serious , still unfocused child with little drive to do anything school related. Increase, change meds. Dont know what to do. I want to get the base tests also to figure out where he stands healthwise.
Allison,
He is having a somewhat atypical response to Vyvanse [BTW check out this ADHD Med Tutorial page for a collection of videos]. The underlying challenges and actual contributory factors require many more questions and more specific info than you have here – having said that I completely agree that he should have more precise testing if the problems continue.
On the surface of matters:
1. Make sure to check the DOE, he might be on too little.
2. Comorbid depression will often create mood swings when stim meds wear off.
3. Bipolar is unlikely w/o previous bipolar symptoms firmly in place.
4. Metabolic challenges are likely to coexist and could be evaluated by more specific testing.
cp
Fascinating article — it’s refreshing to see a doctor so engaged with science. (wow, that sounds odd — one would think all doctors are engaged with science!) Is the video for this article still accessible (I think it says that it’s been removed). Speaking very generally, do you think that “top of the window” side effects generally mirror the blood levels of the medication at any given time? For example, many doctors say that if side effects like overfocused intensity occur at 3-5 hours (i.e., when a med like Vyvanse is at it’s peak), it means the dose is too much, but if they occur after 6 hours, it’s really “rebound,” but it seems like you’re saying that it can follow another pattern such that when the dose is too high, the effects may actually seem normal until later in the day, and thus the dose may be mistaken as too low (or I may be misreading).
Because of how steady Vyvanse, I think this can make measuring DOE even harder in light of all this. How do you get your own patients to precisely measure DOE when Vyvanse can be so mysterious?
Joey,
Have been meaning to get another video up… the previous was a bit over the top on the abuse research, diminishing the potential for problems. Just have to get another one done, and will do so when I get back on track after the recent office changes. Lost my right hand woman to the entertainment industry [her life passion], hired another, she didn’t match, and have been training a great new woman, so much background noise at my shop.
You are reading it quite correctly. The hyperfocus is a problem just as you say. Excellent last question: can only be answered by precise measurement of objectives on the front end, see my paper on Precise Solutions, and my new book, which will be out late March early April for details. White paper, Precise Solutions for ADHD Meds is free here.
cp
thank you. but thanks the same is what Dr.Tisnado told me thank you agin.
hello im sorry this idatic question but i need a prfesional advice. also sorry for my inadicuqet spelling and grammer. Im 15 years old and i takeing 40 mg of vyvanse. my questiond is does caffine cut the effects of vyvanse. the curiuse thing is that 2 to3 mounths ago i went from 50 mg to 40 mg. These was so because i was felling very strange. first i toke estatera then retaline then aderal and finaly vyvance.the doses of the rest so wat is your oppinion.
Javier,
Caffeine could cut the effectiveness of any of the stimulants by taking the person into a state of excess stimulation, thereby diminishing the effectiveness. I do recommend that you make sure you talk with your doc in detail about questions like this – if the doc knows the problem it is more likely to find a good solution.
cp
Dr Parker,
What is the effect of Vyvansse on Bipolar symptoms. As you know, I am once again trying to titrate up on Vyvansse and we started VERY slow at 40 mg divided in half to start. It is hard to tell what symptoms are Vyvansse but it seems like it aggravates cycling of moods during the day that resemble a worsening of my bipolar cycling of moods. Vyvansse seems much worse at this than the other stimulants that just give a high rise then a quick drop. I know this is normal for Vyvanse, but wonder the direct effect it has when added to the already cycling moods of bipolar, and if a more straightforward stimulant might be less complicated to moniter?
Also, it causes such a hyper focusing at first (I think this is where the OCD part of me kicks in) that makes it difficult to get anything but that one thing done, followed by a scattered, disorganized, forgettful feeling mentally which causes one to feel they need to see an ADD dloctor for meds!!
I know the goal is to get the dose high enough to put off the twilight zone feel until night, but I’m not sure all the rest of it is that great either. This might be because of the bipolar thing, and that’s why I was hoping you would shed light on the difference between Bipolar mood cycling and Vyvansse mood cycling, and how one would know the difference.
Thanks!!!
Lorre Hopkins
PS I know you well enough by now to expect you to say that treatment with Vyvannse should improve the symptoms of many who have a Bipolar diagnosis, because they are misdiagnosed. So I am only writing from the theory/assumption/viewpoint that the person truly is Bipolar and responding well to mood stabilzers, but also is AD(H)D.
Lorre,
You did a great job of tagging my theory and philosophy correctly, but you also know that I am, as I said below, always instructed by what is actually happening with you, with your perceptions. If it isn’t right, no matter what the expectation, it’s wrong. Mood disorder, an excitatory imbalance in the neurotransmitters can be significantly stimulated and aggravated by any stimulant, period. Looking forward to checking out the neurotransmitters, and suggest that you hold on Vyvanse until we have that conversation.
Don’t push it too long, we can discuss it later – and remember my oft stated other rule: If it isn’t working as predicted, and you had that great protein breakfast, then don’t take it. I don’t try to treat ‘on the label’ but the brain function. If the function is off with the med, then the function must be addressed and corrected whatever the diagnostic profile.
Talk soon,
cp
Dr. Parker,
I was perscribed to take a 50mg doseage of Vyvanse a little over 5 months ago and it has been nothing but beneficial to helping me maintain focus and has increased my memory retention ten fold. The issue I’m having is that I had to step up to a 70mg dose a few months back due to the 50’s wearing off in the middle of the day. I noticed that even though I am an occasional smoker that my cravings for a cigarette increased dramatically from day one. I started to notice that after a few months I started to feel depressed and would just have feelings of wanting to cry for no reason. I have a theory and I wanted to get your opinion on it as to why this is happening. I feel like the stimulant effect from the nicotene is causing me to hit the “top of the window” while being on the 70’s. I have lost about 20lbs. over the last six months as well due to me making a diet change and actually being able to stick with it on my mediciation, and not to mention the obvious metabolic increases that a stimulant brings. Could my now smaller size paired with the nicotene and the 70mg doseage be pushing me over the window? What about when being paired with caffeine? I drink about 3 cups of coffee in the morning and have a vitamin rich sugar free energy drink in the afternoons…but it has a high amount of caffeine in it as well. I suppose it’s a moot point as I desperately need to stop smoking for obvious reasons, but I want a professionals opinion as to why there would be such a “depressed” if you could call it that, feeling that seems to plauge me now when the Vyvanse is supposed to be working its best. Would the best remedy be to go a natural diet that completely cuts the caffeine to maximize the positive benefits of the Vyvanse without the terrible “sadness” that comes otherwise? Any help or guidance would be greatly appreciated!
Chad,
Yes to all of the above! I completely agree with your considerations, as every one of them may have some good ‘sea legs’ when sailing out tomorrow. Each of our suggestions is likely true, as you are confusing your various neurotransmitter receptors with your current self conjured brew.
Having said that I would suggest you look at this video which outlines the Dopamine/Serotonin seesaw and Cognitive Anxiety at CorePsych – a possible contributing factor to the depression side.
Additionally, it is an easy speculation to suggest that your NT [neurotransmitter] dysfunction includes other heretofore not considered NT imbalances discussed in detail on the CorePsych Neuroscience page. Reading there will take you down many new paths that will very likely prove relevant.
cp
Dear Dr. Parker,
It has been 10 days since I sent the first email about my brother and our fear that the 70 mg dose of Vyvanse was causing severe restlessness, tremors and insomnia. We took your advice – skip two doses, start taking half and then go to a lower dose for an extended time. His doctor agreed and gave him a new Rx for 50 mg. The anxiousness stopped within days and the insomnia within a week.
Thank you so much for your guidance. We will monitor the 50 mg closely and decide whether any other titration is needed.
Unfortunately, days before I corresponded with you, his doctor thought the best way to treat the anxiousness was to switch him from Lexapro 20 mg to Pristiq, and had already begun that process. So, he is undergoing both medication transitions simultaneously. His doctor recommended the following course: Start taking Pristiq for 1 week with the Lexapro, cut the Lexapro in half for the second week along with the Pristiq, and then take the Pristiq only. He took his last dose of Lexapro a few days ago and is now feeling depressed, discouraged and hopeless to the point of crying. I know this can be withdrawal from the Lexapro, which he has been on for years. Would you recommend he go forward with the change to Pristiq, and, if so, do you think the course described above is not too abrupt? I have read horror stories of SSRI withdrawal and note that many people weaned off far more slowly. Does adding the Pristiq lessen the severity of withdrawing from Lexapro?
We seem to move from one issue to another because fine tuning medication is such a difficult process. Our doctor is fairly aggressive in prescribing, which is great when it’s a match, but scares me now that I see how long it can take to make up for going in the wrong direction. I just want to make sure that the change from Lexapro to Pristiq is not setting my brother up for weeks of possible withdrawal and/or side effects.
Thanks for the help you have given thus far. We are certainly becoming more literate about this crucial facet of treatment.
Sincerely,
Anne
Anne,
Slow and steady is always better with SSRI discontinuation – even if covered by another SSRI. Different receptors are covered differently by different SSRIs. I have found it necessary to slowly transition from Effexor XR to Pristiq even though they are apparently the same medication – in truth they are different as well.
cp
I can relate to all of these problems with Vyvannse. It’s biggest problem is that it is so subtle you don’t recognize the same feelings of being over medicated like on other drugs.
Lorre,
So true, just finished a post on the details including Anne’s note – We see these problems all too often, because Vyvanse is so forgiving.
cp
Dear Dr. Parker.
Your articles and videos have helped so much in navigating the crazy pathway to treating ADD. I serve as my 52 year old brother’s ADD coach. He was just diagnosed two years ago, after a lifetime of failed jobs, frustration, alcohol abuse and all the other common experiences of others in his situation. He was diagnosed with depression years ago and has been on Wellbutrin and Lexapro for years and continues to take both. He is also one of the nicest people in the world.
After reading about and realizing that he has classic symptoms of ADD, we found a psychiatrist with expertise who tried him on several stimulants, finally settling on Vyvanse. This made such a tremendous difference in his executive functioning, success at work and self esteem! The doctor started him on 30 mg and quickly switched to 70. At the time, the other doses were not yet available. He has been on 70 mg for a year and a half. The only negatives were that every once in a while, he would go through episodes of agitated, short-tempered, hyperfocused behavior – especially at work. These were very out of character for my mild-mannered brother and very short-lived. He would call me, incensed at how others at work weren’t doing their job, his boss was treating him like a peon, etc. His language and tone were very volatile and his perspective seemed irrational. Without exception, within 24 hours, he would be calm and rational and question why he had reacted with such ire.
These episodes happened sporadically, but increased this past February to the point that he was in jeopardy of losing his job. His boss, who is aware of my brother’s diagnosis and treatment (which includes behavior therapy) made it clear that he might have to let him go. At that point, it didn’t occur to his psychiatrist or me that this could be a toxic effect of the Vyvanse being above the top of the therapeutic window. The doctor suggested it was “shades” of bipolar that are sometimes seen with ADD. He prescribed Abilify, 10 mg daily. The agitation ceased shortly after, but within 6 weeks, my brother became so sedated that he was sleeping 15 hours a day and half-asleep the other hours. When we realized this was a side effect of the Abilify, the doctor took him off. The withdrawal was awful and included tremors, anxiety and sleep disruption.
It has now been 3 1/2 weeks since we stopped the Abilify, and my brother continues to report “anxiety” which appears to be gaining in severity, as well as continued sleep disruption and some difficulty processing thoughts. Today, he described the feelings as “going 100 miles and hour”, “jumping out of my skin”, and “about to explode”. When he lays down to rest, he can’t stop his thoughts.
After reading many of your articles and watching your videos, I am beginning to believe that too much Vyvanse was the culprit all along. He was agitated; treated with a sedative (antipsychotic) that masked the agitation; and now that the sedative is gone, the agitation is returning because the Vyvanse remains the same. He does not seem outwardly angry just continually nervous and restless. The symptoms are not evident when he first wakes up and ease toward late afternoon and evening – which corresponds with when the Vyvanse is active in his system.
Could you please give your opinion? I would like to ask the doctor to lower the Vyvanse dose to see if it would relieve the agitation. If you agree this is a wise course, how low would you start and how would you titrate upward? I have read people’s blogs that claim lowering from 70 to 60 relieved symptoms. Should the doctor start at 30 again, or maybe 50?
Any advice you can give would be a blessing. It has been a long course, with a lot of twists and turns. My brother, like so many others has shown tremendous courage and perseverance, and was just beginning to experience some success and peace, but the events of the past few months are eroding his confidence and he is feeling helpless, as am I.
Thank you so much,
Anne
Anne –
This is such a classic situation, and so well written/reported in this comment that it deserves it’s own blog post. I will comment on it there, but to cut to the chase here – I often go down to 1/2 of the dose in a situation like this [knowing only these variables, and not knowing about other key issues such as breakfast and transit time]. I’m on the conservative side, but don’t think you have to go all the way back to 30mg. My recommendation, because he is having so much trouble: just stop the med for a day or two and expect rebound. Then start back at about 40, and watch the DOE, – specific DOE timing will set the titration perfectly.
My take with this limited info: it’s not the Vyvanse, you’re right, it’s the dose. Need to go more slowly in the first place. Easier on Monday morning looking at the game tapes!
cp
Hi, my son is 7 and has been taking Vyvanse for 3 months now. We were amazed at the effectiveness from the very beginning. He started on 20mg and we noticed a huge difference the first day. However, his teacher noticed that it was only lasting until right after lunch. After about 2 weeks, his doctor raised it to 30mg and the DOE was extended until about 3 p.m. Again, after about 2 weeks, his dosage was raised to 40 mg which is where he is now. With 40 mg, we seemed to have reached the right dosage. His last month of school was great, his “noises” totally disappeared, his focus has been amazing, his emotional outbursts have been greatly reduced as well as other “annoying” behaviors, his self-esteem has been improving, he doesn’t aggravate his sister as much – I could go on and on about the improvements. I only have a few complaints. He has a little trouble going to sleep at night, but he had that issue before the medication! The DOE has never been 12 hours and never gets us through the difficult evening hours. It’s almost like But, it’s still better than it was. Also, his appetite has really been affected. Initially he ate well for breakfast and dinner but just didin’t want to eat anything in between. He has lost about 10 lbs., which in his case, is not a bad thing because he was about 10 lbs. above what he should be for his age/height. I talked to his doctor about all of these concerns at his last f/u visit. She suggested Melatonin for the sleep issue which has helped some. Regarding the DOE, she said he is probably a fast metabolizer and, since he’s doing so well otherwise on the 40 mg, suggested we see how he does during the summer and readdress it once school starts. And, about his appetite, she suggested that we give him a high protein Boost in the middle of the day if he doesn’t want to eat. About a week ago, however, things just seemed to change. It’s almost like the medication just stopped working. All of his “annoying” behaviors have returned, he is extremely emotional, angers easily, calls himself “stupid” and an “idiot” all the time, annoys his sister constantly, and doesn’t seem a focused as he was. And his appepite has gotten worse – now he really doesn’t want to eat breakfast. I make him a smoothie every morning and he will drink that. This morning I got him to eat a Kashi high protein bar. I”ve read alot of your articles on E-zine about the DOE and the “window” and I’m really having trouble deciding if 40 mg is still too low or if maybe we’ve gone over. Any thought you have would be greatly appreciated. Also, what are your thoughts on Melatonin to help him sleep? We’re only giving him 1 mg. And one last question – could his not eating be sabotoging the effects of the Vyvanse? Thanks in advance for your help!
Tracey,
Great note, very typical, but still not quite enough info:
1. Sleep can be causing the regression and sleep does need attention and melatonin in dose of 1-5mg is reasonable
2. Solid breakfast must come before meds not after for the appetite issue and the Boost sounds helpful but insufficient,
3. When side effect appear too much even with the DOE appearing in the right range I fall back one click especially in the summer, and recalibrate.
4. The neurotransmitter measurement on Useful References here has become the absolute next step for acquiring the next amount of necessary evidence. Like anything else in medicine it isn’t 100%, but it is inexpensive and can direct some of the next steps.
5. I always look at mood and ‘serotonin derivatives’ with unhappiness and crashing in the PM the most frequent drop in affect – and that will need to be discussed with your doc for some slight regulation there, or if you do the NeuroScience that will be easier with their precursors.
Some Ideas to discuss with your doc,
Dr. Parker,
I am pretty sure I’m beyond the effective window and was hoping you could elaborate further on how best to handle trying to reset my brain and body. Of course, my current state of mind has me doubting how taking less will actually help matters.
Also, I know Vyvanse is designed for once-a-day dosage, but I am curious to hear your take on, for example, splitting the contents of a 70mg pill and taking the first half in the morning and second half mid-afternoon.
Thanks for this invaluable resource. I look forward to your responses.
James,
Hasty reply but hopefully helpful:
1. Two times a day dosing can be helpful, but have to watch for the problem of insomnia and the second dose needs careful watching for DOE.
2. If your are on ‘too much’ then titrate [adjust] that single dose downward – each 10 mg decrease will decrease the DOE about 2 hr depending on your specific metabolic variables.
3. Often the second dose plan works well if taken before 11AM.
4. Second dose usually helpful with GI disturbance in AM [in spite of that highly recommended protein breakfast] – or with a push to get more than 14 hr… remember that 8hr is what the sleep experts say is needed for brain defrag.
cp
Hi,
I started on Vyvanse 50 mgs three weeks ago after taking Adderral xr 30mgs for over a year. It was much better than Adderral, but my concentration was not great, so my doc upped the dose to 70mgs yesterday.
I also started taking Pristiq instead of Lexapro for depression/anxiety. The problem I am having is that the Pristiq is causing severe fatigue. I am taking it at bedtime, but I am lethargic all day. Should I cut the 50mg tab in half?? Or, will this side effect go away?
I am very fascinated with the different responses I have gotten from all the SNRI’s. Wellbutrin was very activating, but made me mean, Cymbalta made my bloodpressure spike to the point that I could feel it, and now Pristiq makes me feel like I have taken a benzo.
Any suggestions?
Christine
Christine:
Two changes simultaneously might load your system. You are on my personal favorite combo, but they aren’t for everybody. Pristiq will likely be coming out with a 25 mg sometime in the future because some folks do metabolize it more slowly, and fatigue is less common as a side effect.
Without knowing you, and in the context of review with your doc: I have cut the Pristiq in half and have seen excellent results with the slower, lower dosage, and can’t find a specific reason not to do that except the time release delivery system may be compromised a bit. Every single time I have cut it in half we ultimately went to the 50 mg.
Sometimes going from 50-70 on the Vyvanse creates a side effect, – depending on the DOE and other dial-in factors you might need to do 60mg for awhile as you are near threshold for both and thus more likely to go out the top of the window.
Lower, slower and breakfast all help most of the time.
cp
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 Adderal 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.
Daisy-
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].
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] ultra rapid metabolizers as reported in many books such as Drug Interactions in Clinical Practice leaving practitioners with a challenging few that just don’t get right 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 CorePsychBlog and at http://www.squidoo.com/vyvnase%5D is recommended.
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 DOE as noted frequently in these blog posts.
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.
cp
Dr Parker,
I think I might need to cut back-5,6,and 7 are a big problem for me. I am an emotional basket case in the evenings, my husband can’t figure out what’s wrong with me, and my family is scratching their head. My moods don’t even make sense to me. After listening to your video I think I have all of the symptoms listed above. I’m glad I took the time to read your blog and will discuss this with you soon.
If you are out the top, do keep me posted and let’s talk this week after you have reduced the dose-
cp
Clearest explanation to date…I got all the others, but this one was super user friendly!
Thanks Deb!
cp
Dr. Parker, do you believe Dissociative Identity Disorder is a valid medical diagnosis. Do you have any information from your study and research of mental health that you can forward. My wife’s therapist has asked me to research what DID is about. Thank you. r/Ken Martin
Kenneth
Much on the Internet about DID, often associated with specific trauma in the past and PTSD – and can be associated with chronic stress from years of cognitive anxiety.
cp
I do believe that this is what’s wrong with my husband. Especially key points #4,7 & 8.