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Intuniv for ADHD: Help With Stimulant Side Effects
ADHD Brain Science Beyond Appearances
March 14, 2011ADHD And NeuroScience – San Francisco
April 4, 2011
Panic, Anxiety or PTSD: Image via Wikipedia
Intuniv Answers Even More Challenging ADHD Treatment Questions
You already know this: one can't go far down the road with most ADHD treatment plans without running up against stimulant side effects. Stimulants, those meds associated most often with either methylphenidate [MPH] or amphetamine [AMP] molecules, often bring associated problems with these excitatory challenges:
– Increased blood pressure
– Increased anxiety [cognitive, mental – and somatic, affective]
– Increased agitation, irritability
– Increased sleep problems, usually dosage related
– Decreased compliance due to the profound effect of immediate release prevalence
Too often many simply can't take stimulant medications with these several challenges.
ADHD Medication Rules
I wrote New ADHD Medication Rules – Brain Science & Common Sense simply because so many do have troubles with the side effects of stimulants, the first line medication – often because they are adjusted without thinking about underlying biomedical issues. The good news is that the Vyvanse, Adderall and MPH products are very helpful, but just as with any medication from aspirin to birth control, dosing strategies become the key challenge in preventing side effects. See this series of videos for ADHD Medication Tutorials regarding the stimulants.
Four Exceedingly Key Intuniv Solutions Straight From The Trenches
I have had several individuals who just can't deal with the agitation and increased cognitive anxiety with stimulants. Careful dosing just doesn't solve the problem as you will see from the many Intuniv posts and hundreds of comments there. If you want a more simple review of materials and links you can see a comprehensive page over at Squidoo.com collected there for your reference.
1. Hypertension Resolution/Improvement
I've seen an outstandingly good response from some adults with growing blood pressure problems and stimulant meds. Intuniv not only solved the problem by not increasing the blood pressure, but significantly diminishes the associated somatic and cognitive anxiety, and worked better than the stimulant meds first tried.
2. ADHD and Anxiety Resolution/Improvement
Others with refractory anxiety that appears more cognitive than affective, more mental worries than somatic feelings have responded very well to even low dose Intuniv – adults with only 1-2 mg in the AM and it lasts all day, and, yes, it helps with the associated ADHD.
3. ADHD and Sleep Resolution/Improvement
Those children with sleep issues may significantly improve with dosage at night. I know that the first blush of usage recommendation seemed best as dosage in the AM, – and it often does work best after that protein breakfast. But we have seen an increasing number of patients, especially children, who respond so much better with a PM, bed time dose, and still do quite well the next day.
4. Intuniv With Stimulants: Recent Study Out
A recent ADHD study also documents what we have seen in the office – that using the two med types, Intuniv and stimulants, together often will turn the ADHD tide more effectively. Often the sedative, quieting effects of the Intuniv compliment the greater efficacy of the stimulants in some individuals. Careful titration watching both side effect profiles [documented repeatedly in these pages and in the many previous Intuniv posts] will obviate any challenges as the metabolic pathways show no concern about drug interactions. The advantages of one seems to address effectively the side effects of the other with good result. No this will not be the standard of care, but let's face it, the combination does work well, just as Wellbutrin with Effexor does over in the land of “antidepressant augmentation strategies.”
Interesting new points for treating ADHD – press on… – and do listen to this piece posted on CinchCast recently:
cp
Related articles
- ADHD and PEA – The Stealth Neurotransmitter (corepsychblog.com)
- Know All the ADHD Treatment Options (everydayhealth.com)
- Why Isn't My Son's ADHD Medication Working? (everydayhealth.com)
- Beat ADHD Anxiety and Stress (everydayhealth.com)
- FDA Approves INTUNIV (guanfacine) Extended-Release Tablets For Use As Adjunctive Therapy To Stimulants For The Treatment Of ADHD (medicalnewstoday.com)
- The Side Effect of an ADHD Diagnosis (adderworld.com)
- Drug Combo May Help Treat Kids With ADHD (webmd.com)
- ADHD Medication Problems: Why They Don't Work (corepsychblog.com)
70 Comments
Hi Dr. Parker
I have tried Concerta and found it raised BP to an uncomfortable level. GP wants me to try it again with more monitoring. I take Gabapentin (100 mg 30 day) for pain..cervical disk degeneration. Doesn’t do much at that level..but does help with spasms in gut strangely. An odd symptom that comes and goes..anxiety lot long with the headaches. I also developed hyperacusis somewhere along the line..and I guess the Gaba was suppose to help calm all the “noise” down. Mentally and audio wise. Chiropractor figures it’s related to the upper cervical issues… (Craniocervical syndrome).
My version of ADHD is comprised of Audio Processing Disorder and a fair bit of anxiety. The origin of which I am not certain. I only know the neck pain and tension can amplify the mental activity and agitation/Anxiety. I do have alot of sensitivity..to stimuli I. .clothes..anxiety lot of physical symptoms endlessly distract. Not sure what to do about this.
What are your thoughts on medications and next steps? Interactions etc?
Thank you,
Willow
Willow,
With all of the biomedical issues you raise you absolutely should chase down more informed, more hard-data driven solutions. Testing we recommend at CorePsych: http://corepsych.com/tests
cp
Thank you for your reply Dr. Parker. I do have some test results, recent and over the past few years, food sensitivities, hormone tests (cortisol, DHEA, Testosterone etc. appeared normal..but Free T was low on blood test, but appeared normal during saliva testing.. I also did some neurotransmitter testing 5 years ago. A few things were out of balance. I worked with a Naturopathic doctor to balance things as best I could.
Over the las 2 years the audio sensitivity and neural pain seemed to emerge as primary issue in addition to the ADHD. Although ADHD has been present all my life, the pain and audio issues have come to forefront over last 2 years. Chiropractor postulates this may be due to the Craniocervical issues. Perhaps more intensive structural/functional imaging may be needed? I do not know.
I did review your testing page. I am not sure where to start. Perhaps some of the testing I could do here, in Canada via some of my connections. My goal is to gather what I need and work with a Doctor who can assess and outline a treatment plan for ADHD that is based on sound principles. I have your book and that has lead me to connect with you.
What would you suggest my next best step be testing wise? Should I book an appointment with you directly?
Thank you,
Willow
Willow,
Your completed testing results could help formulate interventions, no question about it. I could review those and pull them together.
We do consult with folks from Canada regularly, just talked to a new patient outside of Calgary yesterday. My recommendation would be to
look at the Walsh protocols on the second page of the testing PDF. If you have IgG already that is always a good place to start – and right below that is Walsh with all the references and posts with links there. Strongly suggested are my several interviews with Bill Walsh at CoreBrain Journal:
Methylation: http://corebrainjournal.com/025
Copper and Kryptopyrrole: http://corebrainjournal.com/034
Bipolar and Schizophrenia: http://corebrainjournal.com/042
– Not that you are Bipolar or Schiz it’s just that his info is groundbreaking and likely to reveal underlying issues for your refractory response – and those more severe diagnostic challenges are quite instructive. And it’s likely you haven’t reviewed those results.
Yes, I would book a time, we can work by phone, or by Zoom/video – it’s a different world for distant consults, and your doc there. We can talk about those details later. Easiest to send a note to Libby at http://corepsych.com/appointments and she will f/u from that inquiry.
Thanks, look forward to talking!
cp
Thank you Dr. Parker.
Can I get the Walsh testing done here in Canada? My IgG eats for foods etc are 5 years old. Should they be redone? Neurotransmitter tests also 5 years old. I can put all this together prior to our consult. Please let me know what you need for assessing and we can begin. Thank you.
Willow
Willow,
Yes, you can get the tests drawn in Canada, – we send you the kits so you can then draw blood, take urine and send them off. We schedule a meeting to both evaluate your current situation, and combine that with reading the test results with specific recommendations on supplements, diet, and meds all combined in that meeting. I prepare for that meeting by reading your results and forms, so you get 2.5 hr of eval for the cost of 1.5 hr delivery – done on Zoom.us, or phone. Best recommendation to make it a one-stop shop: Do the top three tests on the second page here: http://corepsych.com/tests – IgG, Walsh, and OATS.
cp
I have tried many different medications through my GP, often with unpleasant side effects. I have seen a few counselors and medical doctors to rule out this or that, and I have spent a lot of money on testing I can’t afford due to missing time at work etc. So if I test anytging, i need guidance tgat makes sense. That’s why I am here☺My rationale is to connect with a Doctor who k own the “ADHD” territory and that can suggest medication with confidence. It has been a long, frustrating road thus far, with no relief in my “tangled spaghetti brain” yet. Thank you for your reply
Willow
Willow,
This is my focus, the kind of problem set I love to review. Send the results you have, do the other tests and we can get you done. Connect, as I think I mentioned before, with Libby at http://corepsych.com/appointments she’s our Patient Care Coordinator.
cp
Thank you. Sounds perfect. I will contact Libby to get this rolling.
Willow
Solid, talk soon.
cp
Hello doctor my 7 year old some was just prescribed concerta 28 MG along with intuniv 1 MG I am really scared to mix the medicines.. will he be OK taking these together? Thank you
Sharon, not a prob from a drug interaction point of view.
cp
Dr. Parker,
I just stumbled upon your many helpful articles. I am a parent of a teen girl who has had excellet results since 4th grade with methylphenidate meds. Daytrana ended up being the very best since she is active and participates in several extracurricular activities. Since puberty and fluctuating estrogen life has been more complicated with ADHD but she had been doing really well last semester with an increased amount of Daytrana and BC pills. However, she has developed what we believe to be a tic. She started pulling her hair out sometime fall semester. It didn’t go away as we had hoped so when she told her doctor she hated feeling like she wanted to pull her hair, she pulled her off the Daytrana and put her own Straterra in January much to my concern and dismay. Beenn there done that with her older brother. So, she now on the target does, no longer pulls hair, but is so unfocused, scattered, forgetful …..hard to have a conversation with now…and even forgetting tests and such at school. She is normally a Straight A student. She is eating everything in site and can’t stay up past about 10 to do homework. She just falls asleep like the dead on her book.
So, I have been researching as I often do, trying to figure out what to do. Doc thinks only other solution is Adderall. ( It is the only thing we haven’t tried but Vyvanse did nothing one way or the other and my son has terrible anger, moodiness and depression when taking this group of meds so I don’t relish the idea of trying it.) She used to take Intuniv with the Daytrana Patch. We were not sure if it did much so after she went off of it and the patch to participate in a methylphenidate drug trial about a year and a half ago, she never went back on it. Now I am wondering………..could Intuniv help prevent the hair pulling tic? I read where it has been used to help with tic disorders but am wondering ( hoping) if we decreased the Daytrana dosage and added the Intuniv back, is there a chance that the tic may remain gone? We felt we had finally gotten things right with her and junior year was going great….except she had started pulling her hair. Can you recommend anything that we might discuss with our doctor?
Thanks!
Kathy,
Yes Intuniv might help whilst with the Daytrana [no drug interaction there], but it sounds like she has a more pressing problem: a leaky metabolic foundation. In my experience with tic disorder I repeatedly, more often than not, find metabolic disturbances that throw off energy, diet, weight levels, sleep, and the efficacy of meds. Start by measuring Transit Time with this easy Tool: http://corepsych.com/ttt Very expensive test: 69 cents. It’s only a screening tool [used by the Mayo Clinic] but often highlights the undiagnosed food allergies explained under IgG on the second page here: http://corepsych.com/tests
cp
I guess I am trying to understand if she truly has a tic disorder or is it just a reaction to increasing the Daytrana ( they had pushed it to 40 mg because we felt like she had accommodated to the 30 mg after 2 or 3 years on that amount but had done the best on this med) or a reaction to increasing it after removing Intuniv. She is no longer reporting any hair pulling since going off the med and I had never witnessed her pulling it other than her bringing me a wad of long blonde hair on two occasions in tears. So if the hair pulling was associated either with the med or with the higher does of the med, is it still a tic disorder?
I think she is eating all the time because the methylphenidate did curb her appetite some ( not as much as my son who loses weight on Concerta and goes off of it in the summer for a few weeks to gain weight back.)and the Straterra certainly doesn’t. Can’t say if the Straterra makes her more hungry or if it is just her not knowing how to manage her normal teen appetite. I do not think we will be sticking with the Straterra, though we do not talk tot he doctor again for two more weeks, because we are not seeing positive things. The sleep issues only started with Straterra. She has always stayed up late (especially if not finished with homework , etc. ) like a normal, busy teen. Now she just can’t do it. Since starting Straterra she just hits a wall around 10:30 on school nights and she is done. It definitely seems like a heavy, drugged sleep. ( It’s how I look if I take a full does of Benadryl )She seems more ADHD than ever on this med where methylphenidate definitely improved many things. I think she had excellent control of symptoms with it prior to puberty around 8th grade=9th grade.
I don’t mind trying the TT test if she is agreeable but am not convinced yet that she actually has a tic disorder. However, I’m not a doctor so I may not have a clear understanding yet.
Thanks for your input. I wish the doctors we have used were more into testing……at least with tests readily available. We usually only get testing if there is a problem the doctor sees that may require testing info to help. We thought my son was having diabetic issues when taking Straterra ( he also had migrains and motion sickness on Straterra that went away completely when I finally said we had to stop it.) so she ordered testing that confirmed he was not. generally, they don’t test for anything.
Again, thanks for any info.
Kathy
Kathy,
Sorry was out of the office since 1-31, but now back. Yes, not a tic disorder if only a reaction to the stimulant meds, agreed. The TT testing is not simply for tic disorder but to accumulate biomedical evidence at a very inexpensive rate to begin to dig a bit more deeply into the underlying probability that she suffers with a comorbid metabolic challenge. Transit time is not a diagnosis – it is only a marker for her biomedical processing – rate, efficiency, and possible collateral challenges.
cp
Hi, Dr. Parker, I know that OJ taken an hour before most stim meds is a no no. What about Vyvanse? Since Vyvanse is broken down differently, can you take OJ with Vyvanse?
Sandman,
The problem, in short, is the acidity of the OJ, not the OJ itself. Some have said acidity also effects MPH products like Ritalin, but I haven’t chased down that detail at this moment. The original acidity concern arose during the years we learned and spoke about AMP products, from Adderall IR, to XR. Vyvanse, while an AMP, has a completely different metabolic route: broken down not in the stomach, but in Red Blood Cells by a proteolytic enzyme, it doesn’t suffer the same difficulty with absorption as those previous products. Clinically, as you well know, details differ, but in my offices over many years I haven’t seen a single case of OJ acidity effecting Vyvanse based upon these metabolic points.
cp
Hi Dr. Parker,
What is your take on Hemp Oil for Anxiety (which at times results aggressive responses in a child)? The child is 11, and takes Adderall XR 15mg, Escitalopram 10mg, and Intuniv 2 mg daily.
Thank you
ND,
No experience with it whatsoever. For years I’ve repeatedly resisted anything remotely in the THC direction. Now I know some additional research has shown some encouraging results with other cannabis-derived compounds. The real issue is what is causing the anxiety in the first place. Much additional information here: http://corepsych.com/walsh-resources
cp
Hi Dr. Parker,
I have been gluten free (and 16 other foods) for the past 3 years due to allergy testing. My gut motility is normalized. I feel amazing, whereas a few years ago, I felt horrible! I take Concerta currently, but was thinking about adding Intuniv for tighter emotional self-control. I have a few concerns, however:
I have hypothyroidism, for which I have been taking compounded T4/T3. I understand weight gain is a possible side effect, and wasn’t sure if being hypothyroid made me more vulnerable or whether Intuniv could exacerbate my condition. I am a runner and in great shape, but a year ago I was too tired to run. I can’t go back to those days.
2. I have always had low normal blood pressure. Any cautions for exercising or hydration?
I am training for a half marathon.
3. How soon to tell before it’s working or a bust?
4. Any other recommendations for medication for emotional lability? I do not have depression, just some impulsivity with words and react faster than my brain can stop me at times, no matter how well I eat, how much I exercise, or taking Concerta. They all help, but I need a boost :).
Thanks so much for your kind help!
Heather,
Some brief responses:
If you have hypothyroid I would suggest that you consider, because of your past issues with food sensitivities, testing for candida, which could create brain fog and endocrine imbalances including estrogen dominance. Tests for that opportunistic candida that I recommend and use – second page here – IgG and OATS: http://corepsych.com/tests – Sounds like you already did the IgG for antibodies, the OATS hits markers like Arabinose to check actual activity, deeper than IgG markers.
For more info on Candida and Biofilm: http://corepsych.com/candida & http://corepsych.com/biofilm These yeast guys can create imbalances even after the bowel appears to normalize for several reasons outlined in these two pages, and do directly relate to energy issues, adrenal fatigue, etc.
2. Quite simply you already know, do hydrate and some salt may help retain fluids.
3. You will know in about a week. If not responsive it could be simple failure on the glutamate connection, or dose related.
4. Impulsivity may also be curbed if GABA is off downstream from these other invaders. Multiple GABA supplements out there might help, but again would encourage measurement – such as with urinary neurotransmitters, and the best next test for all that is the Walsh protocol on /tests page 2. See: Overmethylation as a possibility.
Some homework for you!
cp
Dr Parker,
I see this is an older post but I’ll ask on the chance you may see this. I am registered nurse being treated by a psychiatrist for anxiety and ADHD-inattentive type. I’m on a regimen of Brintellix 10mg and dexedrine 5mg twice a day. I have periodic panic attacks that are exacerbated by the dexedrine. I worry, maybe unnecessarily, about the possibility of one of my panic attacks after taking Dexedrine turning into a dangerous arrhythmia, because my heart races pretty fast during a panic attack. Do you think Intuniv can be helpful with this issue?
Jennifer,
Brintellix is metabolized through 2D6, and it’s interesting that AMP products, specifically Vyvanse, are indicated as likely to interact negatively with Brintellix. I don’t understand that caution, as both go through 2D6, and the only additional problem would be a genetically small 2D6 with competitive inhibition as they both course through the same metabolic path. If you have a polymorphism on your 2D6 Pristiq would be a better antidepressant as it is built to bypass 2D6.
Intuniv is metabolized through 3A4 so no problem with Brintellix if you and your doc wish to stay there. It’s often not as effective as stimulants, but with some folks is the perfect match. A trial would be reasonable.
Your private email is a famous name in ADHD land – an excellent woman I met years ago in DC.
Hope this helps,
cp
Hi Dr Parker,
I just found your website and I am starting to work my way though all the material. It is all very helpful and interesting. I am 36 years old and have been on intuniv for a few months. It is the first medication I have been on in years for treating ADHD. It has helped my in many ways, but thought my concentration could be a little better. This is main reason I was taking the medication as I have a big exam and promotion for work coming up. I was on 3 mg and went up to 4 mg. Since my increase I have been extremely sleepy and weak to point where I wanted to sleep the whole day. Coffee does not even help. I took my blood pressure yesterday and it was 102/59 which is lowest it’s ever been. Is this something that will pass as I get used to the increase or is 4mg just to much for me? Any advice you could give would be very helpful. I’ve had trouble with stimulants and Straterra in the past agreeing with me, always making me feel uncomfortable.
Also, how long does side effects of sleepiness usually last? Thanks again
Mike
Mike,
If you reduce the medication back to the next lowest dose that sleepiness is often corrected the next day.
Check with your doc, I’m not telling you what to do.
cp
Mike,
In my practice I work carefully to stay in the best Therapeutic Window for each medication: Video: http://www.corepsych.com/tw Sleepiness is out the top of the window with Intuniv and in my office I do reduce the dose. Remember I’m not telling you what to do, but what the parameters are for the effective adjustment for Intuniv.
Stimulant sensitivity, more often than not, especially if it occurs from both AMP and MPH, is dopamine related. Also, more often than not, it’s a result of challenging metabolic problems that can interfere with drug metabolism on several levels, from gut, to liver, to transporter proteins, all documented with videos at my YouTube site – drcharlesparker.
In summary more evaluation for those impediments will encourage a more predictable outcome.
Hope this helps!
cp
Hi Dr Parker,
Thank you very much for your response. I am going though the videos and just bought your book for some more information. Having gone through years of frustration and unsuccessful trails with adhd medication I gave up years ago. My only success is recent, with Intuniv. My doctor would be aware to these further evaluations ? How would you recommend going about them? A family member has celiac disease, not sure if that means anything. Thank you again for your help. Mike
Mike,
We always make an effort to communicate evaluations back to home docs. We have two ways of proceeding for evaluations: 1. Virtual Consult: you don’t leave home we work w you on the phone and use your doc at home to handle medical interventions. 2. Personal Consult: You come to Va Beach and we physically see you in the office, write the scripts and can follow you with yearly visits. Often we can transfer care back to home docs after that intervention process. See this page for more details: http://corepsych.com/services
cp
[…] 3/11 Intuniv for ADHD Medication Side Effects […]
Hi Dr. Parker, I read your book last year and it really had a lot of interesting information. Question…in your opinion, is it preferable if a teenager is on Concerta and Intuniv that the Intuniv be taken in the morning or evening? Thanks so much for your thoughts.
Lisa,
Depends upon the metabolic rate and reaction of the person, always. If he/she is too sedated in the AM try it in the PM, if awake in PM, try it in the AM and look at the other Intuniv posts for dosing strategies. Yes, working with your doc in this way can spell significant improvement.
cp
Lisa – My Dr. suggested Concerta and Intuniv for my 18 year old son. I have been worried about giving them together. I am just wondering how your teenager did on the combination of both. Did you give the Intuniv at night? How many mg did you start with? Thanks!
Amy,
Totally reasonable. For all CorePsych Intuniv Posts: http://corepsych.com/intuniv
cp
Doc I wanted to ask you how one tells the difference between an Extensive Metaboliser of 2D6 meds – who needs continually higher doses and someone who has a bulletproof liver?
In terms of value for Money does the OAT test provide valuable information on Neurotransmitters and Microbes?
Peter,
Testing for 2D6 polymorphisms, we have a test we can send you, have to check w Desiree at services for $.
OATS is a very comprehensive test, covers neurotransmitters a bit, but so much more for 299$ – and yes, microbes including yeast.
cp
[…] 3/11 Intuniv for ADHD Medication Side Effects […]
Thank you so much for such an informative page!
My son just started Intuniv this week and is experience discomfort in his belly. I haven’t seem any behavior changes just yet as he’s on the lowest dose currently. He’s been extremely tired and somewhat emotional, but I’m hoping he will adjust soon. This is his first ADHD med we’ve tried.
So here’s my question – my son has a clear history of a gluten intolerance and has major behavioral and impulsivity changes when he ingests gluten. Is Intuniv an appropriate medication for him? I’m still confused after reading the article.
Thank you!
Renee
Renne,
Any sensitivity, gluten, casein, egg, – any sensitivity can significantly effect meds and supplements that might prove helpful for improved medication function. The effect of the sensitivity is several fold:
1. Cytokines from the allergy compete for neurotransmitter receptor sites.
2. Bowel function, bowel physiology on a cellular level, deteriorates – creating challenges w trace elements and enzyme systems.
3. Nutrition is compromised.
4. Protein metabolism is compromised.
5. Hormones are compromised, including thyroid and adrenal function leaving other complimentary problems that look like psych issues but don’t respond to psych drugs.
These are just a few of the many issues that can look like psych problem, mask the important inquiry system and appear simply as refractory symptoms.
Intuniv is not the issue, the underlying metabolic issues must be addressed to have a predictable outcome.
cp
My son is 6 year old. Currently on 3mg intuniv, it is helping with the hyperness about not his school work at all. He is unable to focus and when it is time to do work acts out in order to try and avoid doing it. We tried adderall, vyvanse, focalin, and all had adverse reactions. Can you recommend something for us to try with the intuniv to help with school work and acting out?
Gwen,
To give good advice I would have to take a hard look at the treatment failures, because they are often instructive. I would discuss with your doc the possibility, with their approval, of:
1. considering a very low dose of Vyvanse using the water titration strategy to down to 5mg [1/4th of 20] with the Intuniv. No drug interaction there, and a peer-reviewed paper investigating that process indicates good results, as does our personal clinical experience http://www.corepsych.com/2007/11/vyvanse-for-addadhd-the-water-titration-recipe/
2. possible metabolic problems are always on the radar with unpredictable results on stim meds. This playlist will break down those investigations more carefully:
http://bit.ly/mindgut
cp
[..YouTube..] I’ve had all the symptoms all my life but no meds help – tried many over 25 years. I’m now 49 can hardly keep a job. Recently tried Adderall. Results? 5 mg (1st dosage) way too much – caused hyperactivity, sloppy mistakes, jitteryness and sweating. And 2.5 mg may help a tad but is woefully inadequate. After a week of no dosage I tried 5mg again – same results – jittery, “speedy”, mind less coherent etc. I’ve repeated this test numerous times. As I type I’m on 2.5 mg. Inadequate.
[…] Medications can help [alpha-2 agonists like tenex and clonidine], […]
Romeo,
Already on board, many thanks!
cp
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Mandy,
Yep, is often heritable and likely gluten, but don’t be disappointed if gluten alone doesn’t cover the problem, as gluten is but one of the main offending antigens. I do like Enterolab, but the testing can be done for less with NeuroScience.
cp
Mandy,
OJ should not be taken within 1 hr on either side of stimulant meds… it prohibits there passing thru the gastric mucosa… not a prob with Intuniv.
cp
Okay, that will be a relief for the juice lovers in the family. We did have stool and genetic testing done on my husband through Enterolab, and he was positive with a 17 on anti-gliadin IgA, and a positive celiac gene + positive gluten sensitivity gene. Am I understanding correctly that as he takes care of the gluten in his diet, his med needs/effectiveness of meds will begin to change? My son tolerates no stimulants, and you stressed to me that it was most likely an immune issue. I believe I have a clue that it is gluten intolerance, and will have him tested.
Mandy,
Wouldn’t be a gluten IN-sensitivity, but a sensitivity – and the blood tests run thru conventional labs simply don’t get down the IgG imbalances. NeuroScience has the most cost effective testing, but even then you have to have some clear experience to interpret effectively… as many blow off the IBA [Intestinal Barrier Assessment] Scores if too low – when they are quite significant.
cp
Thanks. One other question I have is about Intuniv, Vyvanse, and Orange Juice. All that I read tells me that there should not be an issue taking these two meds with OJ, but we are noticing the meds wear off in the evening when my husband has OJ for breakfast. Just wondering if there are others having problems with this.
Smith6sa,
Completely agree – but one quick point: Both the biologic and psychological problems can, and often do, coexsit – and fixing one without the other perpetuates challenging reactions to real life.
cp
Hello Dr. Parker,
My husband was dx with ADHD about 12 years ago due to academic diffictulties in college. (He is 48 now.) He has only taken 5-10 mg of focalin (not XR) rarely as needed for meetings, etc. until recently. After learning more about ADHD and realizing many behavioral challenges he has might be helped by consistent meds, he is trying intuniv 4 mg and vyvanse 50 mg. (He does have hypertension.) He feels more relaxed on the vyvanse than his previous MP experience, though he liked it too, he says he feels less hyperfocused on AMP. Without meds, he has issues with inflexibility, irritability, being controlling, arguing, paranoia that are just awful, but there was an immediate improvement when we added in the vyvanse. But it didnt last. He now unexpectedly, generally in the morning can get started up possibly worse than his previous behavior. But he goes days without this happening which is nice. I noticed yesterday, when he forgot his meds in the AM, and I took them to him at work about noon, he had no difficulty getting to sleep about 10 PM. That made me hopeful that he may not be reaching the therapeutic window. . . and would benefit from a higher dose of vyvanse? But I am also terrified of increasing the vyvanse dose and making him worse. Any insight?
Mandy,
No reason to be “terrified” about the possibility of too much, it’s at most a one day event and can be easily corrected by not repeating that one. Best, however, to really drill down on the DOE, really figure out when it’s out and go from there. It will be harder whilst using the Intuniv with Vyvanse as Intuniv is ~ 24 hr not less than a half day unless really under- dosed.
The combo is good for hypertensive individuals as both side effects are significantly addressed. Go for the 12 hr DOE with Vyvanse and he will likely have a better run.
The exception: if he has immune dysfunction, always a confounding factor if present, as simple food sensitivities can unravel the entire treatment process.
cp
Thanks, Dr. Parker. He and my son are both allergic to all trees and grasses and have an allergy for every day of the year, but nothing came up as far as food allergies. However, my husband is convinced he has a gluten insensitivity, but his blood tests have come back negative. He would benefit from more extensive testing to make sure, I think.
Hi Dr. Parker. I’ve spent about 8 months trying to find the right ADD med, and I’ve finally settled on Daytrana for a lot of reasons. I know it takes a while for it to start working optimally, but I’ve been on it a month now and I’ve been having higher than normal blood pressure, which never happened with any of the other meds. I assume this is because of Daytrana’s increased l-mph bioavailability. So if I were to take Intuniv with Daytrana would that make it more like regular Ritalin? I’ve been on Ritalin forever but I got sick of the ups and downs, the redosing, rebounds, etc.
I used to take 3×20 mg Ritalin/day and now I’m on the 30mg Daytrana.
Thank you. Your blog has been a wonderful resource for me.
Inattentive –
Just working with this new Discus and trying get on top of comments… No, it wouldn’t make it ‘more like regular Ritalin.’ It might however, as we have pointed out here, help with BP issues. With ups and downs with Ritalin I always think about comorbid depression and evaluate for that comorbidity before making any specific stimulant changes.
Thanks for your kind remarks!
I’m pretty sure I’m not depressed, but my metabolism is ridiculous. Most people work their whole lives to get ahead, whereas my life is an hour-to-hour struggle just to stay fed & hydrated. So 4-hour Ritalin only works for about 2.5 hours. But if Intuniv will get my BP back to normal and let me stay on the Daytrana (which has been a Godsend), that would be perfect. I do really well on methylphenidate (and I hate amphetamine!), but with the exception of Daytrana it’s just too short-acting, even Concerta.
Thank you so much for your quick response.
Since you bring up the metabolic piece I strongly recommend that you chase down those details with IgG testing and a full medical review from thyroid to adrenal… those challenges will *always* make the meds unpredictable!
You’re probably right. I’ve always just had a fast metabolism, but the older I get the more hypoglycemic I think I am.
Well said Jeff, so much is missed thru this fascination with appearances… This audio note from the first of the year covers it a bit more emphatically: http://icin.ch/33FVc
Smith6sa,
The ADHD fascination is simple: ADHD is the most completely misunderstood diagnosis out there, with the greatest abundance of misunderstanding and misapplication of medical interventions, with the most people suffering with this profound almost antiscientific misunderstanding.
Institutional, inadequate thinking predominates, even basic science, such as drug interactions, is frequently overlooked, and the multiple implications of mind body interaction are so prevalent as to take my breath away every day in the office.
Short and simple: Many are suffering, and the patterns present for evolved understanding of ADHD will ultimately find application in the rest of psychiatric practice – as humans live far beyond the simplicity of appearance-labels.
cp
Why a fixation on ADD/ADHD?
I think a bit of the head scratching, “Why a fixation on ADD/ADHD?” is a function of the unfortunate label ADD/ADHD. This label does not, in any way, capture the complexity of the disorder and, most importantly, does not in any way capture (or even hint at) the myriad ways in which this disorder can present itself in terms of behavioral issues in school, work, family, in every single aspect of life. Most importantly, we are learning more and more how a sizable chunk of our “social ills” (self-destructive behavior, criminal behavior, etc.) are a result of people with untreated ADHD.
Its become aggravating to find after a couple convincing diagnoses insisting my underlying signs & symptoms were supposed clear hints of evidence something not be right with me, then within that one appointment having psychiatrists declare I’m ADD/ADHD by the time I walk out their door, and come to find out the real issue is even more basic. Personality disorders, or stuble signs of various emotional & behavioral problems, are commonly a result from emotional/psychologicalabuse by an adult onto a child. So maybe since there are reported high numbers of child abuse, instead of jumping to the conclucion some of these people are ADHD and in need of medication as a quick fix, maybe doctors should slow down and listen to the obvious signs of abuse that require different forms of attention and treatment. I could easily be incorrect, simply stating from personal experience.
Dr.Parker,
I searched the site and mostly saw that there is not a problem combining Concerta and Intuniv, however as I was surfing the site last night, I thought I found a comment on your blog saying that there is one incidence of sudden death with that combo?? Now I can’t find it. Can you just confirm if these two are ok together? My son is on 54mg Concerta every morning and has been wonderful on his focus. The doc recommened going on Intuniv in the eveing because we cannot get a handle on the impulsivity.
Thank you so much!
Denise
Denise,
I didn’t report it, because if I had I would have remembered it. Concerta blocks 2D6, not 3A4, the pathway for Intuniv – and therefore is not a problem to my knowledge.
cp
Dr. Parker,
Do you ever recommend sleep studies for your patients?
Thanks.
Sara,
Absolutely! We try to identify specific sleep issues in every first office visit, frequently rec sleep studies and work with the sleep folks to get the job done. So many people won’t put on their CPAP simply because they can’t sleep with it, so we get the CPAP on and help with the underlying sleep disorder, including measuring melatonin – and correcting levels there.
cp
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