- To Change Your Mind - Details Matter
Intuniv For ADHD – Details Updated
Vyvanse Dosage Strategies For ADHD Medication Accuracy
December 18, 2013ADHD And EFD: Complexity, Simplicity And Opportunity
December 23, 2013Intuniv For ADHD Is Guanfacine, But Better and Easier
Fresh Day For ADHD
Note: This Intuniv Dosing Post is the second most visited post in my 7 years of reportage at CorePsych – pub in 11/09 – rewritten here with a collection of all CorePsych Intuniv posts linked below for your easy review. Details matter.
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ADHD Medication treatment evolves:
This will be a short note to quickly address the growing comments here at CorePsych Articles addressing the previous Intuniv post. There I discussed reports on the differences between Tenex [Guanfacine] and Intuniv [Extended Release Guanfacine], now that I have seen the action in my office. Tenex, generic name guanfacine, has been used for years with specific good effect to manage and treat the angry and irritable individuals with “ADHD – the Oppositional and Defiant” [if you can only think in appearance -diagnostic terminology].
Remember: Intuniv is not a stimulant – refills on prescriptions become less problematic. This ADHD medication is not a Ritalin or Amphetamine concern!
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Important Differences Between Tenex, Intuniv, and Clonidine
1. Tenex has a shorter half-life, and often requires at least twice a day dosing.
2. Intuniv is once a day, and, interestingly often remains effective for irritability in the next AM – coming up to my favorite subject DOE [Duration of Effectiveness]: in this case – 24 hr!
3. Tenex has peaks and valleys of effectiveness with dosing strategies that require significant adjustments to dial in correctly.
4. Intuniv is easier to dose: See the protocol below.
5. Clonidine is an alpha 2A agonist, encouraging the closure of the post synaptic calcium channel, but also stimulates other alpha 2 receptors [B&C], thereby creating more problems with hypotension [low BP] and sometimes encouraging sleep.
6. Interestingly, Intuniv often provides a significant soporific advantage, with duration in the 12 -14 hr range, often helping with sleep, without further medications in the PM. No dose necessary at the next noon.
7. Added later: Clonidine, just as tenex, is not approved by the FDA for treatment for ADHD, but, interestingly, Kapvay, a long acting Clonidine [FDA Approved Sept, 2010] also adds another option with a more sedative alpha 2 effect – in the same family, not a stimulant.
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Dosing Strategies: Uncomplicated
1. There will be few problems with dosing as Intuniv comes closer to absolute simplicity than many of the other ADHD meds.
2. Titration: First week 1mg in the AM, second week 2mg, third 3mg and fourth week 4mg as indicated by response – highest recommended dose = 4 mg/day.
3. Bottom of the Therapeutic Window – it isn't working – this will be self-evident!
4. Top of the Therapeutic Window is determined by side effects on the forced dose study completed for FDA safety/efficacy approval – simply being soporific [sleepy] or fatigued – the two main adverse effects when the dose was pushed up [too] quickly for the study.
5. Look for an effect lasting 24 hr regarding the Sides of the Therapeutic Window. AM cranky/anger often disappears.
6. Most people were successful with the dose at 3-4mg/day, so be patient, don't rush the increase, watch for side effects, and if it's too much back down to the previous dose.
7. Most did well at 3mg, the dosage is often weight related, but not always [more weight-higher dose] – details later.
8. A significant number are doing well at 1 and 2mg.
9. If you are coming over from Tenex, drop the dose down, start at the 1mg and work your way up.
10. Not recommended with Clonidine for bed, for obvious reasons – using more of the same type of medication – even though clonidine passes through a different CYP 450 pathway [2D6].
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Update 12-'14: If You're On This Page Because Your Child Suffers With
Oppositional Defiant, Intermittent Explosive Disorder Or Conduct Disorder
You Must Review Videos and Posts On This Page
http://corepsych.com/walsh-resources
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ADHD Details On Videos & Recorded Interviews: 1 pg PDF
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Other FAQ and Observations
1. It can be used with Vyvanse and Methylphenidate products, more posts coming soon on this matter.
2. It has an excellent effect on simple Inattentive ADD, just for attention and is approved by the FDA for ADHD.
3. First line indications for this medication: ODD, anger, frustration, irritation, in spite of doing well on other ADHD meds.
4. For those medical teams out there looking to treat angry kids with atypical antipsychotics for “childhood bipolar” this looks like [purely anecdotal] it will be good for some of those kids who look bipolar, but are actually more ADHD with ODD.
5. Confusing presentations can still be explained by more comprehensive neurotransmitter evaluations reported elsewhere here at CorePsych Blog. Using neurotransmitter precursors to support neurotransmitter imbalances simultaneously with Intuniv show no challenges, and have worked exceedingly well with some of the most refractory kids seen in our office.
6. Incidence of hypotension in the forced dose titration trials was 6% with Intuniv, and 4% with placebo.
7. No deaths reported from guanfacine since it was launched in 1986.
8. More on the specifics of glutamate relevance as a new focus for ADHD neurotransmitters coming soon.
9. This medication is not like Strattera at all [except that it's also not a Schedule II]. Strattera only effects norepinephrine reuptake at the synapse, Intuniv actually modifies/facilitates glutamate neurotransmission. Glutamate is the most prevalent neurotransmitter in the brain, with ~ 1/3 of the brain receptors = glutamate. ADHD can be corrected by enhancing flagging glutamate networks through the post synaptic activity of stimulating that alpha 2A receptor post-synaptically. More on all this, and some important drug-drug interactions soon.
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My Prediction For ADHD Medication
Bipolar Redefined: This one is anecdotal, but relevant for future watchfulness: With all of the ‘bipolar' misdiagnosis so prevalent out on the streets [identifying almost any angry mood as a primary mood disorder] – when the underlying oppositional and anger problems so often arise from the oppositional subset of ADHD, Intuniv will change ADHD medication treatment protocols and outcomes.
Said another way, the use of atypical antipsychotics so frequently in children and adolescents will no longer become the first off label choice – if the diagnosis is actually ADHD and treatable with Intuniv. My take: Intuniv should/will become first line for this subset. We are already seeing, both in our office and in comments from many physicians, a trend in this direction. Time will tell. Intuniv wins hands down on the safety issue, and appears, at this early juncture, to help rather remarkably with those angry moods.
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Drug Interactions: Absolutely Relevant
1. From the Intuniv package insert: Intuniv is a CYP450 3A4 substrate.
> Reduced Effectiveness: It will be induced [reduced in effectiveness] by Trileptal, Provigil and Tegretol.
> Increased To Toxic Levels: It could accumulate, and take the patient out the Top of the Therapeutic Window with Prozac, Paxil, and Luvox all of which significantly block 3A4 – beware.
2. Suggestion: don't use Intuniv with these latter 3 medications at all. Prozac and Paxil, as you know from my many comments on these meds regarding the CYP450 2D6 pathway, regularly create unpredictable outcomes with ADHD medications – and over here on the CYP450 3A4 – I think I'm on an LA freeway 😉 – they are still dirty drugs. This drug interaction duo should always remain on your ADHD medication radar, and off your list for ADHD patient care. If you use, for example, the Trileptal group of 3A4 inducers, expect a significant accumulation of Intuniv when you discontinue any of these as your dose may now become much higher as a result of the previous induction process.
[Note: Our favorite testing site for CYP 450 and related genetic/metabolic testing – no economic relationship: genesight]
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Collected Posts: Intuniv at CorePsych Articles
- 7/09 Understanding Intuniv, Tenex, Guanfacine and Alpha 2
- 2/10 Intuniv For Metabolic Challenges
- 6/10 Intuniv for ADHD Neuroscience Answers
- 8/10 Understanding Glutamate, Intuniv and ADHD Neurotransmitters
- 3/11 Intuniv for ADHD Medication Side Effects
- 9/11 Intuniv Dosing For ADHD
- 9/12 Intuniv For ADHD: Avoid Drug Interactions
- 9/12 Intuniv For Addiction Issues
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Food Allergies Always Matter
Milk addiction, casein, gluten and other food sensitivities preclude effective dosing strategies based upon the Roving Therapeutic Window –
Therapeutic Window Discussed Here: http://corepsych.com/tw = Easy Video Link
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See the multiple CoreBrain Training videos listed here ↓ on ADHD Medications and Immunity Issues.
CoreBrain Training Videos at My YouTube Channel Here: http://youtube.com/drcharlesparker
ADHD Med Playlists
ADHD Meds Tutorial – Overview: http://bit.ly/medstutorial
ADHD Meds Dosage: http://bit.ly/dosevids
ADHD Meds Problems – Mind and Gut: http://bit.ly/mindgut
ADHD Meds & Allergies – Milk and Wheat Details: http://bit.ly/mawimmun
ADHD Meds & Allergies – Basic Immunity Training: http://bit.ly/IorWJs
_____________
Now Vyvanse
For Additional Dosing/Titration Notes on Vyvanse See This Link
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New ADHD Medication Rules Are Available
For many more details see my book in paperback, Audio, or Kindle: New ADHD Medication Rules – Brain Science & Common Sense – it outlines specifically why stimulant meds so often miss the mark. Get on your medical team – Paperback, Kindle, Audible – all available here with testimonials and excerpts: http://adhdmedicationrules.com
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> Please do forward this posting to your lists. Thanks!
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Comments:
Intuniv remains an interesting new ADHD treatment option – please add your comments below to encourage further discussion.
cp
Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
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30 Comments
Hello Dr. Parker-
THANK YOU for all of your work, I reference your book often and am so grateful for the resource.
My 8 year-old was prescribed guanfacine ER 1 mg today, to take in addition to 10 mg of fluoxetine. He did very well on vyvanse (he was inattentive, hyper focuses, somewhat oppositional) but is not gaining weight or growing due to a digestive disease, so we can’t have any suppression of appetite and need to stop the stimulants for awhile. I saw conflicting articles about taking fluoxetine and guanfacine together. Should I be worried about potential interaction? Should I request a non-generic?
Thank you!
M,
Thanks for your kind remarks! – Best to measure and treat the underlying metabolic issues rather than resolve to guesswork. These videos and downloads describe the tests we encourage – in the order of priority at this pdf: http://corepsych.com/tests The wt gaining and digestive problems more than 90% of the time directly relate to IgG difficulties [see that first video on the second page].
Prozac, as you likely know, very well may create problems with Intuniv through that 3A4 pathway inhibition. Yes, that is not the right one. For 8 yo, consider w your doc Zoloft starting low at 25mg in AM, it’s clean on 3A4 interactions [the liver metabolic path for Intuniv].
For more Gastrointestinal info see this video playlist here: http://corepsych.com/gi
Hope this helps,
cp
Daytrana 10 mg patch caused stuttering after 3 weeks on my son (the effectiveness was perfect in all aspects). He has salicylate intolerances that cause stuttering as well. Stopped the patch and couple of days later stuttering stopped.
Now on Intuniv 3 mg at night (for the last year). Worked miraculously at first regarding attitude and kindness, now not so much.
He is about to be 13.
Can we give intuniv at night and something methylphenidate based in the morning, without stuttering?
ALLERGIES: dairy, corn, peanuts, tree nuts, soy,
Wheat, artificial colors and sweeteners, salicylate intolerance, pollen.
Thanks!
J,
No interaction between Intuniv and MPH as outlined in this post. Yes, while providers do give it at night successfully, I leave that to you and your doc to decide, not for me to specifically advise you without sufficient details.
More importantly in this brief inquiry you clearly underline the strong likelihood of IgG issues underlying – that contribute to the other downstream allergies. Two tests strongly recommended for those allergies: IgG and OATS detailed on the second page of this handout: http://corepsych.com/tests
My additional suggestion, one that proves significantly helpful everyday, is the second on that list, the Walsh Protocols, explained in detail there, with videos.
With his many issues these three will likely help considerably.
cp
Dr. Parker,
Two quick questions…
1. Do you believe Intuniv will reduce the intense behavior from Vyvanse? Focus is great for work, but for social situations, the in-your-face argumentative, can’t get a word in, talk too fast behavior is exasperating. Today, my son was visiting without a Vyvanse in his system, and although he was irresponsible and blew off work (possibly getting fired), he was much more pleasant to be around.
2. How do we go about getting metabolic testing, and what exactly is that?
Michelle
Michelle,
Thanks for asking. Your question reminds me that I’ve talked about it so much I take for granted that readers know what I’m talking about. These standard tests and an interview with a very comprehensive questionnaire will tell the tale 90% of the time. It takes 1.5 hour to read all the tests for him and do the psych eval as well, if you decide to do the testing – details for remote [phone or Skype] or in-our-office-at-CorePsych are both at CorePsych.com/services.
Testing options explained here with videos and references on pdf with links: http://corepsych.com/tests14
To answer your question, sometimes Intuniv will help – and there are no interactions between Vyvanse and Intuniv. If he has metabolic challenges it will continue to feel like even with the most informed doctor, and the most arcane medical tricks, that nothing works. – Been there, that why I’ve added on improved biomedical evidence.
cp
Just want you to know, I REALLY appreciate the fact that you answer questions and care so much about us. I can’t even get this much communication out of all my other doctors I see face-to-face. It must take an enormous amount of time and I don’t know how you do it, but…THANK YOU!
Michelle,
Deep thanks back, it’s about building a team at every level. Teamwork, public opinion will ultimately make a serious difference! Appreciate!;-)
cp
Hi Dr. Parker,
In your experience so far with prescribing Intuniv, have you found many people complain that it tends to magnify depressive symptoms if there is co morbid depression as well as ADHD? I took it for a few days (1mg) along with Vyvanse and Lexapro and I found that it tended to give me apathy and depression. (Mind you, I’m sure I have metabolic issues which would probably make any medication unpredictable!)
Mike,
Not often depression – the feeling of depression – but lassitude, tiredness, and an emotional blunting, yes. With the stimulants we frequently see outright crying and anger vs just tiredness. An important interaction between DA and Glutamate is documented in many articles – this is an easy one, quoted below:
The book: “Attention Deficit Hyperactivity Disorder in Children and Adolescents”, book edited by Somnath Banerjee, ISBN 978-953-51-1086-6, Published: June 27, 2013 under CC BY 3.0 license, Chpt 6: Dopamine and Glutamate Interactions in ADHD: Implications for the Future Neuropharmacology of ADHD By Erin M. Miller, Theresa C. Thomas, Greg A. Gerhardt and Paul E. A. Glaser DOI: 10.5772/54207
“2.3. DOPAMINE AND GLUTAMATE INTERACTIONS
A dysfunctional interaction between the dopamine and glutamate systems has been implicated in numerous neuropsychiatric disorders such as drug addiction, Alzheimer’s disease, schizophrenia, and ADHD. The brain regions most often linked to these disorders and the dopamine-glutamate dysfunction are the PFC and striatum, as these regions both receive heavy innervation from the dopaminergic SN/VTA and glutamate innervation from thalamic relays and other glutamate rich regions, as described in the previous section.
Studies of signaling interactions between the dopaminergic and glutamatergic systems demonstrate that the NMDA receptor is crucial in activating dopamine neurons in the VTA/SN [17, 18]. Also, it has been found that stimulation of the D2-class dopamine receptor is involved in the downstream inhibition of the NMDA receptor, weakening the excitatory response to those neurons [19]. Likewise, it was found that activation of D4 receptors depressed AMPA receptor-mediated excitatory synaptic transmission in PFC pyramidal neurons, which was accompanied by a D4-induced decrease of AMPA receptors at the synapse [20]. These results provide substantial evidence that the dopamine and glutamate neuronal systems work in tandem to create a balance of neurotransmission in these regions.”
Hope this helps,
cp
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Dr Parker you kindly answered some of my questions in another thread and it was of huge significance. In Australia where I am based when not travelling on business the Health Care system refuses to prescribe to me an SNRI (Pristiq or Venlafaxine XR) as they are ‘too expensive’. I have been on an AMP product with great effectiveness however Zoloft has only had a partial effect – the Doctors here are however willing to prescribe Strattera (Atomoxetine) to augment my Zoloft and AMP product.
Essentially what I am asking is: would Sertraline + Strattera = similar efficiency to Venlafaxine or Pristiq?
Once again your time and assistance is much appreciated. I have purchased a copy of the Gluten Summit (loving Dr O’Bryan!) which is unbelievable value for money and I would recommend other folks investigating.
Greg,
Don’t know, but doubt that the two will provide the same effect on both S & N as Venlafaxine – but one never knows. I’ve never tried that combo for that specific reason as I haven’t been forced by mismanaged care to cookie cut treatment in that ridiculous way. Everyday the choices become more limited as innocents looking only at counting beans quickly forget the complexity of the human mind. – If it’s available in generic, what’s the problem?
Thanks for your kind remarks – best to you and yours for the Holiday Season!
cp
Dr Parker,
If a patient presents with overwhelming apathy (amotivation or avolition) does this likely point towards Depression or Schizophrenia?
The reason I ask is I am taking Vyvanse which has exacerbated this symptom. Treatment with SSRI’s I am told often makes Apathy worse, and to paint a fuller picture I do not have any kind of sadness (rather emotionless).
ATB
Dougie
Dougie,
Whoever told you that antidepressants make apathy worse hasn’t treated psych patients for 45 years. I can tell you they likely didn’t work in psych for 10 min. That observation takes the cake for what I call the 180 degree advertising theory = Advertize the opposite of what it actually does as it may encourage acceptance!
SSRIs treat apathy and problems of apathy secondary to Vyvanse and stimulants very well 80% of the time. That other 20% is directly related to metabolic challenges we so often address on these pages.
cp
Hello Dr. Parker;
I find bring a lot of good information on your site and comments. I suggest your book frequently . . but. Here is the comparison that also needs to be shared. This is referenced on the Good Rx’s web site. Intuniv 4 mg #30 costs in a range of $262.23 to $268.00 with a coupon.. Tenex (a generic medication) for 2 mg #60 costs in a range of $4.00- $16.39. I don’t find it that hard to get this medication adjusted. This is another example of the pharmaceutical industry reformulating what is really a fairly old drug to be able to sell medications at much higher costs to the consumer.
Providers must be aware of the real world needs and realities of the people they treat. Cost is a consideration in treatment. If a Cadillac is unaffordable, realize a Corolla with still get you where you want to go.
Regards,
George H. Glade, ARNP
Thanks George,
Good point. Economics are at play everyday with every patient, and we must make adjustments in that regard repeatedly. Vyvanse is dexedrine, but that long term delivery system does make it more acceptable for so many – as with Intuniv.
My take on these matters in the order they arise:
1. Cost is almost always on the front end for everyone at every station in life.
2. Efficacy and non-stimulant alternatives for ADHD, a close second pair.
3. Duration of effectiveness, a theme important for long term use and compliance, may live in third place – unless compliance and inability to take doses through the day, so often seen w ADHD/EFD can, in many realities, rise to the top.
Appreciate your input, well said.
cp
Dr Parker,
I have booked a 1 hour consultation with Desiree for the 15th of January and look forward to working with you.
I wanted to ask what your thoughts are on Dr Barkleys ‘Sluggish Cognitive Tempo’ – do you see these individuals as being different to Thinking ADDers?
Would Intuiv be a potential avenue of treatment for them over MPH/AMP products?
D
Dane,
I much look forward to talking w you.
Dr Barkley is spot on to identify and codify ‘speed of processing’ issues – but, to answer your question on meds, I see no predictive variables w either AMP or MPH on that subset. Rather, like a dog chasing a rabbit, my eyes get big and I start barking on the trail of metabolic challenge and, with good testing, often find metabolic challenges that fog the brain, measure and correct them w considerable predictable frequency.
My take on all these ADHD/EFD treatment matters: If we don’t know enough clinically to predict outcomes, we don’t know what we’re doing, myself included.
cp
Hello Dr Parker,
I have thoroughly enjoyed your book which I have read in the UK after ordering from Amazon. I found it sheds so much light on issues that are not covered by UK GPs and even ADHD physicians..
I wanted to ask your opinion on something not covered in your Book or any of the quite excellent posts on Core Psych:
1.) What is your opinion on ‘The Pills don’t teach the skills’? Do you believe that if the medications are dialed in effectively the patient should be fine or do you think time managemtment aides?
2.) Are there any resources or books for skills and self management you suggest reading? I have so far used Ari Tuckman’s workbook
3.) I take Vyvanse at 30mg dose – are there any tips so match the effectiveness if COST meant I had to switch to short acting Dexamphetamine – do you have folks who manage to do as well on either?
4.) I liked the information on Intuiv – which I might as my physician to try but what are your feelings towards MODAFANIL?
This all relates to the fact I have dialed in my deciations well working proactively with my doctor but still find that I have ‘residual symptoms’ of inattention and trouble focusing to a small degree. Also find that managing time and tasks and ‘imagining the future’ is tricky.
Prior to medication I would describe myself as your ‘Thinking ADHD subset’ or ‘Primarily Inattentive’ constantly drifting off in conversations.
I have found that writing a list of guidelines, and objectives is needed to help curve impulsivity.
I want to thank you for you brilliant website, empathy to patients and book/website packed with insightful tidbits for all ADHDers. My Doc in the UK is captivated by your website.
Merry Christmas to you and your team.
Laurent
Laurent,
You’re very kind – I appreciate knowing that these notes provide a helpful impact for your life, and appreciate your sharing with your caring doc – as each doc that converts to the Galileo Way [“Measure what is measurable, and make measurable what is not so.” ~ 1600] will help so many others who find their progress limited by inadequate, superficial information.
1. Completely agree w pills don’t teach skills and encourage most we see w ADHD to find a coach skilled on the ADHD side of matters.
2. Tuckerman is a favorite of mine, if you work w Ari’s program, you’re working w one of the best.
3. Switching from Vyvanse to Adderall is quite possible, and, while Vyvanse is my first choice, it may not prove to be the economic choice. Most make the change quite easily, but some can’t take Adderall. On the other hand some can’t take Vyvanse! I have no idea why at this time on either.
4. Intuniv is great for some, but not as effective for the most part as AMP. Modafanil is the same dollar question and not as effective.
5. Those residual symptoms might be that errant ‘bottom of the window’ and may need some more careful attention for PM dosing?
A warm handshake across the pond, I appreciate your partnership in spreading the word.
Merry Christmas to you and yours!
cp