- To Change Your Mind - Details Matter
Intuniv For ADHD: Dosing Details
Vyvanse diminishes Memory? Watch The Top of The Therapeutic Window
November 14, 2009Intuniv Answers: ADHD & Addiction Indication
December 15, 2009Intuniv For ADHD Is Guanfacine, 
Fresh Day For ADHD
But Better and Easier
Fresh Day For ADHD
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 and Intuniv, 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.
Remember: Intuniv is not a stimulant – refills on prescriptions become less problematic. This ADHD medication is not a Ritalin or Amphetamine concern!
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.
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.
———————–
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
———————–
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.
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.
Drug Interactions: Absolutely Relevant
1. From the Intuniv package insert: Intuniv is a CYP450 3A4 substrate. It will be induced [reduced in effectiveness] by Trileptal, Provigil and Tegretol. 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, causing accumulation and an overdosed feeling.
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, loaded with interaction potential. 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 have been higher as a result of this induction process.
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
- 9/12 Intuniv For ADHD: Avoid Drug Interactions
- 9/12 Intuniv For Addiction Issues
————–
Food Allergies Always Matter
Milk addiction, casein, gluten and other food sensitivities preclude effective dosing strategies based upon the Roving Therapeutic Window >
discussed elsewhere here at CorePsych. See the multiple CoreBrain Training videos listed here ↓ on ADHD Medications and Immunity Issues.
ADHD Med Playlists At YouTube
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 Specifics on Vyvanse See This Link
————————
New ADHD Medication Rules
For many more details see my book in paperback, audio, and Kindle: New ADHD Medication Rules – Brain Science & Common Sense – it outlines specifically why stimulant meds so often miss the mark. Available here with testimonials: http://adhdmedicationrules.com
Intuniv remains an interesting “ADHD” treatment option – yet if you look at the Walsh-Resources page above more options quickly arise.
cp
Dr Charles Parker
Connect & Subscribe To CorePsych News: This Link
Connect & Subscribe For YouTube Updates: This Link
Complimentary & New: Download this 25 pg Special Report: Predictable Solutions For ADHD Medications
Click Here to Download
RSS YouTube Feed: This Link
>>> Please do forward this posting to your lists. Thanks!
Related articles
367 Comments
MY SON JUST WENT UP TO 2 MG INTUNIV IN THE MORNING (HES ALSO ON 1.5 MG AT NIGHT). HIS STOMACH PAIN IS THROUGH THE ROOF. HE EVEN VOMITTED. MY QUESTION IS: DO I JUST STOP INTUNIV COLD TURKEY TO HELP? OR, GO BACK DOWN TO 1.5 IN THE MORNING? ALSO IS THERE ANYTHING YOU ADVISE TO HELP WITH THE STOMACH PAIN. HE’S MOANING ON THE COUCH, GOING ON 24 HOURS.
Meg,
Sorry just got this. My strong recommendation: have him see a medical person ASAP. Sounds like it’s not Intuniv [highly unlikely], but rather could be something more serious thus requiring medical review. 24 hours of moaning… consider appendix as an important possibility that needs ruling out right away.
cp
Dr. Parker– you have been so helpful to me. I have a question and comment: If I take 75 mg generic Wellbutrin immediate release with (2) 27 generic Concerta (Kremer Pharmaceutical) would theWellbutrin (IR) titrate and increase effectiveness? I understand that the FDA has decided that the new generic(s) by Kremer are “approved” but their efficacy is now widely questioned.
Secondly, it is only until Friday, January 9th 2016 when I once again take generic Corepharma adderall 20 mg (3X) daily. Although I would prefer Sandoz which I understand is the closest generic chemically and most effective. You may remember me; I had the gastric bypass 15 years ago– and I had a “substitute” psychiatrist last month who looked at my chart for thirty-seconds and asked why I had been prescribed extended release ADHD medications instead of immediate release medications?!!! Finally, a doctor who understands that RNGB patients require immediate release medications. The adderral is so much more effective although I (again) would prefer the Sandoz version. The CorePharma (after the third dose of 20 mg IR makes me a bit tired– not according to certain ADD Forums is not unusual. Still … Also, I put on 60 pounds since last year because of Quietapine, Doxepin, Amitriptylin (Elavil) and have developed gout– and my depression has obviously worsened because of it. I had a bypass in order not to be obese and the anti-depressants and anxiety medications added the weight.
So, the doctor took me off those medications, prescribed the adderrall (3X) daily plus instead of 1 mg of clonazepam, increased it to 2 mg– which has helped me with my insomnia and anxiety, dramatically! He also believes that I suffer from Bipolar 1, not manic depression– for years I have asked about ECT treatment(s)– he agrees. When my regular Nurse Practitioner returns, I am going to insist on maintaining the new medication regimen and tell her I believe that ECT will alleviate the bipolar symptoms and severe depression that I have suffered since I was a young man.
The psychiatrist who placed me on this new regimen and agreed with me regarding trying ETC said that he would “fight” for this treatment. I have suffered ten years! I hope Dr. Bennett who works for the same CPC Behavioral Center located at a different city, nearby, if I encounter any resistance I will insist on switching to his practice.
A doctor who did not condescend to me or make me “plead” for an efficacious treatment is a blessing. Perhaps it won’t work long-term, but having a doctor demonstrate a regard for your concerns and “treat” you as an intelligent, sentient being is quite a blessing!!!
Gerard – Yes, metabolic comorbidity that requires Gastric Bypass almost always responds better to IR meds. I personally don’t become involved with brand subsets, but more with the clinical presentation of brittle responses and significant side effects secondary to those same metabolic issues which, BTW, don’t resolve until they are individually identified and corrected. See this video playlist for more on that topic: http://corepsych.com/gi
Once that macro picture of neurophysiological “background noise” is identified as a living comorbidity, then these are the tests we recommend to identify the real underlying contributions: http://corepsych.com/tests – listed in the order of my preference from top to bottom on the second page.
I didn’t see you mention serotonergic agents, so with the hint of that drop in the PM you really should take the time to look through this set of vids: http://corepsych.com/drop
Hope this helps!
cp
Hello Dr Parker,
Not sure if my question went through, so here it is again:
What is your take on Hemp Oil for anxiety (which may reach extreme levels, manifesting in aggressive rage attacks)? The child, 11 yr old, takes Adderall XR 15mg, Intuniv 2mg, and Escitalopram 10mg a day).
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, our (new) specialist want to change the triad of “Aderrall XR(15-20mg)- Intuniv (2mg )- Escitalopram (10mg) for a 12 y/o to Prozac instead of Escitalopram and later maybe change to Straterra. Intuniv is now divided bid due to somnolence. This, in order to get better control of Depression/Anxiety (with mood and anger issues) before handling the impulssive part of ADHD.
I know you advise not to take prozac and intuniv together. Is this an absolute ” no no”, or you can see cases it should/can be allowed?
Thank you
ND,
For me it’s an absolute no-no, not from an acuity based treatment failure [major side effects suddenly], but from a chronic reaction that will inevitably occur over time. The result of the chronic failure is more mystifying and rife with denial, rationalizations and more med changes – as those who don’t ‘believe’ in the proven facts of drug interactions will often identify the causal culprit as breakfast, exercise, or at worst: uncontrolled depression. The inevitable result of the depression diagnosis: they add on more Prozac. About 6 mos after that aggressive move and 1-2 hospitalizations is when they call me.
By the way: too much Prozac with toxic AMP build up does often result in more depression. They will be right in that appearance diagnosis, wrong in the functional reason for that deterioration – simply based on pervasive drug interaction denial.
My strong next recommendation: Focus on bowel function with the inexpensive Transit Time Test here: http://corepsych.com/ttt – with a reference to PubMed and Mayo Clinic. That process will very likely drive closer to search for the underlying metabolic issues. Then you can review videos and audio programs on lab studies listed here: http://corepsych.com/tests
Important PS: Strattera is also blocked at 2D6 by Prozac and builds up with a toxic effect of over sedation.
cp
My son is 6 years old, 45 lbs, diagnosed with ADHD at 5 (although he has always been thought to have it, it wasn’t until he attempted to start kindergarten when they really pushed for testing). He started on Quillivant 2 mg bid, as well as behavioral therapy to help with the impulse control issues. This worked fairly well until all behavior changed, mood swings, crying, anger, sadness, etc and many incidents at school involving pushing other children, fighting, etc. Switched him to Vyvanse 20 mg and this changed his behavior in the best way. He could focus at school, just seemed happier, his appetite came around and in the year he has been on it, he has gained weight, not had any big incidents at school, and just felt better. Now here we are at about 14 months on it, and the mood swings are back, so much anger at people and mostly kids who do things to him (saying mean things, knocking things down at daycare that he spent a lot of time building, etc), saying he hates himself almost every other day, crying all the time, fighting kids, holding grudges over everything, and just seems like he is miserable:( I am really feeling like a med switch is in order? This is the first time I have heard of Intuniv and I am wondering if this may be a good one to try. What are your thoughts? This is such a roller coaster ride and I hate this for him. I am a single mom of three boys so this is wearing me down and makes me so sad that I feel like I can’t reach him. He is such a loving boy too.
Dana,
Several issues likely fueled by the underlying complexity of at least three issues – so start with these ‘easy’ ones:
1. Comorbid Serotonin Issues: From the sound of anger and sadness, with underlying vulnerability he does sound like he suffers from an underlying serotonin imbalance seen in this explanatory video and the next video playlist: a. This Video on ‘Balance’ linked here: http://corepsych.com/balance and b. Video Playlist on Drop in the PM referencing a problem that can last all day especially videos 3, 4 & 5: http://www.corepsych.com/drop
2. Depression From Methylation Imbalances: see this comprehensive page: http://corepsych.com/walsh-resources
3. Metabolic Challenges: Intuniv hits another neurotransmitter system entirely, may help, but often won’t if he does suffer from a serotonin challenge – especially if it’s related to a third issue metabolic challenges secondary to Mind and Gut issues: http://www.corepsych.com/mind-gut
Pediatricians as a group often miss comorbid serotonin issues as they simply have not been trained – many are good docs, & well meaning, but miss that serious commonplace challenge. I suggest consult with a child psychiatrist who understands these issues. With these video trainings you will be better able to select an informed clinician without having to pay time and money to further sort out their perspective.
cp
NVLD?
I am trying to help a parent whose teenage son has been diagnosed with anxiety and NVLD. Her son stopped taking the meds for anxiety because they made him feel nauseas, tired and headaches. Understandable since they were Zoloft, Abilify, and Cogentin.
My question is this. I have read up on NVLD and it seems to me to be – well, I don’t want to put words into your mouth. Is this a valid diagnosis or a way to ignore medication (opps, my opinion sneaked in again).
Sandman2,
NVLD is a diagnosis, and outcome of a variety of multiple possible causes. Because of the complexity of these presentations simple solutions don’t cover the multiple variables. More understanding is necessary – consider this fresh information: http://corepsych.com/walsh-resources
cp
[…] Intuniv For ADHD Is Guanfacine, But Better and Easier […]
My son is 4 years old and weighs 32 pound. He was diagnosed a year ago with disruptive behavior disorder. He was recently also diagnosed with ADHD. He is hyperactive, unable to sit still, has a hard time falling and staying asleep, has horrible temper tantrums over the silliest things, throws things, hits others, refuses to listen or follow directions. He was put on Kapvay 2mg at bedtime which has worked wonders with helping and falling asleep and sleeping through the night. The first ADHD medication he tried was Ritalin, it only made him more angry than normal. Next he tried Adderall which made him even more angry than the Ritalin. He had a GeneSight test to determine which ADHD medications would be best for him. The results put the medications into three categories, green for use as directed, yellow for use with caution, and red for use with increased caution. No medications were in the red category. Strattera and Kapvay were in the yellow category. Adderall, Focalin, Dexedrine, Intuniv, Vyvanse, Ritalin, Concerta, Metadate, and Daytrana were all in the green category. We decided to try a non stimulant and since he can not yet swallow pills instead of Intuniv we went with Tenex. He has been on Tenex 1mg in the morning and 1mg in the afternoon for 3 days now. He has been much more sleepy that usual, and still having problems with anger. My husband and I are extremely worried and want to find a medication that will help him. He will be starting school next year and with his symptoms we are very concerned how he is going to perform in school. Is there any medication you could recommend? Do you think the Tenex dose is too high? Should he be taking Tenex during the day and Kapvay at night? Any suggestions would be greatly appreciated. Thanks.
Nicole,
First remember that your GeneSight testing is excellent – but only for genetics regarding the ability to metabolize those meds, especially through liver pathways. GeneSight and others don’t cover other important impediments such as those important challenges associated with methylation that create variables at the synaptic level.
Remember, even with the methylation process some of the genetic testing addresses only one aspect of methylation [such as MTHFR polymorphism], not the overall result of several methylation influencers. See the Walsh video on this page and the note below discussing the MTHFR polymorphism below his video on Methylation: http://corepsych.com/walsh-resources
Also look on that page at the links to that series of [now 7] posts I’ve written about methylation, copper, pyrroles and trace elements for multiple additional contributory factors beyond liver genetics – using relatively inexpensive Walsh protocols – spelled out in detail on this page: http://corepsych.com/tests14 [page 2]. Testing is the answer, and will provide more consistent answers than speculating about meds and possibilities.
I’m sorry, but to advise without more direct information would prove counterproductive. Also he might suffer from other challenges like immune disorders, Candida, all of which could be addressed by proper evaluation and testing.
cp
Hello,
What is your take on Escitalopram (5mg/d) and Intuniv (2-3mg) with Adderral XR 30 mg for a 10.5 yr old with ADHD-Combined, anxiety and (what seems to be) DMDD-Disruptive Mood Dysregulation Disorder? (I read you don’t recommend the Intuniv with Prozac).
Do you have experience with giving Intuniv BID?
ND,
First, there are no serious interactions between those three. Some resources indicate that Lexapro blocks 2D6 minimally. My reading on the literature and from clinical experience is that it isn’t a problem, especially at lower doses. Intuniv is a 3A4 substrate. Yes, have used Intuniv BID especially if looking to take advantage of the side effect of sedation. Some recommend Intuniv at bed, most often we use it in the AM, but, as always it is determined by the patient’s reaction and possible side effects.
I’m guessing that you ask that question because 3 mg in the AM might be too much at the same time. Not a problem to split the dose in my opinion, though not recommended by Shire because they have no studies on it’s efficacy. Anecdotally not a problem.
cp
Hello,
We switched Intuniv (1mg) to evening due to sedation complaint during the day. Now the insurance has changed and Intuniv will not be covered- what is the best conversion to Tenex?
Thank you!
ND,
.5mg 2x/day of Tenex for 4 days would be reasonable and and evaluate – with your doc’s approval and direction. Then: titrate up slowly up your doc’s direction, depending upon response. He sounds unusually medication sensitive so caution is advised. Sedation on 1 mg, quite honestly, does encourage the strong diagnostic possibility of metabolic challenges – see this post: http://corepsych.com/TransitTime
Then download and follow instructions on this PDF to evaluate Transit Time as a possible marker: http://corepsych.com/tt for more specifics as spelled out on that PDF.
Best-
cp
Thank you for your prompt response. As a colleague- I wish all physicians would value and follow patient care and caring for patients in such way.
Thank you ND, it looks like we’re already on the same serious Path,
Together we can make a difference,
cp
My son just turned 5yrs old. 25th percentile height and weight. He has shows signs of ODD and ADHD since age 2. At age 4 he started 2.5mg of Ritalin and it made him wired. 5 mgs of Focalin XR made him a zombie. He started a low dose of Strattera with periodic increases over the year now taking 50mgs. Until recently he was doing well with no focus, fidgety or ODD symptoms. However the last month has been very difficult and he is not able to focus and is extremely fidgety. The Dr added 5mgs of short acting Adderal and he was bouncing off the walls, whiny and sensitive which is uncharacteristic. I tried a low dose of the short acting Folalin with the same reaction. The Dr suggested that the next step is Quinallent however, oddly he is better at swallowing pills than he is about swallowing liquids. I’ve been reading about Intuniv and would like your thoughts.
Melissa,
These are all signs of metabolic disarray, and the very first thing to consider is testing for IgG. See this video playlist: http://bit.ly/mindgut Right next to that one is the absolutely necessary information from the Walsh Protocol discussed on the top of the second page here: http://corepsych.com/tests14 and this page: http://corepsych.com/walsh-resources
To answer your question about Intuniv: it is certainly worth a try, but I would discuss with your physician starting at .5 mg rather than the full 1 mg as he clearly is far too medication sensitive [based up those expected metabolic challenges]. Since it addresses a different neurotransmitter system it might help, but be prepared for the fact that some of these kids get far worse w Intuniv simply because glutamate, the neurotransmitter in question is already in abundance secondary to the immune inflammation. Quillivant XR is methylphenidate, which he has already failed, and collects dopamine.
Do consider those two tests to speed along improved information.
cp
What are your thoughts on using Intuniv and Strattera together in an 11 year old with ADHD? Is this combo often prescribed?
We tried methylphenidate and Focalin which led to developing tics (motor and vocal). Intuniv worked perfect for the tics initially, but the throat clearing has been popping up again. Would adding Strattera in addition help target the ADHD?
Ali,
Any complicated child with ADHD deserves testing with the Walsh Protocol [ http://corepsych.com/walsh-resources ] before simply just trying other meds. Short answer: no drug interactions between those two and Intuniv [ http://corepsych.com/intuniv ] can prove helpful w tics.
cp
Oh, also just noticed that he recently started, ” 2.5 mg of abilify at night.” Probably in late July of this year.
Sandman,
Abilify could add to soporific problems if either not indicated, or metabolized too slowly.
cp
Can strattera and zoloft have the same interactions as stim meds and prozac? Reason is I am trying to help an 8 year old on 25mg of strattera and 25 mgs of zoloft. The child is now having meltdowns which seem to be getting worse. Thus I suspect the interaction problem, but not sure if zoloft blocks the pathways like prozac does. Also could the strattera then build up and cause the meltdowns?
If this is indeed the case. What is the best way to back off the meds?
By the way, I have bought and read your book. It has helped me help others. It is significantly better than any thing else on the market.
Sandman,
Strattera is also a 2D6 substrate, but Zoloft is not a significant 2D6 blocker. More likely is the problem of elemental neurotransmitter imbalances living downstream from immunity issues. Norepinephrine is the neurotransmitter collected by Strattera, and if it is elevated already by immunity issues Strattera will cause problems, just as in the case of Intuniv with backup glutamate secondary to immunity issues.
I would welcome the opportunity to work with you to help you assess these matters w your clients. Take a look at the tests at this link: http://corepsych.com/tests14 – For cost effectiveness the IgG Great Plains and the TMA. Neurotransmitters are interesting, have seen hundreds, but IgG and TMA drive more to underlying core issues. If issues don’t correct with those two then we dig deeper w OATS and NT to cover other contributory possibilities. Links on the PDF will give you even more instructions.
Thanks for your kind remarks! If you have a min please drop a review over at Amazon to help spread the word? Thanks!
cp
Dr. Parker, thank you for your quick reply. I certainly did not expect you to be up and typing at 6 am Sunday morning! And yes, as soon as I finished reading your book, I gave it 5 stars on Amazon and many kind words. The review was March 21, 2014.
The family will be going in to an OT (this week) on our recommendations to evaluate if he has SPD as he does have some symptoms. Of course, if he has SPD and not ADHD, I would assume the strattera could then be part of the problem. And, he might have both – but at least she would then be getting more useful strategies.
I did find more info on the meds. Straterra was started in Oct. 2013 and seemed helpful. Zoloft was started in Spring of 2013. The Straterra was increased to 25mg in April 2014 due to an increase in behavioral problems.
Also, they “did a swap of his cheek to send to lab to determine how his body metabolizes these types of med. There is 3 categories 1)use as directed 2) use with caution and 3) use with increased caution and freq monitioring. His body metabolizes slow so none of the meds showed up in the first category all fell in #2 and #3.”
I have to read your info on slow metabolism, but got a feeling that is certainly contributing to the problems. Wonder if that is letting the Strattera build up? Any other thoughts?
Thankyou,
Sandman2
Sandman,
Another early morning reply! Yes, genetic testing is showing the strong likelihood of med accumulation that will create side effects. One of the main side effects of Strattera, a 2D6 substrate, is that it clearly will create tiredness. I had one adolescent girl fall asleep on the tile floor in the bathroom in HS and they searched all over thinking she had run from school. No interaction w Zoloft tho.
Thanks so much for your very kind endorsements and help to spread the word. The book is not about money I can assure you – it’s about creating a fresh dialogue of more precise inquiry.
Peace,
cp
OK, that makes sense. She mentioned yesterday that he seems to tire out very quickly. Really looks like a strattera buildup. She is seeing a psychiatric nurse practitioner. I hope the doc can figure this out. The child seems to be on way to much medication.
Thank you for your time! On the ADHD forum on Medhelp, your book and your site is the first thing I quote when there is any questions about meds.
Sandman,
You, my distant colleague, are most kind. I look forward to meeting you one day as we walk the same Path. My rule: too much is too much, even if you think it shouldn’t be too much. Metabolic variability is the weapon guidance system, and it either works or it doesn’t.
Thanks and peace,
cp
Hello Dr. Parker,
Are you familiar with how the extended release mechanism of Intuniv works? I tried it before and it helped but I couldn’t go above 1mg or else it floored me.
I am asking because I am currently on a trial of Cymbalta with Ritalin IR (20mg X 3 a day) and I am finding the only way to fall asleep is to hit a benzo which I don’t like doing really.
I could sleep a little better on Effexor but it seemed to cloud my thinking (maybe a little too heavy on the serotonin side), even on Ritalin.
I want to try Intuniv again for this but the cost is too high and the manufacturer coupon is only for children 6 to 17 years old. So I was interested in asking my doctor for Tenex but I am not sure what the equivalent dose would be given the extended-release nature of Intuniv.
Thank you for any information you may share.
Jay,
Your doc will know on the dosage – it’s about the same on Tenex. But if you need to sleep, and are interested in an even more soporific alpha 2 agonist, why not try low dose clonidine [1/2-1 of 0.1 mg] at bed if your doc approves [blood pressure]? Very likely, with that unpredictable tone on each of these meds I would consider many more questions along the immunity line. See these two video playlists for more info: ADHD Meds Problems – Mind and Gut: http://bit.ly/mindgut – ADHD Meds & Allergies – Milk and Wheat: http://bit.ly/mawimmun
cp
SO my husband has been taking Strattera and has done good, but the cost has become outrageous and I saw on Intuniv’s website that its for ages 6-17 and my husband is 30, do you think he can replace the Strattera for Intuniv(if its cheaper, I will check)?
Also, My daughter is ADHD 6 years old and we haven’t gotten her on anything yet but saw Intuniv and thought that might be a good pick as well, but saw it makes people tired. How tired would you think and is it like Strattera that as long as you take it every day and in the morning, you get used to it and you don’t get tired anymore? I know if my husband forgets to take his and takes it later in the day, when it kicks in he is very tired and the same for if he misses a day, the next day he is sleepy.
Tabitha,
Usually tired reactions indicate the dose is simply too high. Often it’s increased when it isn’t working well to a point that it’s simply too much. Multiple other stimulant medications work well if he’s failed these two.
cp
He has had addiction issues with the stimulant kinds, so he stays away. I’ll tell him that it might be to much dosage for his strattra, but can he replace strattra with intuniv, even thou he isn’t 6-17 and he is 30?
Tabitha,
Studies show that Intuniv beats Strattera hands down in efficacy, and does work at any age level. It’s a great product for anyone struggling w addiction issues, simply requires the same dosing-attention outlined in this posting.
cp
Thank you for your time and help!!
God Bless!
Hi, Just wanted to throw a question out there about Intuniv. What are the chances it could work for BPD for mood regulation and addiction on an adult woman? I am in the process of trying to help a friend who is about 40 years old and had a diagnosis change from Bipolar II to BPD. She is severely depressed and has tried tons of meds.Just curious because the two main issues are depression and emotion regulation. Would that along with DBT be a good idea to mention to her doctor?
darla55,
I don’t have the link for the specific posting at this moment as I’m running off to the gym, but SEARCH the Intuniv posts here where I wrote a specific post on addiction and Intuniv as a reasonable alternative. Short answer: yes, absolutely recommend that she discuss w her doc about that option.
cp
PS, yes do recommend DBT as well – explained in this link for those unfamiliar: http://en.wikipedia.org/wiki/Dialectical_behavior_therapy
cp
My son is 26. He was diagnosed with ADHD (but not treated) around 12. Later diagnosed with bipolar (and treated, but never took his meds properly). Strongest symptoms were extreme anxiety and mania/depression, although now I recognize ADHD symptoms from childhood. Currently, he has been taking Xanax and Vyvanse (it keeps him from sleeping all day in a depression-fueled-I don’t want to live-crash.) A couple weeks ago, he started Latuda. He IS actually taking it, because he let me know when he needed a refill. He dropped out in the 10th grade, but has a high IQ, is unemployable, thinks he’s smarter than everyone else, thinks he can “read” people, interrupts constantly, can’t take care of his own business, talks too much/too fast/too loud, is overly sensitive to embarrassment or perceived rudeness; however, he is extremely rude (He calls this “not being fake.”), and many more poor behaviors.
Mine, and everyone else’s problem with him is that he seems so much more intensely volatile (verbally) lately. His father thinks it’s since Vyvanse, but I can’t put a time on it for sure. He used to ask us for information and opinions and seemed to enjoy learning, but now, we can’t get one word in, and then it’s taken up as “us being stupid or rude or not listening, or we don’t get it,” and he FREAKS out if we interrupt him, but we can’t get a word in (and this is coming from separate households.).
Will the Latuda balance out the Vyvanse eventually? Is there something else you would have used or added?
Michelle,
Good history – but inadequate to take a good shot at helping out. It sounds from this distance that he manifests a serious dose of Clint Eastwood Depression – with an angry drop in the PM, or indeed all day. See these vids to tease it apart a bit more: http://www.corepsych.com/7videosPMDrop – I do think he appears in the third video in this series. It does sound like he’s not responding at all as one would expect him to – leaving a “metabolic” suspicion. Metabolic irregularities almost always create treatment failure.
Yes Intuniv would be an option, bu so would several other meds depending on the details. Latuda could help, but if it doesn’t he should have a more careful workup. That crashing during the day is typical of both depression and mood disorder – thus the encouragement to move more carefully on your/his next steps.
cp
My 4yr 5 month old son has severe ADHD and Autistic… He has trouble in school and at home.. past meds. So far Focalin 10mg, Focalin 5mg, Methylin 5mg, for ADHD… For sleep we had tried Melatonin 3mg, clonidine 1mg tab 2tab at night. He is now seeing a different dr. She put him on Tenex (Guanfacine) 1mg. his dose is 1/2 tab at 5:50am, 1/2 tab at 8:00am, 1/2 tab at 2:00pm, 1/2 tab at 5:00pm, 1 tab at 8:00pm… he is still very hyper including at school and on the bus, he wont stay still no more then 3-5 mins. He is also not sleeping again.. Today was his appointment the dr prescribed Adderall 5mg in the morning when he wakes up… My question is: Is is Safe for my son to take all that. Also what else can I try to help him sleep. He is barely getting 3-4 hrs of sleep a night…
Jennifer,
I personally don’t mix Adderall and MPH products for the reason that they might do well at the outset but often create problems with interactions over time. MPH blocks 2D6 the Adderall pathway. I’m compassionate with your doc’s reaching out and trying hard to help.
Your boy is clearly a challenge, and rather than speculate about helpful solutions without markers in the face of his complexity I strongly recommend testing as outlined in this pdf: http://corepsych.com/tests14. Most especially OATS, IgG and TMA. Neurotransmitters can add helpful information, but many are limited by the cost – and that additional testing is about 230$.
We don’t upsell those tests. With our practice you simply pay the lab what we would pay if we did upsell – our wholesale price from the lab.
Our reimbursement comes from consult time, and we do make supplements available at the CoreBrain Store, but you’re under no obligation to buy from us. All this is explained in detail in that pdf linked above – and through our Services Page: http://corepsych.com/services
cp
I was diagnosed bipolar between the ages of 18 and 22. The subsequent medications ruined and controlled my life until finally one doctor felt “brave” enough to try a stimulant… when everyone else ran out of medications to lab rat me with. Surprise…I’m ADHD, and it went unnoticed my entire childhood and beyond, which is beyond infuriating.
I really do hope Intuniv changes the way doctors approach ADHD, not just in children but in adults too. It’s not an insane controlled substance that scares doctors to prescribe. And instead of being labelled bipolar and given hardcore anti-psychotics and anti-depressants, the answer could be as simple as Intuniv, then providing a basis for a stimulant if needed.
Also, just to add my two cents on the topic of ADHD; it seems parents, teachers and even doctors these days only notice or recognize hyperactivity-type symptoms. Its really sad that inattentive-type has become the silent disorder that makes adults think kids are just socially inept, “spacey” or messy, (like me. Sigh.) They are all red flags that counselors and others should be able to recognize without thinking they’re just “bad students.”
As an adult of 24, (even though its not labelled for older than 17), Intuniv has been a god send. No more anger or irritability from my Vyvanse, way less irrational anxiety, and best yet, its like it works almost in conjunction with Vyvanse to reinforce my concentration on tasks.
Great article.
Thanks so much Eleanor,
Your testimony is the real reason I wrote New ADHD Medication Rules. I was, for years, the bipolar guy in this region, until I stepped out the box to see the mistakes I was making. The additional problem today: with the pharma changes, the silencing of speakers and dinner programs the essential dialogue on these matters is gone from the national scene. Innocence and downright ignorance will now prevail more than ever, and free speech, even tho paid for, is gone – with the consequence of serious harm to untold thousands.
cp
my 8 year old son has adhd and is taking 1mg guanfacine 3 tablets a morning and 20mg of methylphenidate a morning he still has bad days in school and at home is this too much for him is this effecting his liver and what else can they put him on that will help him and not hurt the body
Tellis,
The problem with 3mg of guanfacine in immediate release form is more likely a drop in blood pressure [BP] w the pk curve with a rapid hit that might lower the BP. I know of no criteria for necessarily checking liver function for that med, but will leave all that to your doc who appears more comfortable w that dosing strategy than I am.
cp
Dr. Parker,
I am enjoying reading your articles/response to questions. I have a 9 year old whom has been diagnosed with adhd since age 3 and odd since 5. We have never given him medication however, because of his behavior in school and home and especially social issues we are contemplating to reverse our decision. He has suffered from tics and we have Tourette’s and bipolar in the family. Based on my research stimulants are not best based on his history. I am thinking the intuitive iwill be the best med for him if we choose. My question is how long are the studies showing this to be effective to take? I have only read studies being conducted for 9 months. My son will not even take vitamins so requiring him to swallow a whole pill may be a deal beaker also. Is there no other method of consumption for this med? Also, you mentioned that in some reports it as shown to aggregate the tics. If this occurs would the tics stop after stopping the med? Are there any recommended tests to take prior to med in regards to tics?
Lisa,
More likely than not Intuniv would help, but the possibility that I am wrong, from my own office experience, is about 20%. Tenex can significantly help the symptoms of tic, and with ADHD, but the underlying issues will likely prevail if not attended.
I would try the Intuniv, but without long term expectations. Every person I’ve seen w tic disorder has comorbid, associated, metabolic challenges. “Every” is a big, categorical, word – but it is what it is.
My strong recommendation is a series of tests: Organic Acids,IgG also w Great Plains [no economic relationship], and Tissue Mineral Analysis [TMA] by Trace Elements.
We do all of these at CorePsych, and would be happy to set you up with long distance review… set up a Brief Chat as outlined here:
Hi Dr Parker
My 10 year old son has had a diagnosis of ADHD since 5 yrs old and more recently his psychiatrist is considering adding Bi-Polar. There is a history of Bi-Polar in the family.
The psychiatrist had him on Intuniv last year, but we took him off it once school was out (with the doctor’s approval-she felt he did not need the meds over the summer). Recently, the doctor added Trileptal to help with the terrible mood issues our son was experiencing. It seemed to help a bit. Last week the moods became overwhelmingly depressed and we took him to the ER. He was taken offsite to a psych hospital where the doctor’s have given him Abilify along with Tenex. Does this combination have a successful history with children who have ADHD and Bipolar? Any bad side effects to know about? He seems pretty lethargic. We are hoping he is released today or tomorrow. This has been a parent’s worst nightmare.
Thank you.
Robyn
Robyn,
Sounds like pretty standard care, conscientious and thoughtful. Details like this are best worked on w your doc as it’s just too little info to guess next steps. Do take a look at these four vids to see if they help> Playlist on PM Drop: http://bit.ly/1jykmt9
cp
Hey Doctor,
Quick question, I’m wondering if Tenex pills can be split in half and retain their therapeutic properties. What I mean by this, is that I am now on 3 mg (1 mg 3x daily) but would like to try going down to 2.5 mg per day on the tenex. If I were to split my afternoon pill in half and take that, would that be a viable alternative? The pills don’t feature a score down their middle, so I’m assuming they aren’t meant to be split…but I guess that can be worked around?
Not a problem Andrew – Tenex is IR and not time release.
cp
Hey Dr. Parker,
So I’ve been on Tenex for the past few months, and just today stepped up to 4 mg (2 mg twice daily). Is this a safe dosage? I suffer from GAD and worry about certain things, one of them being medication readjustments. I had been faring well on Tenex 3 mg (1 mg taken three times daily), but in consult with my psychiatrist, I am preparing myself for going back on an ADD stimulant, in this case 5 mg Dexedrine IR. One of the reasons I’ve chosen the Guanfacine is because it helps to counteract the side effects of the stimulants, which tend to cause me a lot of anxiety. However, I am currently on a good treatment regimen for my anxiety, which is 1 mg Klonopin daily in addition to this Guanfacine. The Guanfacine has certainly been helpful overall in treating some of my anxiety as well.
One of the things I worry about with going up to 2 mg twice a day on the tenex is that it might be too much, or that my heart rate might get too low…keep in mind that I am a healthy 23 year old, have some level of cardiophobia, and take my pulse too many times than I know I should. And I am working on taking it less! My cardiologist, internist, psychiatrist, and cognitive behavioral therapist have all told me to stop taking my pulse everyday. But regarding the Tenex, so far I have been side effect free on the 3 mg, and my resting heart rate is usually in the 60s – 70s on this dosage. I will find out today how I handle the 4 mg, but I believe that I should be just fine. What do you think? Have you had other patients who were on 4 mg Tenex? Is it fairly common? Reassurance really helps to alleviate my anxiety.
My plan is, once I’m comfortable on the 4 mg Tenex, I will reinstate the Dexedrine and get my ADD controlled once again, with much less of the anxiety that it had provoked pre-anxiety therapy.
Andy,
Not a prob on the dose, only a prob if, in fact, the dose actually causes side effects w lowered BP, as we have seen that occasionally. Not a prob mixing w Dex either. For adults and larger adolescents yes it’s possible but I personally never go by any cookie cutter strategy based on appearances or weight alone. Titrate With Metabolism – TWM – that’s the only way. And your doc will likely help you w those details.
cp
Hi Dr. Parker – My psychiatric nurse practitioner has put me on intuniv and so far so good. My adhd was undiagnosed, which is amazing to me now, – I’m 53 and have been treated for MDD several times and just low level depression since I werr clear and I rejection sensitivity was almost gone the next morning. So she wants to try me on the trazodone extended release with the intuniv, and I am hopeful I can Hi Dr. Parker – My psychiatric nurse practitioner has put me on intuniv and so far so good. My adhd was undiagnosed, which is amazing to me now, – I’m 53 and have been treated for MDD several times and just low level depression since I was 14! And of course it was always labeled atypical. I am being weaned off of zoloft and effexor. I was having serious depression issues, and as the ADs were increased it started to really exacerbate the ADHD symptoms and in particular my extreme rejection sensitivity. I had a very positive result w trazodone IR that I took to sleep- it really calmed me and my thoughts were clear and I rejection sensitivity was almost gone the next morning. So she wants to try me on the trazodone extended release with the intuniv, and I am hopeful I can get off of the zoloft and effexor completely. My question is that since she really knew nothing about intuniv or even the emerging thinking among a few in the psychiatric field that a hallmark of ADHD can be rejection sensitivity, I brought her the information, I am wondering if this is the way to go, and if it will be okay to be completely off of the effexor and zoloft if my symptoms allow for it. I have read your articles where you mention dirty drugs etc., and I would like to know what you think about trazodone XR (oleptra?) and zoloft. I believe I read that you are okay with effexor and intuniv, and am wondering what your thoughts are on the other two. And btw – I am not nuts about effexor – even the XR doesn’t seem to cover me for 24 hours. Thank you so very much for your time! I am looking forward to getting my life back and am very hopeful that I’m heading to the end of this nightmare I’ve been living for so long.
Bonnie
Bonnie,
Watch for a return of the depression, just be careful… it can be both, not just one or the other. Glad the NP got it. Love those NPs with serious curiosity and willingness to consider options not explicitly in the “book.”
No interaction w any of the meds you mention, and Traz is fine. My recommendation is to get back w the NP and have her/him watch the vids, especially the dosage vids at the end of this posting.
Peace! You’re on the Path, do keep us posted!
cp
Dr. Parker – My psychiatric nurse practitioner has put me on intuniv and so far so good. My adhd was undiagnosed, which is amazing to me now, – I’m 53 and have been treated for MDD several times and just low level depression since I was 14! I have always been labeled atypical. I am being weaned off of zoloft and effexor. I was having serious depression issues,Dr. Parker.
Bonnie,
Watch for a return of the depression, just be careful… it can be both, not just one or the other. Glad the NP got it. Love those NPs with serious curiosity and willingness to consider options not explicitly in the “book.”
cp
[…] This Intuniv Dosing Post is the second most visited post in my 7 years of reportage at CorePsych – from 11/09 – […]
Hi, my daugther is 6 years old and was just prescribed Intuniv 1 mg for her ADHD. Her doctor recommended taking it at night because it may cause her to be extremely sleepy. She took her first dose around 6 pm and the following morning after she woke up and had breakfast she could not stay awake at all the entire day. At the most she would stay awake for 1 hour at a time and then fall back asleep. I kept her home from school to monitor her with it being her first day on the medicine and her lack of being able to stay coherent. My daughter is very small for her age weighing only 35 lbs. Is 1mg too much for her age/height? I never understood the phrase “my kid was like a zombie on medicine” until the other day. We skipped the next dose simply because I didn’t want her “sleeping” the entire weekend away. I gave her another dose tonight…should I consult with her doctor? Thanks!
Jessica,
Absolutely consult w your doc, but not to worry, no harm. Side effects of Intuniv resolve quickly w/o aftermath. Dose is a problem and perhaps Intuniv itself is the problem. Your doc was right in starting in the PM, and, in addition, if a person taking medication has a problem w side effects the challenge is, more than 90% of the time, metabolic – based on how the body breaks the med down, and how much glutamate is already available synaptically [measurable w neurotransmitter through urine]. If I think metabolism might be a problem I start w .5 mg vs 1 mg even tho the package insert disagrees – it saves problems like this.
Then See:
1. This Video Playlist for an ADHD Meds Tutorial generally: http://bit.ly/adhdmedtut
2. This Video Playlist on Dosage [even though it’s for stimulants] to give you much more perspective: http://bit.ly/dosevids
3. This Video Playlist for likely Mind and Gut causal factors in metabolic unpredictability: http://bit.ly/mindgut
cp
Hello Dr.,
My son is 10 now (ADD/ADHD combined) and has been on Intuniv 3mg for about 9 months. Initially, we had him on Focalin but then his underlying tics became so severe he would suffer from headaches (head shaking, arm spasms and facial tics) and bullying . While on Focalin, he went from a D average student to an A-B range. After taking him off Focalin and enduring the multiple tests and doctors, he was put on Intuniv and the tics are very minimal now. I only can see them when he’s anxious, lying or late in the evening. Unfortunately, his grades have suffered in the interim. He is calmer and sits still in class but doesn’t pay attention and absorb what he is capable of learning. Today, his doctor prescribed Strattera (still also taking Intuniv). I’m very hesitant of adding something else (even though it’s non stimulant) because I would rather have him get bad grades then suffer from other kids & self esteem. Is there anything I should look out for with the 2 drugs combined? Doctor also advises to get his weight down. His weight (4’8″ 120 lbs) was a problem even before introducing medications and can’t get him to pay attention to a sport or activity long enough for him to become more active. Any advice? Thanks in advance!
Lupita,
Your boy has, most likely, a metabolic problem. The tics, the response to Focalin with coming out the top of the window, and the good response w Intuniv on the tics, and his weight, all point to immune system challenges that should be tested rather than speculated. As you see from these pages I’m for data, against the too-common guesswork. To start I would look at my playlists on YouTube, especially these two:
1. ADHD: Mind and Gut: http://bit.ly/mindgut
2. ADHD: Milk and Wheat Immunity: http://bit.ly/mawimmun If pressed for time just see the last vid on this playlist on testing w Cyrex the lab we use for immunity testing.
And for an interesting overview see the Sample Recording on Reality here: http://corebrain.org/reality.
Hope this helps. We regularly do consults long distance thru Desiree at CorePsych.com/services – get the testing, review the history in detail and make recommendations – all described in detail on the Services page here.
cp
Hi there,
I came across your site after researching Intuniv. My son was diagnosed at age 5 (right before Kindergarten) and was prescribed Vyvanse. It was GREAT at first – but, then he started some bizarre tics and very sad (he told us he was always sad), angry and didn’t enjoy things he usually did for a 5 year old little boy (such as going for a train ride..). These symptoms were also showing up at school. So, we went back to the Dr. who prescribed Intuniv (about a year ago) It was great!! No mood issues, no tics, participated in group activities, was happy and over all enjoyable to be around! We did the typical dosage recommendation, 1mg, 2mg & stopped at 3mg. The last couple months have been quite trying.. He is argumentative, he has moments of refusing to follow directions and “does what he wants to do”, and really appears that he “knows it all”. We called the Dr and asked to be bumped to the 4mg (especially since it’s been a full year) assuming he needed the extra dosage because of the route we are going with defiance. He has been on the new dose for a few days now… But, is still exhibiting the same “symptoms”. (Also it’s good to note that I use the word “symptoms” because on the VERY rare occasions we miss a dose – he is VERY VERY happy, in a good mood…etc.. Just VERY VERY busy and hyperactive.) Clearly we will wait another couple weeks before revisiting the potential possibility we need to switch.. But, my question, have you come across anything of this nature before? Aggression, Depression, defiance as side effects while on Intuniv? Or could we simply be over reacting as Parents and he is simply being a regular kid he needs stronger discipline? Any advise would be appreciated!!!
Jamie,
See these problems everyday, and while I can’t say for sure it clearly sounds like he’s on too much, is accumulating the Intuniv, likely secondary to metabolic issues which did the same thing w the Vyvanse. From this brief report my guess is that the dosage problems arise from a Roving Therapeutic Window phenomenon. See this entire YouTube Dosage playlist first, then make sure you see this Second on Mind and Gut, and finally take a look at Milk and Wheat Immunity. My Audio book is out just today at Audible [if you’re interested in the audio] that goes far more into these details.
cp
Dr. Parker, upon your advice my doc has prescribed Intuniv 1 mg. along
with my 200 mg. Zoloft, Modafanil 200-400 mg. daily for sleep apnea
alprazolam 1 mg for sleep and wellbutrin 150 mg SR. I am 68 years old
with metabolic syndrome. I took my self off of modafanil as a possible
contraindication with Intuniv and am lowering my dose of alprazolam
as I am sleepy early in the night but fight sleep via the mask but still use CPAP. This polypharmacy is confusing and my doc Psychiatrist
has not said anything? Ok to take modafanil, intuniv & alprazolam
together? Or am I on the right track. Intuniv pak via increases each week or stay on for 1 month as Psych has indicated/ Mike
Mike,
No blocking interaction w Intuniv – which passes up thru CYP450 3A4 – but because Modafinil induces, speeds up, the passage of 3A4 substrates you very well may find that the Intuniv doesn’t work as well, simply because the effective dose found previously, is no longer effective w that interaction. Your polypharmacy, with the sleep apnea and treatment failures is more likely secondary to a combination of Phase I [CYP450] and II interactions downstream from metabolic origins of another type.
Take a look at this video playlist on Mind and Gut from YouTube..
cp
My 12 year son has been taking ADHD meds since age 6. Started with Focalin then switched to Ritalin LA with a Ritalin booster about 2 years ago. This is been effective for focusing at school and controlling hyperactivity (talking etc.) He is also ODD and since the switch to Ritalin has been exhibiting very angry moods with occasional loss of control (kicking, fighting etc.). Could this be a side effect of the Ritalin? Would INTUNIV be an effective replacement and would it reduce the angry mood outburst? URGENT!
Leah,
Take a look at these 2 video playlists on stimulants –
1. On Dosing
2. On Gut and Brain Challenges that effect dosing.
Hope these help, could be either comorbid depression, wrong med, or too much Ritalin – these would be the first three considerations w your doc.
cp
I am 40 years old with ADD and type 2 bipolar disorder. Im a 130 pound woman. I take 100 mg of topomax a day, 10mg of abilify, and 20 mg of adderall 3x daily. The adderall dosage isn’t high enough I don’t think, and I was on Ritalin for years when it recently started being less effective. I would like to add intuniv to the mix rather than increase the adderal or jump to another med. What is the proper dose for an adult? Can adults take it?
Thanks!
Heidi
Yes Heidi,
Intuniv is indicated for adults, and the best way to start it is just as if you were a child. Most Docs have the starter sample pack, 1mg x 1 week then 2mg the second – available because it isn’t a controlled substance. As usual every new med needs careful titration.
cp
Hi Dr. Parker. My 8 yr old son has been taking Adderall XR 20 in the am and 10mg in the afternoon with Clonidine 0.1mg 1/2 tab 2 x daily with good effect for 2 years. Prior to starting any meds he presented with severe aggression and assaultive behavior. Although the stimulants greatly reduced these behaviors they have never gone away completely and have peaked off and on over the past 3 years. Within the last month my son has required hospitalization 3 times because the agression was so severe. One episode lasted 2 hours, required 4-point restraint etc. During this and other episodes he presents with seizure-like symptoms. A sleep deprived EEG showed “mild abnormalities but no epileptalform activity.” His psychiatrist is at a complete loss as to why the aggression suddenly reappeared at the same level or worse than it had 3 years ago before any meds were introduced. After discontinuing the adderall a short trial of risperdal was tried but resulted in a severe allergic reaction. He is now taking clonidine 0.05mg qam and Intuniv 1mg qhs. There has been no noticeable effects…and he continues to exhibit low frustration and aggressive/assaultive outbursts. Also, I think it’s important to add that he is newly incontinent of urine. ANY ideas or suggestions that you might have would be greatly appreciated! Diagnosis: ADHD, Asperger’s, Anxiety, Mood Disorder. Thank you
Cindi,
The glaring phrase in this report, that sticks out like a sore thumb: “Incontinent of urine” That evidence throws his presentation, with an 80% likelihood, into the realm of immune system dysregulation. He needs an IgG eval, and not an IgG with a skeptical, negative doc – the allergists think, for the most part, that it’s quackery, in spite of profuse evidence in the literature, and in my own clinical experience to the contrary. They are skeptical about IgG because it doesn’t hit targets of life and death, but it certainly does effect brain function – which, regrettably, is not remotely on their radar.
He very likely has a food allergy just search my site here for all the IgG articles – a theme for many years.
cp
Thanks, Dr. Parker. We spoke to our doctor last night and he started talking about Risperdal instead of Intuniv. His reasoning was that since our son was not gaining good weight (due to the Concerta), that that would be a good addition and would slow him down. I’ve never heard of Risperdal with ADHD, so am NOT going to fill the prescription. I am looking into a second opinion as when I looked up Risperdal, it says it’s an antipsychotic used for treating schizoprehnia! My boy is just hyper and doesn’t want to eat on the Concerta. So, am looking into switchign doctors. We will try Intuniv and go from there. No Risperdal. Have you heard of this being prescribed to use w/ a stimulant for ADHD? Thanks.
Jen,
Sure, it’s used all the time, way too often IMHO. I only use it when we have problems that almost require hospitalization. On your doc’s side, it’s not a problem at low doses and not really used in that instance for antipsychotic purposes – but to manage behavior… not as a weight assist.
cp
Hi, Dr. Parker. My son was diagnosed w/ ADHD Combined-Type 2 years ago. He’s almost 8 and we’ve been on 3 different types of methyphenidate meds in these 2 years, recently changing to Concerta about 10 mos. ago. Concerta (36 mg) has been the best as it’s longer lasting. He started out w/ 12 hours of effectiveness, now it’s down to about 9 so we give him a short-acting dose of 10mg Methylphenidate around 5pm. Helps through the homework hours! My concern is that he is so hyperactive and impulsive in the early morning (before his meds kick in) and at night before bed that I’m wondering if I should ask his doctor about adding Intuniv to his daily regimen (or try Intuniv by itself)? He’s so hyper in the morning that these bizare comments and sounds come out of his mouth and to top it all off, he can’t even focus to eat! We have to sit next to him to get him to eat! During the day, he doesn’t eat much and is so skinny. He’s not diagnosed with any other illness (Asperger’s, etc.) as when the Concerta kicks in, he’s just your average boy (does well in school, well-mannered, polite, follows directions, etc.). Am hoping you can share some of your expertise on our situation. We love our little boy and want to help him in any way we can. Thank you.
Jen,
Very reasonable, and in the literature, that Intuniv works well w stimulant meds. As we always say here: talk to your doc, then go low and slow and anticipate that he might dramatically turn around in the AM w only 1mg in the previous PM. That trial would be the most conservative, least problematic first step.
cp
Hi my 8 old son has ADHD he struggles more with impulse control rather than with hyperactivity. We have recently tried our 1st ever med, Intuniv 1mg. He has been on it for almost 2 months. In that time his grades and comprehension have diminished dramatically. His weekly spelling tests are suffering and its almost as if the material just isn’t “sticking” anymore. His doctor suggested raising his dose to 2mg but I feel like this wasn’t even an issue before the intuniv. Could this possibly be a side effect from the intuniv for my son?
Thank You,
crystal
Crystal,
Intuniv, if working correctly, corrects ADHD, doesn’t aggravate it. To answer your question I would need to know much more regarding side effects and actual cognitive function targets. My own opinion: it’s almost impossible to adjust ADHD meds without improved targets based on brain function… not on behavior or grades. Superficial assessments don’t compare to brain function questions, and give inadequate information for medication dosage titration – that’s why I wrote
New ADHD Medication Rules. With New Rules the public can see improved target and dosing strategies.
cp
Hello,
My son is 6 years old, has Asperger’s. He is sweet and loving but prone to anxiety and anger when he’s frustrated. I fought the decision to medicate, and then finally gave in, and he was put on .50 mg [1/2 of 1 mg] Intuniv. After a couple of weeks, the change was miraculous, and we were so happy. That lasted for about a month, and now we are back to the old ways. He is angry and melting down constantly, aggressive towards me and his siblings. I am seeing psychiatrist next week, but am concerned that this will be a trend, that his dosage will constantly need to be “upped” every few months. Do you see that, or do children tend to show steady progress once proper dosage is determined?
Concerned,
With Intuniv it often takes more time to hit the correct plateau, and requires more patience in the initial phase of adjustment. It far too speculative to guess what the outcome will be down the line, but is highly unlikely that one can’t find the “sweet spot” after correct dosing is accomplished.
Multiple other interventions could apply but without far more details it’s not reasonable to shoot from the hip.
cp
[…] For Additional Notes On Intuniv Dosing Titration, A New Non-Stimulant: Intuniv Notes […]
Dr. Parker,
My 12 year old son has been on 3mg of Intuniv going on two years this summer. It has worked great for him. He originally presented with high anxiety some ocd tendencies, compulsions along with explosive temper and low frustration tolerance. When we originally tried stimulants it aggravated his ocd/anxiety. So needless to say Intuniv has been a miracle for him/us. Since he started puberty and the 6th grad, the last few months he seems to be falling back to his old ways. He has been very oppositional and aggressive wit his anger. Basically I strongly believe it could be cognitive anxiety at play hindering him from being able to resolve conflict and be in a constant irritable mood. I wonder if persuing an increase to 4mg would work or should we seek out a Dopamine medication to help relieve the cognitive anxiety? Is bupropion an appropriate medication? Or do you recommend one that is safe and has worked well with children? I’m just not sure what our next step should be to stabilize him. I agree that he is definatley not a bi – polar child but have been told that if intuniv didn’t work we might want to try Depakote.
Darlene,
Working with your doc an increase might prove helpful, but also review sensitivity and vulnerability issues as they are quite often tied directly to serotonergic challenges even though boo-hoo depression with crying and sadness don’t present on the front end. Rather than some of the other meds I’d look at first the increase in Intuniv and secondly at low dose of, for example, Zoloft [1/2 of 25mg to start] to eval response to that way of thinking.
cp
Hi Dr. Parker,
My son has been on ADHD medicine since he was about 6, and it seems like we have finally found a great combination of Adderall XR (30mg) and Intuniv (3mg). After trying him on stimulants alone it became clear early on that his metabolism was just running right through it, so we went to the combination therapy. He did Strattera for a long time, but he was so emotional and really starting having other issues on it as well that were of great concern to myself and his doctors. Intuniv has been great.
Now he’s 12, and he’s hungry all the time, obviously in a major growth spurt, and there are a few changes in his behavior at school, although its late in the day when this happens. I’m almost positive that an adjustment needs to be made, but I don’t know which med to adjust. He’s been on the adderall dose for at least 2 years now, and he’s been on intuniv for 1 year or so. How can I tell which dose needs to be increased? He’s going through early puberty too, so won’t he need the food he’s been chowing down on, and need his rest too? I’m concerned about him not having enough energy, or not being able to sleep if he’s on a higher dose of adderall.
This kind of snuck up on me, I was just happy to see him eating so much for the past few months I didn’t consider the fact that his growth spurt would require a medication adjustment. I don’t want to adjust the wrong one.
Sharon,
One can’t be sure without an eval, but it occurs that quite likely he is experiencing a drop in the PM due to the DOE of the Adderall running out. Don’t try to go over an 8 hr, perhaps 9-10 at most. If he’s seeing a pediatrician they are, as a group, loath to give PM meds. Likely a very small dose of immediate release [IR] Adderall would turn the tide.
See this video series to get a clear picture of DOE and what I’m sharing with you here.
http://www.youtube.com/watch?v=rmuCkCRFUQM&feature=share&list=PL321-bGRTfd9xcGzJtPGu6neFvnLVo2LO
And whilst there do Subscribe: http://www.youtube.com/subscription_center?add_user=drcharlesparker
These notes will cover more details for you,
cp
Hi Dr Parker,
My son is 11 yrs old and 85 lbs. He has been on Intuniv 4 mg for Over a year after trying every stimulant on the market. Overall, we think it working ok. He still presents with executive functioning deficits involving organization and difficulty getting started on his work which goes along with his ADHD diagnosis. Over the past year or so he has highs and lows with moods. Also, recently he has been exhibiting OCD type checking behaviors at night. He rePeatedly checks to make sure things in his room won’t topple over at night and make noise that would wake him up. He checks to make sure his phone is off so it doesn’t make noise in the night that might wake him. He has been taking 3 mg melatonin for many years and it is no longer effective to help him let go of his worries or compulsions enough to get to sleep. How much melatonin is safe to give? Should he be on other meds to address worries? I don’t want him over medicated but I want him to be able to let things to and be the best he can be without being bogged down by worries. He has tried therapy several times and feels it is not helpful because logically he knows what to do he says he cant help the checking behaviors at night and feeling worried a lot Any advice you have would be helpful.
Thanks
Michelle
Michelle,
While it’s inappropriate to make specific suggestions, some generalities might be in order upon running them by your med team:
1. With affective, almost somatic anxiety, even without checking for my four types of depression, [three are more cognitive vs affective], consider an SSRI by all means. Don’t use Luvox, Prozac or Paxil for these reasons: http://www.corepsychblog.com/2009/12/intuniv-for-adhd-avoid-drug-interactions/
2. Sorry to sound like a broken record if you have been with CorePsych Blog for a few years – but Rule #1: when in doubt, ask different questions about biomedical issues,
3. And always follow with Rule #2: Test for IgG and neurotransmitters, or trace elements and heavy metals if those fail. Don’t be bound by the limitations of inside the box thinking – the possibilities for recovery exponentially increase with biomedical data.
cp
Hi Dr. Parker
My son started taking 25 mg Zoloft along with 4 mg Intuniv. His OCD type behaviors decreased significantly after a month or so. But his inattention and disorganization are much worse and he is sleepy all the time. He falls asleep at school sometimes and naps almost every day at home which is not like him. I wonder if I should switch back to a stimulant that worked well for him (Concerta or Ritalin LA) and use that with the Zoloft and have him go off the Intuniv. Also, I have thought of switching him to Wellbutrin instead of an ADHD med and a SSRI to try to get the attention and affective effects from one medicine. Any thoughts? We are trying to get an appointment with the Dev Pediatrician, but it will be some time until we can see her, so I just wanted to get your take for now.
Michelle,
Clearly, from this limited perspective, I’m still on the IgG immunity theme. Take a look at this video for more info on Medication Sensitivity: http://youtu.be/wQg1eMwRrPE
Then look at this video on IgG and dietary issues that could very well be causal: http://youtu.be/MzmVz6KFzX8
cp
Hi Dr. Parker,
My son is who is 12 (130 lbs, 5’5) was diagnosed at age 2 on the autism spectrum. He’s extremely high functioning and presents more as Aspergers. He currently is taking 2mg of Intuniv and 10mg of Paxil. I’m concerned now after reading your comment about not combining Paxil and Intuniv. My son cannot take stimulant meds for ADHD/ADD. They have the complete opposite effect on him and we have to peel him off the ceiling. I am wanting to wean him off Intuniv as I’m not really seeing any real benefit and he seems meaner since he’s been on it the past year. What is the best way to wean my son off Intuniv. Should I drop the 2mg to 1mg for a month and then stop all together? He’s been on the Paxil for 8 years for OCD behaviors. I too would like to wean him off of this but he’s had horrible weeping episodes when we’ve tried to do this. I’d really like to see who my “real” son is without any meds.
Any advice?
Brenda Myers
Hey Brenda,
Really can’t leap specifically into recommendations on this small info, but some generalities might help. My concern about Paxil and Intuniv is based upon the fact that Paxil can back up Intuniv through the 3A4 pathway with links here at CorePsych Blog: http://www.corepsychblog.com/2009/12/intuniv-for-adhd-avoid-drug-interactions/
I would much rather see you scrap, with your doc, the Paxil for another SSRI as a start [not Prozac or Luvox] to see if the irrationality slowed – as it could be a drug interaction, subtle, but problematic. He clearly needs an SSRI, and Paxil is not by any means the only act in town.
After that you might consider further workup for metabolic issues that could interfere with all meds: IgG Qualitative, not Quantitative. We’ve had considerable success with biomedical measurements for these challenges, that’s why I’m so supportive of more data vs just trying more meds without knowing the underlying problems. Target recognition is more likely with careful measurement.
cp
My son is 13.5 tall and. 165 lbs. has been on 5mg of Abilify since 4 years old and Intunive 5mg 2x in 24 hours. He still reacts at school. Angry and explosive with any frustration. I’d this the ability. I would love to get him off but am afraid to titrate him off. Does Abilify. Affect the Intuniv in any way.
Sheryl,
At 13.5 your son is pretty tall! Bottom line, the Abilify does not affect the Intuniv in drug interactions – this question is not clear enough to respond with further comment.
cp
I apologize, my son is autistic, high functioning.. loving, social and in many ways functions very normally.
He is very tall( correct guess) his mother is 6’1.. He was on Vyvanse and had violent mood swings, prior to that adderall, ritilan etc..all of them created other issue’s ( tics, mood swings etc) we tried other meds at one point he was on Abilify, Vyvanse, Xanex, Clonidine and metformin. We removed him from Vyvanse and put him on Intuniv and the mood swings and violence ended, his liver panel was showing high levels and we took him off the clonidine, xanex and metformin, one at a time..
He is now on Abilify and Intuniv. He takes at bedtime 5mg of abilify with a melatonin and 5mg of intuniv and a omeprazole and then in the am takes 5mg of intunive with omeprazole
His mood is better, but he still has a ” flash reaction” and gets extremely sensitive and hurt with the slightest fustration from others outside the family.. He can cry for hours, and his mood almost gets ” stuck” . My heart hurts for him as he cries.. ” I want to do good mom, i can’t , I wish I was dead I hate being this way..” I truly believe he wants to do well and then the slightest fustration boom, he ignites.
We have took him off dairy and gluten for 5 months he lost 25 lbs and then started vomiting daily for 45 days, they every test possible, the GI doc said there is no gluten allergy or reaction , nor was there any reaction or allergy present for dairy.. I allow him some gluten products now and see no difference, but.. I have kept him off dairy as when he drinks it, he wets the bed.
My question is, what should we look at about the mood reaction, I saw something that struck a chord with me about seratonin.. your right.. he seems anxious and sad.. rarely true joy… lots of anxiety.. wondering if we are on the wrong meds..
Sheryl
Sheryl,
My best rec at this point is to chase more specific info rather than add to the good conjecture… Somethings working, but some parts are simply unpredictable. For those who seem lost following good follow thru with IgG, and for atypical reactions to going off IgG antigens, it’s time for a TMA: Tissue Mineral Analysis, yes, in street language, a hair test or, with Metametrix, an organic acids to see just what’s actually going on biomedically. The other test that would likely provide more answers: neurotransmitters. Non of these are absolutely ‘diagnostic,’ but any of these will take you closer to useable evidence.
We do provide consults/data reading long distance if you don’t have someone in town,
cp
Hi Dr. Parker,
I just recently went to my sons doctor to report he is getting very agrressive on his ritilan. He was taking 10mg in the am 8am and 5mg in the afternoon at 12pm. We began to notice very impulsive behavior. A few months ago we had him on intuniv alone and it made him far too groggy but now the dr suggests putting him on 5mg ritilan 8am and 12 pm along with 1mg intuniv at 8am with his frist dose of ritilan. Im concerned and want to know if this is worth trying or dangerous?? He eats perfectly normal and sleeps well. The fits of agression are not at a set time sometimes in the am and sometimes in the afternoon.
Please let me know any thoughts about this…..
Rebecca,
The very first consideration with increased aggressivity through the day is the strong possibility of serotonin downregulation. The key question: is he whiny sensitive, feeling easily hurt, like everything is magnified and painful. Is he acting like everything that happens is amplified and he’s crying out in pain that to the average person appears completely irrational? If so, likely a cognitive form of depression has been dramatically aggravated by the Rit.
Remember this, your doc is doing a good thing, trying to move meds into some different neurotransmitter systems… he may not know that’s why he’s doing it, but there is a possibility that it will work. Intuniv facilitates glutamate neurotransmission, serotonin [more than dopamine] regulates feelings/affect, and dopamine helps with executive function, cognition. Stay tuned for a serious group of blog posts coming up that will address these issues. Each day of the week will hit a certain theme, and you want to watch for the neurotransmitter [NT] postings… there will be at least 13 different, specific NT postings. See this video [http://youtu.be/fu0mN68rkEs] on Anxiety and ADHD, and if you want skip to min 4:30 wherein I discuss this seesaw effect from the other, serotonin side, you’ll understand more about the underlying problem.
Remember this as well. We can’t treat heart disease with medicine for diabetes. Don’t expect that Ritalin, a dopamine collector, will fix vulnerability secondary to a serotonin imbalance… one neurotransmitter may have a mild secondary effect on another, but in the office it just doesn’t work that way.
cp
My 13 year old is currently on Vyvanse and has taken clonidine strictly at night to help him sleep for quite a few years (before starting the clonidine he slept maybe 4 hours a night, if we were lucky) we’ve tried taking him off the clonidine, but he just does not sleep. His doctor recently added Intuniv to his meds. He takes a few other things as well, but my concern is the addition of the Intuniv in the morning while continuing the clonidine at night. Is this in any way a safe practice? My son weighs about 88 lbs and takes 0.1 mg of clonidine at night and is prescribed 4 mg of Intuniv. I’m afraid I need to look for a new doctor here…
asplemom79,
That practice is clearly worthy of caution, as the two meds apply their actions at the same receptor site and could aggravate a hypotensive reaction. I wouldn’t rush to change docs as I do see this confusion going on often – not good – but often missed. He’s being careful as that Clonidine works so well, and there are not a great selection of sleep aides for kids that appear free of challenges. Several quick, safe ideas come to mind:
1. Try melatonin 3-6 mg, chew it up for the fast effect, swallowing it slows it down, and get into bed.
2. Try L-theanine see more at this link [http://en.wikipedia.org/wiki/Theanine]… it blocks excitatory glutamate and can work at night.
3. Other medical intervention are out there, that one will require your doc’s medical attention to consider the options.
cp
Thank you for your response. My sons doctor pretty much waves his hand and said ah everybody is doing it when I brought up my concerns. When I persisted he continued to mumble about how it’s fine in children etc. My son is a 100 pound person and not really a child. He pretty much dismissed my concerns and would not even check my sons blood pressure. He suggested I take him to a machine at the drug store if I wanted his bp taken.
We have gone the melatonin route as well as 5-HTP, we tried it for many years before giving in and going with the clonidine. It was not helpful for him. We have now weaned him off the Intuniv completely and have seen no negative change in his behaviors as of yet.
Asple,
Without a more careful review it’s too speculative to comment, – except to say that if you are unhappy it would be best to find someone who will work with you on your level of awareness.
cp
Dr Parker,
My 8 year old son was diagnosed 3 years ago with severe ADHD. We have tried several different prescription medications over the years including Vyvance, Focalin, Clonidine, Ritalin, Methylin ER, Concerta and currently Adderall XR. By far Adderall is giving the best results out of any of the medications, but far from complete effectiveness. Although I can tell a significant difference he still struggles in any social setting, has extreme hyperactivity, and even borderline OCD. But the biggest issue is school!! He is in constant trouble, cannot focus on task or lessons, is constantly restless and distracted and is often times out of his seat, jumping, running, crawling around, climbing or in anyway moving. He is extremely intelligent and has tested off the charts on standardized academic testing, but is currently failing 2nd Grade. His teachers, school, staff, counselors and myself are at a loss on where to go from here or what to do. Adderall is the ONLY medication that has in anyway helped but only seems to take the edge off of the hyperactivity and has drastically helped with aggression and anger issues he had. He is 8 years old and only weighs 42 pounds so his pediatrician feels that his current dosage (20mg Adderall XR) is at its maximum for health reasons. She believes that any higher dose would dangerous in his growth and development along with the dangers malnutrition and being seriously under weight. While researching and trying to educated myself further on his condition I came across many sites promoting Intuniv. It is the 1st time I have heard of it and am wondering if it is an option for my son. Is it a safe combination with Adderall and Intuniv and could Intuniv work with the Adderall to enhance effectiveness? Do you think this is an option I should explore further or do you have any other/better suggestions for us?
Thank You
Carrie
@carrieblanton Sure can use Intuniv with Adderall together, and with your doc certainly worth a try given the seriousness of his poor response to stim meds. Taking your doc’s side for a moment… yes we certainly use more than 20XR, but your doc is likely right on listening to your son’s metabolic side, the weight side. Those symptoms can present as a manifestation of an underlying problem. If the Intuniv proves counterproductive, and if there is a prob you will see it as serious deterioration sooner not later, then your next absolute step is seeking more information – such as IgG testing. Put IgG in the Search Box here and always remember qualitative not quantitative testing for specific foods not global IgG numbers.
Hope this helps!
cp
Please clarify
Qualitative vs.quantitative? I thought (for the sake of highest level of research) quantitative is considered higher…IgG is an interesting thought on the subject as it is responsible for our immune response.
Thank you.
My 8 year old son has just started on Intuniv; one week on 1mg & now one week on 2mg & we are seeing good results. I have just started learning about PANDAS & I was curious if it is possible to have a mild case of PANDAS? My son seems to exhibit some of the symptoms, but at a very mild level. Do you know of any docs in the Dayton, OH area that help with PANDAS? Although the Intuniv is working for him, I would love to treat the whole issue, not just band-aid the small problem. Do you have any insights for me? I would appreciate any help. Thanks!!
Erin
Erin,
Most often the PANDAS-informed are pediatricians, especially those at academic centers, as they are accustomed to the lab assessments. Many well informed docs in the community may know about PANDAS, it’s only a matter of asking that office if the doc treats PANDAS. PANDAS is only one of many possible comorbid conditions… my most common one, seen and measured in my office regularly, and easily correctable [80% of the time] by diet changes: IgG qualitative, not quantitative.
cp
I am new here and we are new to Intuniv. 2nd day. my 6 year old little girl have been on Vyvance since Jan with great results in school. However, I am not happy with the side effects. Too many to list…you all know them all I am sure. So we started Intuniv yesterday. ALL DAY today she has wanted to sleep. I am hoping this will pass?? Then, when we move up to the 2mg will it start over again?
Hi I am new here. How do you wean a child off of intuniv if they are only on 1 mg?
Thanks
Maria
Dr. Parker, thanks for the great review on intuniv. I have a question about using strattera and intuniv together. I have been on strattera for 4 months and it changed my life; however, over the last few weeks, it has been messing with my memory and I would feel extremely fatigued after the strattera wore off, thus, I stopped taking strattera and was put on 2 mg of Intuniv instead. The positive effects of intuniv are subtle, but I noticed that my memory has improved while on it; however, I felt that when strattera was effective (before the side effects of poor memory recall and fatigue), it addressed my ADHD symptoms more effectively. I am thinking about asking my doctor to put me back on the strattera along with intuniv; however, I wanted to know if you think the strattera + intuniv combo would be beneficial. I know that strattera works by flooding the synaptic cleft with NE to down-regulate NE receptors producing anxiolytic effects + addressing ADHD symptoms, while intuniv works by acting as an alpha-2 agonist to decrease NE release. Moreover, strattera also increases the amount of dopamine in the pre-frontal cortex, and this is the main reason why I am interested in trying the strattera again along with intuniv to get that mild dopamine effect without using a stimulant. I would greatly appreciate it if you can provide me with more info on how these two drugs could perhaps interact synergistically.
Thanks, Jake
@Jake K Not a problem with these two, Strattera runs up through 2D6 and Intuniv is a 3A4 substrate, so they’re clean together. As you can tell from just a little reading here at CorePsych Blog I am a proponent of what-works-best, and therefore suggest a low dose AMP product for greater efficacy.
Not a problem though if you stick with Strattera it appears, over the short time you’ve taken it, that you are having an atypical reaction with the memory and tiredness. Keep your eyes open for a return of those symptoms even with Intuniv.
cp
Hi, Doctor Parker. I started Deplin on Monday and I am noticing a weird taste in my mouth. It feels like I just ate a pepper. It lasts all day and night, basically stays in my mouth even when I try mouth wash and other things. I can’t really find any information on side effects. Is this normal and will it go away?
Srscaffa,
Haven’t seen this in the office, haven’t heard of it, and if it is Deplin related it very likely will “go away.”
cp
Jen,
There are, regrettably no absolute rules in the adjustment of meds – even tho in my book I suggest we should be following at least some ‘Basic Rules!’
Having said that: Blood pressure issues encourage the conclusion that she has a metabolic background noise anyway, even tho it’s a side effect and not primary. That biomedical slowing, that likely dysregulation of excitatory neurotransmitters, specifically [most often] norepinephrine, often occurs downstream from immune dysregulations – see IgG in the Search Box here… many refs there.
Without being there these are some ideas to discuss with your doc: 1. Adjust the Vyvanse to get the 10–12 hr DOE as described elsewhere here. 2. Intuniv, yes, should sharpen but isn’t obviously, but seems to help would leave it unless further problems arise.
If you continue to find you are chasing vapors it would be best to get some data from IgG and Neurotransmitter testing – details matter, and we can do that long distance wherever you are out of our office.
cp
Hi Dr. Parker,
My daughter is 11 with adhd, she is a great kid, with a very outgoing personality and very athletic. She has been on Adderall and we changed her to Strattera due to weight loss and anger issues. On the Strattera she has done well until she started her period and became moody with it, it was not helping her much in school. Her DR. recommended we try the Intuniv versus topping her out to the 60mg of the Strattera. I decided to try and take her off of everyhting for a month and see how she did. Attitude wise, great. School wise she has begun to fail completely. My concerns with the not overheating as she is so active and runs track. What can you tell me about these side effects and your advice on it.Intuniv is of course the side effects. The low blood pressure and fainting is a major concern for me and also
Holly,
Yes we’ve seen the hypotension with Intuniv, but very uncommonly and most often with associated metabolic challenges, not eating breakfast, irregular bowels, clear estrogen dominance – all of those other variables make a big difference.
Each one needs to be considered to find the underlying culprit. Just make sure she eats a protein breakfast to start – that simple plan may turn the tide.
cp
Jane,
Absolutely could be – we’ve seen this reaction often in folks with immune system challenges – download the “Transit Time” pdf by searching here – Glutamate increases from allergies, especially milk, eggs and wheat, can throw them into a rage.
cp
[…] CorePsych Blog by Dr. Charles Parker http://www.corepsychblog.com/2009/11/intuniv-for-adhd-dosing-details/ […]
Dr. Parker,
My son is 9 years of age. He has ADHD and was started on Intuniv 8 months ago, and he is now on 4mg. During the last 3-4 months he has been less focused, too talkative in school, and much more active. Intuniv is still working, if he misses a dose, I can tell right away by his behaviour. What medication will you recommend to add along with Intuniv. I have no medical insurance and will prefer something in the generic type. please let me know, Thank you
Braft,
First make sure you are at the best dose of Intuniv, if you have room to increase do so, if at 4mg, then the next best thing without insurance is simple adderall IR but he will have to go to the school nurse at noon, no biggie. If he is too sensitive for that look into the generic ritalin time releases.
cp
I just caught your other note, and edited your first comment to include that he is on 4mg, so the next steps are as described.
cp
KES,
Look forward to seeing you – the answers will be in the data… most often the tests that have already been run don’t cover the chronic subterranean factors that we test for. Talk soon!
cp
[…] Intuniv also requires precise dosing strategies | CorePsych BlogNov 28, 2009 … We started Intuniv three weeks ago and is now on the 4 mg dose. The first week was wonderful! Like a miracle. Since then things have really … […]
Dr. Parker,
My 9 year old son was diagnosed with Tics about two years ago and ADD this year by his pediatrician. His tics became extremely bad this past summer and after doing much reading on-line I asked that we try Intuniv since there is some indication that it might help with tics. We worked our way up to 3 mg but weaned him back off since it did not help his tics at all and 3 mg seemed to make him “sedated”. It did seem to really help with ADD and mood swings!
About a month ago…his temper, irritability and rages were really starting to effect our family. So I asked our Doc if we could try Intuniv again, but this time we were looking to treat his ADD not the tics. We are up to 2mg and that’s were we’ve stopped since we know 3 mg made him too sedated. We have seen some improvement in his mood but now we are having sleep issues at night. He wakes up every night around 10:30/11 pm and has trouble falling asleep again and when he does he is constantly flopping around in bed and does not seem to fall into a “deep” sleep?
The first time we tried Intuniv we gave it to him at night after dinner, but he was very sleepy during the day. This time we are giving it in the morning and he does not seem as sleepy during the day but now his teacher is reporting that he gets a little sleepy at school? I really think this might be because he does not get enough “quality” sleep at night?
Do you have any suggestions as far as night/morning dosing or what might help with sleep at night? And do you know of any Docs in the Dallas area that might be able to help us sort this out? Or maybe we should schedule a phone consult with you?
I would appreciate any suggestions!
Thanks,
Gerald
Gerald,
Quite honestly tics are some of the most difficult situations to resolve, are quite often seen with ADHD, both on the front end before stimulant meds, and after stimulant meds as well. For many years the original tenex seemed to help with tics somewhat, and in our practice we have regularly had some salutary effect not only with tenex, but with Intuniv, and quite frequently with Neurofeedback.
Further, as you well know, stimulants can significantly effect/encourage tic disorder. Interestingly you and your doc need to know we have seen tic encouraged/aggravated by Intuniv at times, – so Intuniv isn’t simply a panacea, tho it is my favorite med if insurance will let me use it.
What I do recommend, now having had many levels of experience with neurotransmitter testing [see this video in spite of it’s poor production and slides -> http://www.corepsychblog.com/2011/10/adhd-treatment-video/%5D, is that glutamate excess does not respond well to Intuniv, and in fact all tics are encouraged by two main issues: immune dysregulation not corrected [e.g. casein, gluten, eggs], and, often associated but sometimes independent, toxic issues secondary to heavy metals lead, bismuth, mercury, etc. The toxic treatment requires specific chelation and is less common, but needs consideration/attention if other, easier data proves refractory with subsequent treatment.
Final note, quite simply: after all of this, I do feel a consult would be helpful because we could quickly drive down to the root cause instead of chasing symptoms. We have had significant good results with IgG and neurotransmitter testing, subsequent changes in diet, and neurotransmitter precursors mixed with meds as indicated in the context.
Not promising anything, as medicine always has a significant unpredictable element, but more data frequently brings better results, and we can do all this by phone, unless you would like me to write for meds. Increasingly we are finding docs working with us locally, just depends on your local medical crew, how data driven they are, or how much in denial of basic science.
cp
Dr. Parker,
Thanks for your response! My wife and I are very eager to start working towards a solution, not only for our son but to bring a little peace to the household. How do we go about contacting you for a consult?
Gerald
Gerald,
Sorry to be so late, now having to cover the comments on the weekends as have been working on CoreBrain and posts that are burning to get out on time. Easy ans, wer to your question: connect with Sarah at http://www.corepsychblog.com/244-2/ our CorePsych Services page, and she will get you filled in on the details, bottom line we will push to get you in asap.
cp
Karl,
My quick take: when you talk to your doc drop back, not up. Let Intuniv sit a bit longer before going up and take a more conservative dosage adjustment strategy as your guy sounds a bit like a “slow burner” [Type that into SEARCH for more info]
cp
Karl,
My quick take: when you talk to your doc drop back, not up. Let Intuniv sit a bit longer before going up and take a more conservative dosage adjustment strategy as your guy sounds a bit like a “slow burner” [Type that into SEARCH for more info]
cp
Laura,
Sorry completely inappropriate for me to suggest specific changes on the Internet – especially with folks I haven’t seen… the troops would soon be at my door and leave with my license in their hands. Won’t go there on the Intuniv.
On the other hand your guy has very typical findings of metabolic imbalance and it would be completely reasonable for you to consult with me long distance on the measurement of those imbalances. Type in “IgG” in my SEARCH here, read my digital *Rules* book [only 10$] and begin to look more carefully at things immune. Just doing an elimination diet doesn’t fix the problem if you miss a single detail. You need all 4 wheels for the car to move down the road!
cp
Heather,
I can tell you much more on a long distance consult… we do them all the time. Do read my book – for 10$ it’s filled with information you should absolutely have for next steps. If you don’t call I can tell you with considerable certainty more if you SEARCH here for “moving therapeutic window” and “narrow therapeutic window” – with this Disqus I haven’t figured out how to put the links in …. so you will have to check them out. He will be found in those comments.
cp
Dr Parker, thanks for the response, I ordered your book and have been reading the pdf form. A bit over my head with some of it, but I’ll keep reading. I called today and ordered a new patient packet to fill out for a phone consultation.
In the meantime, can you help me understand the dosing for intuniv? My son was taking tenex 1mg am and 1mg around 5:30pm, but now is taking 2 mg at 8am for 2 weeks now. School reports even more improvement than with Tenex, but we are having problems at home. At first he was falling asleep around 6pm, then understandably had trouble sleeping at night. But now he has trouble sleeping even if he doesn’t nap. The last 4 nights we have noticed that the intuniv appears to “wear off” around 7 or 8pm. He becomes hyper and impulsive similar to what we saw before if he got his tenex later in the afternoon. He does not fall asleep until at least midnight – 1am no matter what. Is it possible that the intuniv is wearing off after 11 hours?
BTW – oddly enough, mornings have been great.
Heather,
Look forward to talking. Several possibilities for discussion with your doc.
1. If doing better needs some melatonin at bed, or Clonidine depending on response to Melatonin.
2. Some folks have a better response with Intuniv just at night, check with your doc on this one.
3. You might need to go down in dose and trim with a stimulant like adderall or Vyvanse. This combo proves useful in that it covers the side effects of both meds thru low dosing of both.
Look forward to talking,
cp
Dr. Parker,
My 6 year old, 40 lb. son is on Intuniv. He is ADHD and moderately autistic. We just refilled his 3mg prescription of Intuniv and he’s really wired. He was finally at normal kid energy on the last prescription. Do you think that he needs 4mg? I often wonder if the amount of medicine slightly varies from pill to pill or batch to batch. The last batch was wonderful! He was enjoyable and of course, did have his moments but it was like we got our son “back” from this condition. He did seem a little more soporific but not terribly. He’d take a nap and would be fine after he woke up.
I or my wife will call our pediatrician tomorrow (today is Sunday) but I wonder if 4mg would be the right dosage for him.
Thank you,
Karl G.
Dr. Parker,
I am new to your blog and want to thank you for the great information! My son is 5 1/2 yo who was given an official diagnosis of ADHD with sensory integration disorder and fine motor delay by Kennedy Krieger Institute in May. Prior to the official diagnosis we tried Concertante for a few weeks and had the angry psychotic a/e’s. So then we tried Focalin for a few days but it made him a zombie. We took a break fro and decided to focus on diet we tried the cassein washout….no change. We have been dye free and HFCS free since March, along with organic meat, milk and produce. Still, no big changes in hyperactivity. So, when Intuniv received it’s official indication we consulted with our pediatrician and began therapy at 1mg in May. It took the edge off his impulsive behaviors but the awful drowsiness and nighttime sleeplessness has never gone away. We tried 2nd but the daytime sleepiness was worse. We dosed it in the a.m, up until this past weekend we changed to the p.m. He just started kindergarten and has a wonderful teacher who says that he isn’t focusing, agitated and still extremely sleepy all day long.
We are seeing our first psychiatrist on Thursday afternoon so I am hopeful that we can start on a new soltution. In the meantime, is it o.k. To cold turkey the 1mg of Intuniv?
Dr. Parker,
Thanks for all the info, I’ve been reading through all these posts. Where can I find someone who will try some of these things in Minnesota? My 10yo son has Tourette’s, ocd, generalized anxiety, and Adhd – though bordline on the attention, he is definately hyperactive and impulsive. We started chlonidine 2.5 years ago to help with tics and were amazed when his teacher reported less impulsivity in class. Unfortunately it made him so sleepy that we couldn’t increase the dosage as necessary, so it eventually became less effective for that, but still helped with tics. Last year our son asked his doc if there was something else he could take to help with school as he was always “being bad”. We started him on Strattera and seemed to help at first, then he became paranoid when we increased, cried all the time and said he was scared. We reduced it back down and continued 1 month at the lowest dose, the crying stopped, but defiant incidences at school increased 400%! Off it he went. He also had started having an issue when he became worried about something and suddenly couldn’t talk. This started before Straterra, continued while on it and got so bad after it, that he was spending 1 hour in the pm and am unable to talk because he was worried about school. Dr told us it was anxiety problem called selective mutism, with atypical presentation, as it was happening in anticipation of something. He started taking Celexa, and the episodes completely disappeared.
Still was having trouble in school, so we tried Concerta, again seemed to help at first, cranky in the evening, and AM was near impossible, as he was so hyper. Then one day he forgot to take it, school called and I had to pick him up, they said he was literally climbing the walls, running around and hiding. He jumped out of the car when we got home and starting running down the street. Off it he went.
Dr started him on Tenex, he currently takes 1 mg AM 1 mg 5:30pm. Two months now and much better results. We are trying Intuniv tomorrow, but I’m worried about switching.
My son has been tested for allergies and food sensitivity, I don’t know if it is the kind you are talking about, but they took blood and sent it away, it was called “delayed sensitivity” I think. He was not found to be sensitive to anything they tested. But he does have allergies. What is this histamine level thing you keep talking about? Could his allergies be a reason these medications haven’t been working?
We planned on starting the Intuniv in the AM, is this the best time?
Thanks for your help.
Heather
Dr.Parker, First…thank you so much for this blog! It is beyond helpful and informative. Quick question regarding how soon is too soon to assess that Intuniv might not be the right drug. My 9 year old just started Intuniv 5 days ago for ADHD-Combined Inattentive/Hyperactive. He was on Daytrana for 2 years successfully till anxiety and tics made us stop. He gained 7 pounds and 1 1/2″ in height in the 3 months off Daytrana and we are thrilled. We have been on Intuniv for 5 days with dosing at 1/2 milligram (days 1-2) and 1 milligram (days 3-4). We have already seen an increase in hyperactivity, tics, and he has tingling under his fingernails. He’s had no sleep issues, tiredness, or dizziness. I just want to get your take on my assumption that maybe his glutamate levels were already normal/high and this just isn’t the right drug for him. OR…do I wait it out to see the drug reach it’s full potential and how long do I give it to make a correct assessment? Any input would be greatly appreciated.
Sazzy,
Sorry to be so late, been writing a great deal getting Rules ready for an Amazon launch, see the post today.
Yes, your guy is highly likely already out the top on glutamate. The tics etc indicate too much excitatory activity. You very likely got that one right! Sometimes, don’t know why yet, Tenex might work when Intuniv doesn’t if the tics are quite easily stimulated. The tingling is often associated with a variety of issues not the least of which is relative toxicity.
He very likely would be a candidate for neurotoxic review, hair sample, to get that data and assess comorbid challenges from that perspective.
cp
g,
If no BP problems tenex would be a good choice, the half life is only about 6-8 hr, so you might need to take it AM and Noon, starting with your NP approval of course at .5 2x/day.
Ensure is a protein drink with significant protein, try that for breakfast. Get more serious about absolutely staying off of milk and wheat, and if that doesn’t do it try off eggs – the Trifecta in allergens.
Hang in there,
cp
Kev,
Those two are completely kosher together, excellent choice, just commented elsewhere on the blog on a similar question. With Downs or *any* developmental delay issues I always find, yes always find, improvement, no cure asserted, with neurotransmitter testing to balance those biomedical challenges. See the Testing Options page, your psych would probably like that info, tho likely would be suspicious as we all are of things we don’t know.
cp
cp
Dear Dr. Parker,
Please forgive me dumping my life story here but I have nowhere else to turn. I’m on SSDI with Medicare, and I’m sure you know that they don’t cover anything unless you’re hit by a
bus. My primary care is a nurse practitioner at a low income clinic,
and she has no idea about meds. I get to see a psychiatrist once a year
for med reviews, and that’s it. I can’t afford to do any fancy
testing, although I’m sure I probably need it. I have a fairly
complicated medical profile, hopefully you can make some sense out of
it.
My current diagnosis is Bipolar Depression (slow cycling), Generalized
Anxiety Disorder, ADD, Chronic Fatigue Syndrome, Fibromyalgia, Delayed
Sleep Phase Disorder and Migraines. I’m 46 years old, height/weight
proportionate – but I have to work on it.
In the morning I take Zoloft 100mg, 250mg Depakote and 30mg Buspar.
At night I take Zoloft 100mg, 250mg Depakote, and 1.5mg Lunesta
Right now, my ADD is completely untreated, and my disorganization is
making my anxiety really bad, which then triggers migraines. I am
highly distractable, irritable, and prone to wanting to kill people
/jk. Trying to stay on track all day is exhausting, and then I go into
CFS mode. I’m pretty sure I have no adrenals left at all. I’m a train
wreck!
Another big problem for me, is that I have NO appetite, ever. I have to
force myself to eat when my blood sugar gets low. Just the idea of
eating in the morning is enough to make me feel nauseated. I have
always hated breakfast, even as a child. It usually takes me several
hours to work myself up to wanting to eat anything at all. I eat as little dairy and wheat as possible, and try to focus on lean protein, fresh fruits and veggies. I don’t eat
packaged junk foods at all, and I try to get some moderate exercise like
walking the dogs or gardening.
I can’t take stimulants because I have a transient heart murmur,
anxiety, and mania. I really want to try Intuniv, but I don’t have $500 a month to
spare. Tenex is only $5.00 a month at the big chain drugstores. I am
very compliant with my meds, to taking one every so many hours is not a
problem with me.
So my questions are, do you see any contraindications with my current
meds? Considering my sleep cycle disorder, do you think that I should
take the Tenex in the morning or evening? How can I get past my intense
dislike of eating when I first get up? Is there something I might be
overlooking that I should research? (Preferably that isn’t expensive.)
Thank you so much for your time and concern!
g
My 11 yr old daughter (75 lbs) has been diagnosed with the following: Down’s Syndrome, ADHD, and Sensory Processing Disorder. My wife and I accept her disabilities, our main concern has been to find some med combination to make her disposition happy or at least pleasant. She is very irritable, often growling rather than speaking. Currently, we are trying 3 mg or Intuniv and 15 mg of Celexa. Do you see any interactions between the two? Also, do you have any suggestions, our Child Psychiatrist is very open to suggestions.
As you know it would be inappropriate to formally suggest your next steps, but I can tell you from a number of discussions with colleagues and clients that night dosing is not at all contraindicated, and, as you point out, it’s likely that the initial response will improve over time.
cp
My daughter is 6 1/2, weighs 44lbs. She has been Dx w/ ADHD and ODD. She has tried many stimulants and i didnt like the anger and irritabilty she had when she was taking those. She used to take clonidine QHS to help her sleep, they have just started her on Intuniv and the first days she took it, she slept all day and was very lethargic, with this being said, I want to give it a try but will it still be useful if we give it to her at night instead of in the am? Thank You
Carolined,
Only piece you need covered better is the PM drop, and a small amt of stimulant on the immediate release side of things should cover family time! Good to hear from you-
cp
My son is diagnosed PDD-NOS, which hyperactive characteristics. His doctor does not give him a true ADHD diagnosis, but he has been taking ADHD meds successfully since Kindergarten (he is not in 4th grade) and they have helped him immensely. He is currently on Concerta 36mg. He started 2 1/2 years ago on 18 mg and we quickly raised him to 36. He has been very successful on this medication. However in January his para was complaining that his focus had completely fallen off and his behavior was a problem. After discussion with his doctor we raised him to 54 mg. It was awful. The poor kid was a zombie, so we dropped him back down. He had lost his whole personality on the higher dose. He went back to being the happy kid he was, but there were changes so as it turns out we do need to make a switch. Concerta used to inhibit his appetite and now he eats like a horse…that’s just one example. And he definitely cannot focus the way he used to. Sometimes we even wonder if he is overfocused because he will concentrate on one thing and it completely stops him from doing anything else. For instance, he’ll write his name and get stuck on the second letter.
We have a med check tonight and his doctor told us to research Intuniv. I’ve read some very good things about it, and I love that it is not a stimulant or controlled substance. I’ve also read, though not on your blog, that some children wake up in the middle of the night frightened and out of sorts and cannot go back to sleep.
Our doctor wants to try to introduce Intuniv in addition to the Concerta. I’m not sure whether he wants to keep the 36 mg dose of Concerta or lower that when the Intuniv is introduced. I’ve read a few items saying that the balance of the stimulant and non-stimulant has been successful.
What are your thoughts?
Tinkermom,
The balance can be successful with Intuniv and Concerta, and poses no problem from a drug interaction point of view. When I have problems like this I consider two things:
1. Concerta is very difficult to titrate and find the right dose because of the way it’s made – the doses don’t help with small adjustments. That’s another reason I prefer Vyvanse.
2. I always consider the possibility of metabolic challenges when the med sweet spot is narrow, or appears to narrow as in this case. Breakfast, sleep, bowel frequency, nutrition and even immune dysregulations can all contribute to significant problems with med precision.
cp
Michele,
I stay away from Prozac with any of the drugs for ADHD for the following reasons:
http://www.corepsychblog.com/2009/12/intuniv-for-adhd-avoid-drug-interactions/
Everyone is different on Intuniv, some do better at bed some in the AM… likely the Prozac is backing it up, giving your team a cloudy picture based upon the interaction with the Prozac blocking 3A4… and making it almost impossible to regulate. If he was on stimulants with the Prozac that is the specific reason they didn’t work – reactions based on 2D6 interactions – this from a post almost 3 years ago: http://www.corepsychblog.com/2008/12/add-adhd-medications-amphetamines-2d6-drug-interaction-update/
I completely agree with your view of the “playing with it” concept – nuff said.
cp
How exactly does Intuniv work? I know most ADHD drugs increase nor-epinephrine levels in the brain but this one decreases nor-epinephrine levels. What exactly is the physiology behind the drug?
Take a look at the several blogs I have earlier than this one on Intuniv – specifically the one on tenex and alpha 2 agonism – the specific action on glutamate neurotransmission is documented and linked there. Thanks,
cp
can intuniv be used for adults adhd?
Darrius,
Not approved for adults by the FDA as yet, but many are using it with the caution about the blood pressure as the main concern for side effects and proper screening.
cp
Hi Dr. Parker,
I am writing to ask what the difference between Tenex and Intuniv is in terms of the side effects. My son has Aspergers and Tourettes with a possibility of ADD. The doctor put him on intuniv but we had to ween off the meds due to paranoia and “zombie-like” behavior. The doctor is now suggesting Tenex. I am so confused.
Charlene,
This one is always a roll of the dice:
1. If failing Intuniv the pharmacology is most often [seen on neurotransmitter testing] the glutamate elevation downstream from untreated immune dysfunction – this cause would obviate the Tenex, due to the same mechanism.
2. The failure might be due to the dosage of Intuniv, and with those who are sensitive I always start at .5x 1mg [1/2]. Your guy might be able to actually take the Tenex due to the very low amount you can deliver… but honestly, I doubt it will work, as it most often doesn’t – but hey, this is medicine, and I have seen Tenex work when Intuniv doesn’t – so even tho the percentages are not there, no harm in trying. You might ask your doc to go to 1/2 of the 1 mg Intuniv and let him adjust over more than average time.
3. The other problem with Tenex, as you well know, is the dosing issue, thus the Intuniv.
Best,
cp
[…] Blog by Dr. Charles Parker http://www.corepsychblog.com/2009/11/intuniv-for-adhd-dosing-details/ Douglas Cowan, Psy.D. – Dr. Douglas Cowan is a family therapist who has worked with ADHD […]
I’m sorry. I don’t have it anymore. Unfortunately I threw it away thinking I would never let me daughter be zombie like again. I’m thinking it was 18 mg a day…I think??? However, it was the extended release, one pill a day and she is 11 years old, 63 pounds. So, I basically was asking is it possible to give her a lower dose of Intuniv to help her focus and help her mood but NOT make her so sleepy all the time? Her doctor said that was the lowest dose but from what I read I got a little confused. I wouldn’t mind giving a pill to her multiple times a day I just want it to work for her. ODD is her biggest challenge and secondly focus. Our lives are turned upside down everyday with her mood and inability to cooperate. She is 11 years old and can not walk into the other room and complete any task ie, brush teeth, take a shower. We try everyday but end up either waiting a long time for her to wonder around to complete anything or we help her through it. You say black and she says white. She continually says, “I hate you, stupid” etc… because of her own frustrations with trying to get through life. She also started this new tic where she rubs her hands on objects to feel them and says it makes her feel calmer. So, she is constantly running her hands on the table in front of her or feeling the paper in front of her or running her hands up and down the length of her hair brush. We have tried the Fiengold diet and for a short time while we were really sticking to it I saw her calmer with all the ODD stuff. But due to lack of cooperation from her father and her extreme disapointment of “missing out” on all the food she can’t have we compromise weekly on the diet. She is so intelligent and full of talent in art and music. Her art and music teachers say she really has a gift. I am filling you in on details hoping that you can see the big picture to guide us in the right direction. I’ve really been encouraged by all your other posts to help the other families on this blog. Thank you!
Cristi,
I don’t make specific recommendations, but can tell you that I, and others, have used 1/2 of the 1 mg with some benefit. Not rec by Shire, but can help. Strong suggestion: work harder on the replacement foods, do some research.. if milk use coconut milk, etc. Immune dysregulation and family differences can play an important part in school pressures. She sounds like a great girl!
cp
We tried Intuniv for one month on our 11 year old daughter. She weighs 63 pounds and was diagnosed with ADHD, ODD & OCD by the Melmed Center. After one month of Intuniv, we took her off and switched her to ritalin 5 mg am & 5 mg @ noon. She was simply too tired all the time on Intuniv. I do believe the Intuniv helped her control her mood but because she looked “zombie” like all the time it was hard to see that as a success in controlling her mood. I would love to try this type of medicine again to help with her ODD. BUT…want to know if there is a smaller dose available than the once a day pill she was taking (thinking it would help her not be as tired if the dosage was smaller)???? She literally took naps and went to bed early on Intuniv. Now she has trouble falling asleep sometimes with taking the ritalin.
Christi,
You didn’t tell me the dosage of Intuniv that you are asking about.
cp
Dr. Parker,
I have been a longtime reader of your blog. I appreciate your work so much. If only there would be more doctors out there like you who continue to seek new information and research ADHD, understand how far reaching ADHD can be in learning and behaviors and dig deep with your patients to seek effective individualized treatment.
That being said, I know you cannot give me your most accurate assessment via a web blog…but I’m curious what your gut instinct would be here, given the following information about my son:
9 year old boy in 3rd grade. Extremely talented in art, comedic, affectionate, advanced math skills, lags in reading skills (fluency has great improved over the years with reading intervention, but reading comprehension is improving at a slower rate), was delayed as a pre-schooler in the areas of receptive and expressive language, had speech therapy from 18 mos to 3 yrs, is somewhat socially immature compared to most of his peers but does have some close friends (tends to bond with others who seem also a bit socially immature or who are younger though) and is well liked by most everybody in his grade, was diagnosed ADHD in 2nd grade (we were not surprised – he has always had low attention span in many areas, yet could hyperfocus on things like legos – it was in 2nd grade when ‘independent work’ became expected that he really fell apart…teacher would find him sitting there with a blank paper), my son is a perfectionist…REALLY hard on himself – disappointed with any other grade but an A, went on 20 mg of Vyvanse in 2nd grade and it helped a little, bumped to 30 mg and it was a MIRACLE!!! His grades went to A’s and everyone at school was amazed at the difference in him academically and socially. He was really plugged in for the first time. Only downside – REALLY unfocused in mornings before Vyvanse kicks in and HYPER (wasn’t even diagnosed hyperactive type ADHD but seems more hyper and unfocused in the mornings now that he takes meds) PLUS he gets grumpy and moody in the PM. We have had a few episodes over the past 16 months where he has YELLED at us and one time where he even hit me! He’s VERY sorry and remorseful and miserable after these episodes. Very hard on himself. I’m very afraid that just a few of these episodes and someone is going to slap an ODD or bipolar dx on him. I don’t believe these things to be true. The grumbles are ONLY in pm’s when meds have worn off and he is REALLY prioritized on what adults in his life think of him. He is a major rule follower at school, church, etc. Again, he’s very much a perfectionist. He is still on 30 mg of Vyvanse. First half of 3rd grade went great schoolwise – still doing well socially and academically. But, last few months we’ve been hearing from his teacher that she feels like she’s losing him, she’s not sure how much he’s absorbing, he sometimes seems in his own world, he’s not participating in class and I have noticed the Vyvanse is not getting us through homework anymore and he’s grumpier than ever after home from school. In the past 6 weeks, I have watched his grades SLIDING DOWN. Last night, he cried to me, “It’s like my pill has EXPIRED, MOM!” and he also told me he thinks he is “a really bad and mean kid.” I should note he has NEVER had any behavior problems at school – just attention issues.
One more thing to note is that my son has been chronically constipated since he was a baby. We’ve had him tested before for food allergies and nothing found. We’ve tried removing gluten and dairy and have never seen any impact on his bowels or behavior. His pediatrician has had us do Miralax, but after reading here and other places about Magnesium we are going to try that. I also am going to get him on Omega 3 supplement, too (how much of each of these for a 9 year old boy who weighs 55 lbs?) My hubby and I are both small and were tiny kids. He eats well…though he hates that he is skinny and feels it is the Vyvanse’s fault. But, he eats a big protein breakfast, eats lunch I pack (I have school let me know if he does not eat), eats snacks, has a protein shake every day at nurse’s office, eats a good dinner, etc.
Seems like his upcoming med check this week we need to talk about a bump up? But, then I also am reading so much positive things about Intuniv in combination with Vyvanse. Could the Vyvanse be causing his anger/moods in PM? Is it the drop-off from it? Is the morning hyperness some kind of REBOUND effect? One doc told me no way, no such thing, Vyvanse clears body in 24 hours.
Just off the cuff…I won’t hold you to it…would you be thinking bump the Vyvanse only, bump the Vyvanse and add Intuniv or leave the Vyvanse as is and try adding Intuniv?
I know you are a very busy man. I would be SO SO SO grateful to hear back from you.
Kelly,
This is where the rubber meets the road:
“One more thing to note is that my son has been chronically constipated since he was a baby. We’ve had him tested before for food allergies and nothing found. We’ve tried removing gluten and dairy and have never seen any impact on his bowels or behavior. His pediatrician has had us do Miralax, but after reading here and other places about Magnesium we are going to try that. I also am going to get him on Omega 3 supplement, too”
– and without a clear understanding of the underlying elements here in the bowel you will remain awash with guesswork. I strongly suggest IgG testing here, likely milk. O3FA will help, could take 1-2 gm, but that will not fix the situation as everything you are asking [without knowing] is directed to treating symptoms not the underlying problem. We do this testing long distance and can read and recommend it that would help.
The up or down Vyvanse question is based upon the downstream effect of a Narrow Therapeutic Window, pure and simple.
cp
My child was do similar to your child!! He is a
Very gifted 1st grade boy that has had his best year yet in the treatment of his ADHD! We have been treating for 3 yes now and I have tried every combo under the sun to find the best results for morning, noon and night! As you are also seeing, the more effective his days are with stimulants, the harder they fall in the evening. For a while, we did the bid long acting stimulant and they gave him a noon dose at school! This was great for schools bs after
School activities bit he plummeted at about 6:30 or 7 an and I couldn’t stand to be around him because his mood was so volatile! We started on Intuniv about a year ago and have played around with multiple things and our best combo is the long acting stimulant taken in the morbid with the Intuniv! Titrate the intuniv very slowly because the sleepiness and sedation will make you want to bail! Don’t!! It has been life changing for him! He has almost nonrebound anymore and is truly a joy to be around! He plays great with all the neighborhood kids now and seems to be much more with the world around the clock!! Don’t give up! Parents should not get the worst part of their childrens day!! Your son should not have to feel
Miserable
Every afternoon when his mess wear off!!
I need advice. After many trials, we have found Vyvanse to be the best treatment for our daughter. But, she is 8 and weighs only 45 lbs. We started on 20mg 1 yr ago. Then we bumped up to 30 (with clonidine 1mg at night), and finally about 6 months ago we went to 40mg Vyvanse am and 2mg clonidie at bedtime. Now, unfortunately we need to “bump” again. But due to my daughter’s low weight our doctor is reluctant. So our new plan is 2mg Intunive along with the 40mg Vyvanse in the am. No clonidine at night. This is not helping at all. She is so out of control and hyper.
We took a stimulant vacation over Christmas break. She was better on .5mg clonidine 3x per day than she is on Vyvanse 40mg + Intuniv 2mg. What are your thoughts on Vyvanse 50mg for 8 yr old underweight girl? I just want her to be able to help herself with impulse control and hyperactivity. She is screaming alot. Was thinking ritalin 3x a day might be our last resort. She is so smart, in the gifted program. But struggles with self esteem b/c always in trouble. Should we bump? Any other suggestions?
Brandy,
When anyone is loosing weight and Vyvanse is not working my first thought is always: is it too much? If she needs the Vyvanse to increase, and the dose appears to help I would absolutely pursue IgG testing and looking at metabolic contributions to the weight loss and insomnia. With food challenges the dopamine frequently is elevated as a natural consequence of those allergies and the child or adult becomes relatively toxic on dopamine altering products – thus the clonidine seems helpful. Quite often none of them work until the underlying culprit is unearthed and corrected.
cp
Hi I have twins boys that have been diagnosed ADHD, ODD, OCD, and recently have found both to be autistic. Have tried everything from Ritalin, Focalin, Adderall, Concerta, all diff milligrams of each and at times two diff meds at time(one in a.m. one in afternoon) also one has been on Depakote as well at one point in time. Originally used Melatonin to sleep but once they went as high as they could and it no longer worked we then switched and used Remeron and then Clonindine. Right now we are using Vyvanse and Intuniv in the a.m. and are using Clonidine to sleep for both. Both did well on 50mg Vyvanse and 2mg Intuniv originally. Have since raised both to 3mg Intuniv. Lately one of the boys has been having problems again..hard to control, temper flare ups, crying for no reason, very aggressive behavior, rolling around on the floor at school when should be sitting, etc. I did some research of my own and I like what I have read (including user reviews) about Daytrana. Talked to my childs doc about it and insurance won’t cover it because my child is able to swallow pills. I spoke with the pharmacy and before having to pay for this med out of pocket just wondering what you may know about this med. Thanks
Daniele,
Your guys very likely have much more going on that simply ADHD – just using Daytrana will provide some few answers, but the few remarks you made indicate underlying problems… as you and your doc are doing things well, but the reactions are typical of neurotransmitter imbalances.
cp
Dr. Parker,
Your website is very helpful and I have been looking at it for over a month. My daughteris 9yo and has ADHD- hypertensive/impulsive type and anxiety. She has been on Concerta 18mg and Strattera for over a year. We tried Vyvanse but it significantly increase her anxiety and even added OCD symptoms to the mix. Concerta does this also if we increase it beyond the 18mg dose. We recently tried the titration of Intuniv and it was like a wonder drug. However, during the first week of the 4mg tabs, she started experiencing insomnia. It got worse and worse and by day 7 or 8 she wasn’t sleeping hardly at all. I backed her down to the 3mg than the 2mg but her insomnia was so bad I took her off it entirely. That was about 2 weeks ago and she is now only on 18mg Concerta but continues to have insomnia. I think it may have become a pattern where she gets so anxious at bedtime that she is not going to sleep that she doesn’t. Have you seen insomnia with Intuniv? If so, do you think a nighttime dose would work better than the morning dose? My doc said the side effects tend to be the worst around 10 hours after taking it.
Please advise! I really want to go back to the Intuniv!
Dana-
The first and easiest question: how many times a day does she go #2? Then, if it’s one to two times give her this Transit Time Test – from the Mouth to the South -to ‘dig into the details.’ I’ll bet she has food challenges that will corrupt every trial of meds – as we have seen this so often in our offices. Then you need to test for IgG antibodies – and you need someone who will listen to all of this, as most traditional medicine is not there yet – they will be, but expect blow-back on this topic.
I know these interventions work because I regularly answer this kind of question in my office with this testing and find the culprits.
cp
Dr. P,
Now that you and other docs you meet with around the country have had a fair amount of experience with Intuniv, can you share what the range of side effects are that you see when the med is simply too high for an individual? I assume that one is sleepiness that does not dissipate over time, but can you discuss the other, perhaps more subtle, signs? Thanks so much for your invaluable input on this medication!
J
J,
Sleepiness is the most obvious symptom of dosage challenges – another can be the obvious one of anger and temperament dysregulation. Subtle signs are always the hardest, and the one subtle sign that Intuniv is too much is the deterioration of cognitive function… and increase in ADHD.
cp
Dr. Parker
I have a long drawn out story but I’ll try to keep it short. My son that is 8 was diagnosed with Autism at age 5. He mainly has social and expressive language issues. Teachers are now telling me that he is losing interest with his school work and has a really hard time focusing. We’ve tried several medications and none seem to work but the Intuniv. It made him very,very sleepy just being on the .5 dose. I took him to a neurologist and she said that he has Aspergers with Add. He is not hyper and actually very calm natured. I’m now believing that once he gains interest is something he can’t get it out of his head and that’s all he’ll think about(while in school) and can’t focus on anything else. We’ve tried Daytrana which seen to work good but burned his skin. Tried Vyvance and that made him nauseous. Concerta according to the teachers made him worse with some slurred speech. Now as of today he is on Foclin 10mg with .5mg of Tenex in the afternoon. Sometimes I feel that i should just leave him alone and let him be him because he is a beautiful boy without the medication. On the other hand I want him to fit in and be social and have somethings in-common with his peers. If this doesn’t work do you have any recommendations? Thanks for listing and look forward to your response.
Arine,
My rule on presentations like this: absolutely get more evidence, more information. He absolutely has complex metabolic issues that must be measured to proceed forward. I see so many with significant enteric allergen challenges that suffer with the bulletproof liver and counterproductive reactions to meds.
Testing will provide answers that will widen the sweet spot on his far-too-narrowed Therapeutic Window.
cp
cp
Dr. Parker,
I found your website while desperately searching for help with my 5 year old son. He walks the fine line between ADHD and the PDD spectrum but doesn’t quite fit into either. At the end of his last preschool year he was unable to sit in a group for more than 5 minutes in a chair with a weighted vest on. He was like a human ping pong ball literally bouncing from one thing to the next. We were using 1.5 mg of melatonin at night to help him sleep which seemed to be working well.
This summer we were referred to child psych who initially put him on Methelyn. His reacted with being agitated on the meds and calm when they had expired so she started him on 1mg of extended release Intuniv. He took the pill in pudding for about 5 days but then we realized he was biting it. When we encouraged him to swallow it whole he refused to take it. Our Doc then prescribed the Clonidine 1mg patch which worked really well for over a month until he started having bad dreams resulting in what seemed to be panic attacks at night and refused to sleep alone. We are back to the Intuniv trying to “teach” him to swallow it with the help of an Oralflo cup (like a sippy cup with a grate to hold the pill which is supposed to get washed down when he drinks) which worked on days one and two but now he just pushes it back into the cup with his tongue and says he can’t do it. We are at a complete loss.
The Doc said she could prescribe Prozac for anxiety but we aren’t sure if it is for the swallowing anxiety or the sleeping anxiety. She doesn’t seem interested in looking at any other kind of meds. In your opinion is this the most logical route and do you have any suggestions?
Jess,
If you type Prozac into the CorePsych Blog SEARCH you will see that I am not a fan in any respect – the reasons are repeatedly spelled out. Many pediatricians like it as it has been sold as safe with younger children and pregnant mothers. I’m not challenging the safety or that research, just the high prevalence of drug interactions make it less safe in a secondary way. And regarding the symptoms it doesn’t appear indicated from this distant perspective.
All the Prozac discussion aside, your guy does need immune testing through IgG, qualitative, not quantitative, and a review of urinary neurotransmitters – once the imbalance is identified he could have a trial of specific neurotransmitter precursors. Children who are refractory to the variety of drug machinations are excellent candidates for further precise inquiry. I strongly suspect a biomedical problem and these tests would be an easy way to start.
cp
try putting a little peanut butter on a spoon and put the pill in the pb and cover it…..he may be able to swallow it better that way…my 5 yr coulndt swallow and my dr suggested that…it works great
Christy –
Brings new meaning to the idea of just another peanut butter sandwich 😉
cp
My son is ADHD, Tourettes, some anxiety/panic and some OCD. He has been recently diagnosed with epilepsy. He has a small spot on his right frontal lobe per a MRI. He is currenly on 3 mg Intuniv every mornings since January. Intuniv works great with ADHD but the Tourettes cycles every month.
The dr has recommended Trileptal. Is this OK with Intuniv? Should we take him off the Intuniv and see if the Trileptal will help with ADHD and the epilepsy?
Kerri,
Trileptal is a 3A4 inducer, which means it burns thru the Intuniv very quickly – with the result that you and your psych docs will feel like the Intuniv isn’t working… and it isn’t!
I will be sending out an interesting post on Taurine this weekend [another take on some of your question] with a number of references on epilepsy and brain function. We test for taurine and 11 other neurotransmitters with every neuroscience test – and have had some significant improvements if the taurine is found diminished.
cp
Our doctor gave us a sample starter pack of Intuniv to try for our 11 year old son, who has adhd. If it works, he will then prescribe Tenex (because our insurance will not pay for Intuniv). My son is very athletic. He is involved in soccer, basketball and snowboarding. Our summers are very hot (we live in the southwest). I’m a little hesitant about putting him on this med because of the side effects that may occur during exercise/overheating; however, he has not responded well to stimulant drugs. Should I give it a try and are there any precautions (other than keeping him hydrated) that we can use to prevent these side effects? Thank you.
Carla,
If your doc suggests that strategy based on his findings I would certainly go with your doc. No contraindication from what you have reported here – and will leave the multiple other details to you and your doc. You are right to watch the hydration, and continue to watch for possible continued outcome issues – as it does occur quite frequently that those with problems with stimulant meds ‘in general’ may have problems with guanfacine as well. Don’t despair if Intuniv or tenex presents a problem – that kind of finding only underlines the fact that you will have to do the additional testing to dig a bit deeper for the underlying cause of his refractory response.
See the many other comments on the several other Intuniv posts to consider those next testing options.
cp
[…] CorePsych Blog by Dr. Charles Parker http://www.corepsychblog.com/2009/11/intuniv-for-adhd-dosing-details/ […]
Good Morning Dr.
My son is 14 years old. Diagnosied w/ ADHD in the second grade. We have tried many medication including Strattera, Ritalin, Vyvanse and now Intuniv. He has expercienced sleeping and eating side effects with the Vyvanse as well as with the Ritalin. The strattera did not help much. For the past 2 months he has been taking 2mg of Intuniv. In that time he has gained 15lbs. Putting him in the “normal” BMI range. He says that is attention span in about a 6 right now (on a 1-10 range) so we were looking to up his dose ro 3mg. However, Over the last 4 weeks he has expericience intermittent burning in his stomach and vomitting. I noticed that stomach pain and vomitting were side effects of the intuniv. Is this a side effect that is generally here to stay or is it a transitioning thing? He is very turned off by taking any medications. He has conceded to taking the Intuniv b/c it does not make him feel “out of it” and it does not interfer w/ sleeping and eating. If this is a side effect that will go away I dont want to mention to him that it could be the meds causing this but if it is a lasting side effect I think we may have to look into another option.
Two more thing of note is that he does take his meds at night. He also experience stomach pain while on vyvanse.
A second question is….
At times he misses his evening dose so he takes it in the morning and then resumes his dose that night. Is this something that could cause a problem?
Kaycie,
Your deep questions do suggest the need for more precise inquiry regarding GI issues, not the least of which is a suspicion of food sensitivities with IgG antibody challenges. Breakfast may be an important variable.
Dosing or med itself could be the problem – from the sounds of matters he might do well on very low dose Vyvanse mixed with the Intuniv, but way too little info to fully understand the underlying problem – sounds like a picky eater with GI issues beyond just meds..
The switching at night is not likely the problem.
cp
Thank you so much for your info. I agree with you a quick blog question does not provide nearly info for making a change. I have had a hard time finding a Dr. to sit down and listen to all the issues and help us sort these things out. We are in Baltimore MD. Is their a Dr that you could recommend?
Thanks Again
Kaycie
Kaycie,
Sorry don’t know anyone up there, but will be working on training folks nationally this next year.
cp
Hello. My grandson recently began taking Intuniv in addition to Adderall XR (15mg). He started Intuniv at 1 mg and is now at 3 mg daily. We suspended the Tenex he was taking. He has begun to exhibit a little tic behavior, and I am wondering if that is related to the Intuniv or to the absence of the Tenex.
fbragg,
Paradoxical, but seen in my office, some tic disorder behaviors secondary to Intuniv. Intuniv is time release tenex, – same compound, better release system, most often improved delivery. My take on this phenomenon when I see it is that the child has other metabolic issues that contribute to the tic disorder in the first place – and once they are identified the entire situation improves. In the meantime would talk to your doc about possibly decreasing the Intuniv back to 2mg to see if that helps. If not, he needs the more comprehensive workup – IgG, neurotransmitters as noted here on this Neuroscience page.
cp
Hi Dr. Parker, I have an adopted son who is 11, he has always had violent outbursts at school primarily and through the trial and error was on many meds at once at one pointe abilify, straterra, xanex , clonadine
now he takes guafacine 2mg am and and 2 mg at lunch and abilify at bed time.
He has gained significant weight ( obese wit the abilify) and he has started having meltdowns( violent) at school about 4.5 hours after the first dose.
Do you think intuniv would help , I am wondering if abilify is making him angry as well.
He goes through constipation bouts and then diareah. i try to give him only protein but now at school am limited.
Sheryl,
To guess at the possible outcomes with the GI symptoms currently so obvious is a serious roll of the dice absent the necessary evidence. The boy needs a workup period. You can shoot medicine blanks for years just guessing, and the seriousness of the problems strongly suggest a more careful workup for IgG, and a variety of other issues including neurotransmitters. Intuniv may work, it very well may not, as his glutamate is likely elevated with histamine – and Intuniv would only aggravate the current situation.
Try the Intuniv if your doc will go for it, and give me a call if it doesn’t work we absolutely have to move on with clear evidence.
cp
Thank you, I called his psychiatrist.. he wants me to try intuniv, again.. last year I briefly tried it and wasn’t sure if it was good or not. .he would have good and bad days.
Just a note as I can see I wasn’t clear. he has always had violent tendencies when he is fustrated at school. We took him off all but the abilify at night .5mg and 2mg guafacine twice a day and all last year he only had 3 melt downs at school, significantly less aggressive.
I am concerned about the weight gain and now that school started he is back to daily meltdowns. maybe just a need for adjustment in meds again.
What workups should I request be done, I want to make sure that I am informed for my visit tomorrow .. Bless you.
for your help
Sheryl,
Sorry too late for your visit – and honestly what I would encourage you to now consider is more information for a deeper perspective regarding what you likely are dealing with. See this Neuroscience Page here at CorePsych Blog for more info.
So many possibilities it would be inappropriate to just sit back and speculate… I can say, however, that when I hit a wall after doing everything right, I search ardently for more evidence to change my thinking.
cp
Hi
I forgot to add, he also has chronic constipation and has had that for years. He is only daily Miralax.
Thanks
Elizabeth,
Bingo!! He really does need a workup for the constipation, likely food immunity issues and neurotransmitter levels. We can help you out long distance if you would like to get further into those issues.
cp
He does see a GI doc and has had several blood tests that included tests for food allergies, celiac, thyroid, sugar, and anything else she can think of. Everything comes back normal. He is lactose intolerant and has low Vit D levels. Tried him on a “D” supplement, but it gave him diahrea. He is thin as a rail, has a low BMI. Was hoping that the Abilify would help with weight gain, but it didn’t have any effect on that.
So far I don’t notice any difference with the intuniv. We’ll increase to 2mg on Sunday.
How do you test for neurotransmitter levels?
Elizabeth,
Most GI and Allergy docs test for IgE, not IgG results. The more chronic, the more subtle reactions follow IgG – and if not IgG other workups become necessary. Neurotransmitters are easy to test, NeuroScience instructions here. The challenge is finding good interpretative skills. All of this can be done with a phone consult.
cp
We started Intuniv two weeks ago, for anxiety and temper, started at 1mg evening, went to 2 mg last Sunday, supposed to go to 3mg tonight.
So far, we haven’t seen any anxiety/anger reduction. He is raging more actually, and raging in the morning now, which used to be his best time. His frustration tolerance has lowered. This morning after a meltdown, he flipped back to normal after he ate. Then felt horrible that he acted that way, then got silly. This is the pattern for meltdowns.
Do I conclude that this isn’t working for him or is it still too early to tell- is it irritability from starting it? Will it get better at the higher dosage or should we quit now, before it gets any worse.
Thanks
Elizabeth,
My cautionary take on these matters: lower and slower almost always beats faster and higher. The food reaction is odd, but tends to suggest a metabolic variable associated with GI/liver or both. Metabolic variables need even more deliberate and slower strategies on the front end – and after that careful approach, if that process doesn’t work, you definitely need more testable information – neurotransmitters, immune function, the full workup.
cp
Hi
I am about to put my 10 yo son on Intuniv. Previously he was on Abilify for mood disorder, and while it helped him a lot, he had to get off of it because of elevated liver enzymes. He was on it 6 months before that was discovered.
My question is, what are the chances that Intuniv will cause the same issue? We are hoping it helps him with his anxiety and low frustration tolerance.
Elizabeth,
Much as I like and use Abilify, it’s a clear second choice to Intuniv for a variety of reasons – mostly the metabolic issues [e.g. wt gain]. Highly unlikely that Intuniv will cause enzymatic changes in the liver. Certainly worth a try switching, Intuniv is very safe, but if it doesn’t turn the tide then a more careful workup will be in order.
cp
Dear Dr. Parker,
My son is 14 years old and was diagnosed with ADHD at the end of first grade. He has been on every medication under the Sun, and while some worked, always within a few months time they caused severe angry outbursts. This has especially been evident over the past two years as he has become a teenager.
His personal favorite was the Vyvanse, he wanted to stay on it forever. But, after taking it for six months, he began to have violent outbursts in the evenings that would last for several hours. I took him off meds and said “no more!” Unfortunately, things took a turn at school and his grades dropped big time. Then we started on Focolin, short acting and he would stop by the nurses office and take one at lunch. This helped him but not as much as past meds. This worked for several months then once again right as school was starting this year the anger issues reared up again. It’s like he gets caught in a loop that he can’t get out of in his mind. He will argue and fight about one issue for hours.
Once again, I said “no more” meds. He was off for three weeks and became his happy self again. School started and he is ninth grade now, high school, and he spent the first week in oblivion, not doing any homework or even acknowledging that he has work to do, and the stress of that on his own mind caused the anger to come back. So now he is on the Daytrana patch for the past few days and although it is helping some, I feel totally defeated and beat down by this process. I know it’s only a matter of time before the side effects start showing up.
Does he seem like a good candidate for the Intuniv? Would I have to give him something else with it. He cannot organize himself in anyway, and is very forgetful on simple tasks.
Thank you so very much,
VC
Vanessa,
Very likely he is not metabolizing meds correctly and is toxic secondary to the Number 2 disarray. These responses beg for a more comprehensive review, good evidence and, because he does well on the Vyvanse for an extended period of time, I suspect he will correct if we clear up the rusty pipes, both liver and gut.
cp
Dr. Parker,
I had a question. I have had some issues with overfocusing at times and dealing with stress overload when I have multiple things to do and then doing and executing one job at a time. This predicament has had quite a negative effect on me and caused me to stop , then start a task and this ends up carrying over into life and seemingly I have issues doing many things at once with accuracy. At work I am speaking of working as a broker and doing several things, by email, instant message and phone calls all at once. It has lead me to alot of frustration and even physical symptoms of anxiety at times. Well, I have tried ssri’s in augment to my stimulants but it quite frankly turns me into a zombie at work and makes things work. I mean two weeks go by and I end up being less frustrated with amplified adhd symptoms and no motivation… I have tried tenex at night at low dose and feel alot better, a few headaches when starting but I think this must be the right path for me. As with tenex , based on my experience I feel that the stress overload is basically me to be more and more distracted at work with incoming channels of stimuli and the addition of an ssri would in theory make sense but actually worsens my syptoms, thus making tenex the likely choice by lowering frustration without lowering cognition while decreasing distracting stimuli while at work. Would you agree with that?
Jeff,
Tenex would be a good choice if, in fact, it was helpful! If you were in my office I would ask you many pointed questions about Cognitive Anxiety, which seems to be abundant in your presentation. See the very last 1-2 min of this video to show you why the SSRI is creating that problem!
My quick take, since you asked, – why struggle with Tenex at night with its short half life, no effect during the day, and some significant ADHD symptoms.
If you were in my office and I had the time to go over your situation more carefully to confirm the findings I very likely would suggest a good stimulant med like Vyvanse as a first choice with its 12 1/2 life. No need to struggle when you can get correction so easily with a careful titration of a more effective stimulant med.
cp
Hi Dr. Parker,
My 9 year old son is doing well on 5mg of Abilify and 2mg of Intuniv. The Intuniv seems to help with his follow through and his ability to participate in activities. His diagnosis is ADHD and SPD. He has some Asperger’s traits but not enough for a diagnosis. He does not do well on stimulants…way over focused and more inflexible. Zoloft alone made him hypomanic. His Doctor does not feel we can diagnosis Bipolar disorder at this point.I tried to take him off Abilify last spring hoping maybe Intuniv would be enough. He started showing some hypomanic behaviors about a week after we stopped the Abilify so we started it again. He was better in a matter of days.
I have 2 questions. Do you think his prior medication responses indicates Bipolar disorder? Also he has gained allot of weight quickly both times we have put him on Abilify. It is very difficult to keep his weight from going out of control. We work very hard to keep him active. Try to avoid sugar and processed food. It sometimes feels like a losing battle. Any thoughts?
Sandy,
Many think that meds reveal underlying bipolar – but I don’t. Bipolar is a diagnosis of appearances only, and from that perspective, yes, he may *appear* bipolar. I don’t think that anyone should be writing meds without thinking metabolically and of the multiple biomedical reasons a child can regress. I can guess on this one: his serotonin is likely too high, he is likely suffering with an immune condition, likely has significantly modified bowel transit time, and I can be certain that without knowing the biologic his treatment will remain a roll of the dice based upon appearances.
My new book ADHD Medication Rules documents these issues in some detail.
cp
Hello Dr. Parker,
My 61/2 yr old son is on Intuniv( 2mg for 2 months). Originally he was taking the med in the morning, but this made him terribly sleepy. We switched to the pm and he has been doing beautifully. I thought to change it back to the am dosing time because it was built up in his system and wanted to see if the great results got greater. Well…he was off the wall today! Extremely hyper, impulsive (placed himself in over 5 dangerous situations), some aggression, irritability and so on. I was taken back. Of course we will go back to the pm dosing starting tomorrow night (he had it this am and I didn’t want to give it to him again 12 hrs. later). My question is WHY? Why did this happen? Just to be clear…he had his dose of 2mg at night (Tuesday), nothing on Wednesday night and gave him the following dose Thursday morning. I know it is a 24 hour duration and I didn’t want to overmedicate.
Also, I have heard that this medication begins to wear off after time. Why does this happen? And in your experience, what is the duration of expectancy long term? I feel like it’s too good to be true sometimes and I’m waiting for it not to work. I don’t want to be negative, but I saw this happen with Focalin XR with him. He was on 10mg and was great for 2 weeks, then bumped it up to 15mg and he was withdrawn. Then Focalin XR 10mg with Intuniv 2mg and he became OCD and terribly anxious, withdrawn and depressed. So we are just on Intuniv now. I just wish there was something that worked that we and HE can depend on.
And one more question. 🙂 It is my understanding that Intuniv helps with the adhd child’s working memory. Is this true? On stimulants, my son was focused, but appeared robotic. He was almost too focused. It also was in the system and then gone..so what skills and strategies are they really learning for the long term? I feel as though the Intuniv does not help with focusing as much. However, over time, I am noticing he is able to recall short term memory skills which he was unable to do in the past. Does Intuniv help build the working memory, given that it is a 24 hour med and there is no lapse of effectiveness?
Thank you for your time,
Melissa
Melissa,
Yes, it does look to the researchers that Intuniv does assist/address working memory. Sounds like the PM dose is the best based upon your experience in his specific response.
Regarding changes in effectiveness over time: All psych meds can and do change in effectiveness over time, as neurotransmitter availability changes with growth, nutrition, stress, hormones etc. It appears that Intuniv is not one of those meds that has a high rate of deterioration over time, but that it is comparatively stable to some of the stimulant meds, requiring less frequent adjustments once dialed in correctly.
cp
Hello Melissa,
What time of night do you give your son Intuniv? My 7.5 year old son has been on Intuniv for about 4 weeks now-first was up to about 4 mg but we quickly changed to 3mg because his blood pressure was so low. He has ADHD and Aspergers. I have been giving him the 3 mg in the morning but he will NOT SLEEP! No matter what I try he will not sleep during the night-he has developed horrible night terrors and is literally afraid to close his eyes! I am thinking of switching to an evening dose but I heard he may not be able to function at school. He is also taking 18 mg of Concerta which I am considering taking him off completely.
Any words of wisdom you have regarding dosing and time of day to take Intuniv I would GREATLY appreciate!
Jasmine
Jasmine –
Seriously challenged sleep requires its own intervention system – very likely downstream from more than ADHD. Asperger’s frequently is associated with # 2 issues and gut immunity compromise – deeper gut testing is needed for IgG levels.
In the meantime ask your doc to help him with getting ~ 8.25 hrs [total ave hrs – TAH] of sleep.
cp
Hello Jasmine,
We give our son 2mg every evening at 8:00 PM….not a hour sooner or later. When we didn’t give it at the exact time every night, he was more moody. I cannot tell you how well he is responding to Intuniv. Being on a stimulant and Intuniv brought on anxiety and depression. He is on only Intuniv now for I knew it was the stimulants causing those behaviors. It gets better and better as months have been going by. There was a time when my son was going through night terrors. We gave him 3mg of Melatonin to (natural sleep aide) to help his bedtime routine get back in order. Night terrors are horrible..I feel your pain He slept with one eye open (to be sure we didn’t leave his side 🙁 I thought it was the Intuniv too. I changed his dose from night til morning thinking it would help, but he does not respond well to taking it in the am. It did pass (the terrors)…it lasted about three weeks. Also, I heard that it takes 12 hrs for Intuniv to “be at it’s best.” So a nightime dose might be a good choice. Keep me posted. Much luck to you. 🙂
Melissa
Melissa,
Good thinking, often does happen the way you describe, and yet every person has a considerable latitude for different reactions based upon variable biomedical foundations. Thanks for your support and weighing in!
cp
It’s Melissa again…
It’s been a while since I posted…2mg of Intuniv reached it’s ceiling and was no longer working. We tried 3mg and it was too much. He became more irritable, angry, aggressive, very, very, moody and extremely sleepy. I was so sad to see this happen. It was working so well. So I tried switching the time of day to give it to him and that didn’t work either. I tried 2mg at night with 1mg in the morning. That didn’t work either. It was simply too high of a dose for him. So….I gave him 2mg and I cut 1mg in half for a desired dose of 2.5mg and it is working beautifully. I know it says not to cut it, but I did. And we have our baby back. Why doesn’t Shire offer 1.5mg, 2.5mg, and so forth??? How can I contact them to let them know my experience. I feel that I may be onto something here. Many people give up Intuniv when it no longer works and they find increasing it makes there symptoms worsen. Has anyone ever tried my approach? It’s been three weeks with this new dose. I wanted to share with you my success with it. Any thoughts would be welcomed. Thank you, Dr. Parker
Melissa,
You are precisely on a challenge witnessed everyday in my office for years – titration precision almost always solves the problem – and the science of the medication often will guide that precision as I have carefully outlined in this complimentary White Paper on ADHD Meds. Interestingly careful titration sets the stage for the details of my recent book on ADHD Medication Rules as well. Both of those could be resources for further inquiry… and of course no one, including my colleagues who do research for Shire would argue with your *method of success.* One break doesn’t appear to significantly change response, more breaking or crushing likely would create problems.
cp
Hi Dr. Parker-
Many questions…is your book available in hard copy, or only as an ebook? Also, what are your thoughts on Celexa for OCD/anxiety? I’ve written you before, my son has ADD, OCD, Tourettes which is mild right now, and Trich (has pulled eye lashes out so many times it appears they may not ever grow back). He’s been on Luvox for OCD, but compulsions don’t appear any milder, and Luvox is quite expensive under my plan, compared to Prozac & Zoloft. Doc is willing to try what I suggest. I’d like him off anti-depressants (since they aren’t helping w/OCD), but when we tried last summer he was still emotional after 3 weeks, so doc said it may be him as oppposed to withdrawl. SO, how long does it typically take to wean off of SSRI’s (it was Zoloft then)? Off of Luvox specifically? More than a few weeks? He’s had suicidal thoughts, so as much as I want him off (it’s been 3 years), we have to be cautious.
Also, doc suggested we try Vyvanse for ADD, as he seems to get tolerances to…so far…Adderall, Focalin, and now Concerta. I know everyone reacts differently, but what is a preferred combo for OCD/ADD…SSRI/stimulant, from your POV?
Thank you,
Mk
MK,
Only an eBook now, will be a hardback after we develop a readership on this level. Hope you enjoy!
RE: your guy – every single one of the characteristics you describe is representative of
1. Disarray in the neurotransmitters, likely unbalanced with some too much and others too little.
2. Immune system dysregulation is highly likely – with a likely Histamine elevation on the NT testing.
3. A consequence of the immune dysregulation is a bowel problem, either constipation or diarrhea or both, picky eater etc. The GI problems can occur in either the North or the South!
Speediest intervention: measure and correct the imbalances whilst mixing the appropriate meds as indicated by history and NT findings. Likely will need a dietary plan/change as well when you get that info.
cp
Hi Dr. Parker-
How do we undergo testing for his immune system, Histamine, NT? Also, he’s on Vyvanse now, 30 mg. Focus isn’t consistant per teachers. Some obstinant behavior & incessant chatter at times. He’s on Luvox, which isn’t helping w/OCD. We go to doc tomorrow. I may have him go back to Intuniv. Concerned about weight gain & what SSRI plays well with Intuniv. He’s been on an SSRI for nearly 7 years, so don’t want to just stop it. He was lethargic and sleeping in school on Intuniv & Luvox, I told Doc we need to stop one of them, after reading your materials.
Concerta worked ok last year, then seemed to not be effective. Impulsiveness and compulsions from OCD seem to be the biggest factors impacting his life negatively right now. Thoughts? He’s been on Zoloft, Prozac, Luvox, and Tenex (prior to Intuniv launch) for OCD, none seemed to work for that, but now we need overall anxiety lowered.
Thanks!!!
Mk,
Testing protocols are quite simple, outlined on the ‘Testing Options’ page on the nav bar – with a simple outline of instructions in this Lab Testing pdf.
As you can guess it would be quite inappropriate to make specific suggestions here on this blog with such a paucity of information.. and don’t even necessarily agree with your conclusion that something should be stopped, but do agree that something does need changing. When I reach this conundrum in my office I do consider more specific testing rather than just trying to change meds without direction – evidence of challenge. Immune testing is available through IgG Lab Corp, but you must be careful that your insurance will pay for it because Lab Corp significantly increases prices compared to other companies.
cp
Dr. Parker,
My 11 year old daughter was being treated for ADHD with 2.5mg Abilify and 15mg Focalin XR. Due to side effects and emotional outburst we stopped the Abilify four weeks ago. She did fine at first, but became more and more frustrated on just the Focalin XR (DOE was about 6 hours). We tried increasing the Focalin to 20mg which substantially increased the frustration and irritability. Decreasing her dose decreased the DOE and she was still frustrated/irritable. She has always had trouble on stimulants alone. Her Doctor suggested we try Intuniv without a stimulant at first to see her response. We are on day 3 at 1mg am dose and she is extremely tired. She sleeps most of the day becoming more alert 9 to 10 hours after the am dose. Should we try pm dosing, add a stimulant, or both? Years ago she tried low doses of Adderall XR. DOE was within expected range but she would pick at herself.
Thank you for your help.
Chandra
Chandra,
When tired like this we often find the attention has fallen off and continue with a stim, and if the Adderall XR working in the past, that might be best. My personal choice for augmented/combined therapy is Vyvanse and Intuniv, and, as I have always indicted here, if the basics don’t work well, just make sure you get into that next level of inquiry, don’t let it drop, and try the neurotransmitter testing.
cp
Dr. Parker,
Thank you for your prompt response. Your website has become an invaluable source as I try to educate myself regarding ADHD medications. I just downloaded your new book and look forward to reading it. Intuniv is not helping the way we had hoped. The somnolence during the day did not improve and we saw an increase in her irritability. We stopped after only 5 days. I know this is too short but she was feeling worse not better. We have gone back to low dose tenex -.25 mg in the evening. She becomes a happy, pleasant child in about 30 minutes. Why can she tolerate very low doses of Tenex but not Intuniv? Would this indicate a problem with her metabolic rate? (As a side note, I have not yet tried Vyvance because I wanted to chart the effects of one medication at a time.) We see her doctor this week and I am going to ask for neurotransmitter testing. I think he will be open to this, if not, I will find someone who is. What other testing do you recommend?
Chandra,
Thanks for taking a look at Rules – it is pretty darn comprehensive – and therein I think you will see that your girl very likely has a metabolic problem. The rate of burn is just too slow, and no genetic changes in the system that metabolizes Intuniv. The dose of .25mg is so very low it is below the side effect level. Interestingly, if you stay with the Tenex for awhile you may find that a very low dose of Intuniv [1/2 of a 1mg] might work after a few weeks on Tenex.
Testing, no question about it – I have had so many good responses with NeuroScience neurotransmitter testing – but if that Histamine is up you will have to chase down possible immune system challenges with an IgG review of food allergens. NS has several different test options including one for ~49$ [22 basic foods] you can check out their website and more info here on this CorePsych Blog page.
Thanks again!
cp
Doctor,
Thank you for your interesting and informative website. My 7-y-o son has been diagnosed with ADHD and ODD. He is incredibly bright, but unable to control his emotions or temper. We tried stimulants starting at age 6(Concerta and Adderall), which left him zombie-like, crying and with tics; Strattera for a few months with very limited effectiveness, Strattera and Celexa, which seemed to help with anger and frustration at least for a month or so but then stopped working; and most recently was on Intuniv and Celexa. He started the Intuniv at 1 mg for the first week and then stayed on 2 mg for a few more weeks. At the start of those weeks, he responded so well that his teacher and parental assessments were coming back to no longer put him in the ADHD/ODD diagnostic category. However, after a few weeks, he became increasinly tempermental and frustrated. He was taken off the Intuniv and left just on Celexa for a week. He became not only more irritable, but absolutely manic. He then went med-free for about a week and while he was no longer manic, he was incredibly angry and frustrated. We have put him back on Intuniv (just finished 1 week at 1 mg and are now in our first week of 2mg). As with our previous experience, hyperactivity is greatly reduced, but still having big problems with anger/frustration/irritability/violence. Is there another medication that can be combined with Intuniv to help with the anger/frustration issues (I know definitely not Paxil, Prozac and Luvox from your post above)?
Nancy,
Zoloft might be a good choice to discuss with your doc – is clean on 3A4 and 2D6.
Likely the Celexa dose was a bit too much, sounds like you were on the right path. Zombie on the previous meds only indicates a dose that was not adjusted carefully enough… he sounds very med sensitive, needing very small doses rather than the average for his age/size.
cp
Dr. Parker, I have an 11 yo son who originally was diagnosed with PANDAS when he was 3. We already know of the immune issues as he and his neurotypical 7 yo sister both inherited my celiac disease. I am currently using Vivaglobin SGIg for my PID. Things were pretty well with Cameron for the last 2 years but this year we have had more aggression, ODD and just horribly mornings and emotional explosions than we can really handle. He takes 18 mg Concerta in the am and at noon, .05mg Clonidine 3x a day, and his Risperdone was increased to .25 3x a day but it’s just not working. He has been diagnosed as having TS (related to the basal ganglia damage from the PANADAS and it acts up when his strep titers are too high), ADHD, and PDD-NOS. Two months ago he was asked to exit his school at the end of this year because they can’t provide the appropriate environment for him any longer. As we live in Japan (US and French citizens) we are forced to deal with the bulk of our medical situations during summer holidays to the Dallas area. My neighbor was recommended Intuniv for her daughter who has many of the same aggression issues stemming from her ADHD and PDD. I would like a bit more knowledge when I go in to speak with the doctors who are great at giving behavioral advice but poor at listening to “the parent”. We do have a doctor who does our follow up here in Japan, but she goes on the recommendations of the US doctors and unfortunately the Japanese system is a bit ancient in these areas. I would welcome any advice, because it’s looking like I”m going to have to home school and it scares me to be honest.
Robin,
You do have your hands full, but don’t despair, much more can be done nowadays with more info. I do like Intuniv for these kinds of complicated issues with the impulsivity and ODD dysregulation, but I would encourage you to drive deeper for more information rather than simply treat the symptoms. Over here more understand and use it, and the fact that it hits different receptors brings excellent promise for a trial.
You [yours is already in evidence], and likely Cameron. both could profit from further testing such as the IgG testing mentioned elsewhere and here under Metametrix to find possible offending antigens and remove them. If you want to do the testing in Japan and have LabCorp available there the test # is 680230 for IgG [96 foods].
Downstream from immune issues very often is leaky gut, and perpetual increases in immunity related issues if the gut isn’t directly healed. With the immunity is almost always found nutritional problems secondary to the malabsorption with the gut deterioration. Many of these folks have symptoms of changes in transit time that foretell the need for further action.
Take a look at the many other references here at CorePsych Neuroscience on this complicated subject.
cp
My daughter is 6 and we have tried about all the stimulants there are, some worked for awhile, then we upped the dose, they made her angry or anxious, nail biting, skin picking etc… She has adhd and odd and she has been very argumentive, interuptive and angry. She is currently on metadate cd 40mg, does not work at all, lots of problems at school, thinking about trying intuniv, what do you think,? IF she does try it, should she contine taking a stimulant along with it, or quit those and just be on the intuniv, thanks so much
Traci,
Every time I hear this series of stimulant trials with no or little response I am quite certain the person in question has:
1. Measurable neurotransmitter imbalances, likely a mixed breed of too many excitatory neurotransmitters, and too few inhibitory, with a diminished level of dopamine. Measurement is the absolute next step. Many other combos could be at play, but this pattern is one we see multiple times everyday in our office.
2. Highly likely that she has an immune dysregulation with IgG imbalances and specific reactions to food. Could be other toxins, but foods need to be assessed first as they are so easy thru many nationally available labs… see other comments here on which LabCorp test. The food thing is big, and many specific books tell you what to do once the offending antigen is discovered.
Yes, Intuniv is certainly worth a try, and often works in these challenging presentations – absolutely. Especially because it hits that different neurotransmitters system: glutamate. Only problem: PEA, DA, and NE all effect concentration and focus on the excitatory side – so the solution is not a simple one trick pony.
Your next best bet:
1. My strong feeling on the new standard of care – Always: Measure neurotransmitters before moving down the line for the big atypical antipsychotics with their multiple metabolic challenges and long term side effects.
2. We measure in every other aspect of medicine when we are unsure, why not psych? Basic…
cp
Hi Dr. Parker, You seem to have an incredible handle on all of the ADHD medications and a wonderful way to explain the pros and cons to parents. My son is 9.5 yrs old amd weighs about 64lbs and has ADHD and some aspects of Aspergers as well as recurrent worries. He has tried every stimulant on the market except Vyvanse. He had a lot of anger when on adderall and since it is in the same family as Vyvanse, our dev. ped. has been reluctant to try it. He has been on Strattera 40 mg for 2.5 years. He seems to do better with the Ritalin family of meds and has been on Ritalin LA (not long lasting enough), Daytrana (bad skin infection) and is currently on Concerta 18mg in addition to Strattera 40 mg (pm). He also takes 3 mg of melatonin to help him get to sleep at night. We are not at optimal now as he is extremely disorganized and unfocused though his body is relatively calm. We tried to increase to Concerta 27mg and he got very weepy and angry so we dropped back down to 18mg. So we have been using the non-stimulant Strattera as the main medication with a low dose stimulant as a boost to improve focus. Since we are not at optimal and a new non-stimulant is available, I have considered weaning him off of Strattera and trying Intuniv. Which is better for kids who tend to have anxiety? It is not completely terrible right now, but I feel if my child is going to be medicated, we might as well have the intended results. Thank you for your consideration of our situation.
Michelle,
Thanks for your kind remarks.
1. Intuniv would be a good choice as the main thrust of your concerns at first appears to be the ADHD symptoms.
2. Vyvanse often works well when Adderall doesn’t – same molecule, different delivery makes a considerable difference and with his sensitivity you might try the water titration process at very low doses.
3. Strattera is almost purely NE in effect. Meds aren’t specific for superficial symptoms such as anxiety, but are only specific for different neurotransmitter indications measurable thru, for example, NeuroScience.
4. I would seriously look at enteric allergens, see the IgG testing pdf on the Neuroscience page here.
Totally agree with shooting for predictability!
cp
Dr. Parker,
My son is 6 yrs old. He has TSC (tuberous sclerosis complex). He is on Trileptal twice a day for seizures (he has been seizure free for 2.5 to 3 years). We strongly suspect that he may have ADHD (OC type) and I came upon Intuniv, however, I see that it is not as effective if taking a class III med. Any suggestions?
Kelly,
Intuniv and/or stimulants are both indicated. The Intuniv might be the best bet to try first, as it is a non-stimulant.
cp
Hi
My son is 9.10 years old. He has been on Abilify for 6 months, 1mg daily (we started with 2mg, but it was too sedating) and it has worked well for him. He is diagnosed with a mood disorder, GAD, ADHD, emotional dysregulation, tic disorder and has LDs (and is a super sensitive sweetheart!). Anyway, his GI doc found that he has elevated liver enzymes and thinks it’s from the Abilify so we (with his neurologist) decided to take him off. I have a prescription for Intuniv here. It is day 3 without Abilify and he is having a really rough time. He is crying a whole lot, angry, aggressive, unfocused, says he ‘misses’ the Abilify and hates how he feels. My question is, do I start the Intuniv now, or wait till the Abilify is out of his system? If i start the Intuniv now, how will I know if he is having a bad reaction to the Intuniv or if it is a withdrawal from Abilify? Will the Intuniv help with the withdrawal side effects of the Abilify? Thanks.
Elizabeth,
Abilify has no withdrawal, and does not increase liver enzymes. Liver enzymes are likely elevated by immune dysfunction that could be tested by LabCorp #680230 IgG 96 Food Sensitivities – been there, seen that one, worth a look-see. No reason to wait for Intuniv, no interaction, no problem, and less cost to the system than Abilify. Both can be used together, but need to chase down those liver numbers and look at bowel function.
cp
Dr. Parker,
Your blog continues to be so helpful! Based on your anecdotal experience with Intuniv, have you seen any benefit in going above 4mg with an adolescent who is tolerating it well but seeing little benefit? Stims and Strattera have not been well-tolerated so our md is considering going higher on the Intuniv, but believes that those studies are just being done now.
Any insight?
Thanks, JB
JB,
With Intuniv and the ADHD meds I look for every option before going to the non-approved levels. To answer your question specifically: I don’t go over 4 mg. For your situation, unless you are completely against stimulant meds, that would be the next move in my office. As you likely know my favorite is Vyvanse, and often a very low dose like 20 mg will turn the day. Remember to work with your doc to dial it in correctly and the two often significantly compliment each other.
cp
Hi there! After a couple years of battling with being told my son has attention & impulsive issues in school and a late diagnosis of Dyslexia, we just recently started him on Intuniv 1 mg daily. Over the past few years I have changed his diet, limiting junk food to nil if possible and trying to avoid dyes as much as possible, feeding him the most natural foods I can that he likes with an occassional splurge. There were some small changes in behavior but not consistent. He has been on Intuniv for approx 2 1/2 weeks. We started it in the evening because I thought that is what the doctor had said. The teacher, tutor and myself noticed a small change in his focus and reading, more smoothly and at a better pace. I noticed here at home that I didn’t have to repeat myself so much when asking him to do something. Since his checkup last week we started giving it in the a.m and he seems to be more distracted again when getting ready for school and more hyper. What dosage seems to be the most effective for a 9 year old and when is the best time to administer it? The doc said we could increase the dose, I was wondering if 1 mg in the a.m and p.m would work? Curious on your thoughts, you seem to be more experienced with this med. His pediatrician is new at administering this for ADD. Thanks & look forward to your response.
Bobbie,
Agree with your ped, clearly can go up as discussed here in the dosing details. We never prescribe for ‘9 yo’ but always individuate dosage for the specific needs of each patient based upon their metabolic rate and individual response to the medication.
At this moment going up seems most reasonable as the DOE is not covering to the following AM – a sign that often indicates insufficiency.
cp
6yr. old daughter diagnosed with ADHD. Intunive 1 mg. prescribed once a day at night. She has just started med but has slept a lot especially on the second day. Will this improve as her body adjusts or should I call the doctor?
Ginger,
Do review this post on Intuniv Dosing, it gives all the details for dosing and timing, and yes, that is a common side effect, and yes, 6 yo is always more likely to need more time to make adjustments. Don’t think yo need to call unless it persists more than a week, or if it simply is impossible to deal with.
cp
Hello Dr. Parker,
First…I think your website is wonderful and so very informative! Thank you for sharing some of your knowledge with us!! My daughter is 15, diagnosed in July 2009 with ADHD Inattentive Type. She was basically misdiagnosed in the 2nd grade and struggled until right before entering 9th before receiving a diagnosis. Stimulants work very well for her…. Vyvanse was a wonderful medication but she developed grade 4 acne from it. After discontinuing the med her skin cleared up quickly, the dermatologist was shocked at how quickly it cleared up after stopping the med. Before Vyvanse she never had issues with acne, just a pimple here and there. Her doc switched her to Concerta 27 mg, she became very irritable and emotional so it was lowered to 18mg and again she did very well on it. But she developed the same acne- I use the term acne but it was more like open sores and the “acne” sores caused a lot of pain for her from both of the meds and she only got it on her forehead. Her child psych changed her to Strattera 25 mg but later dropped to 18 mg and it was a nightmare for her on both dosages. Severe mood swings, dizzy, very sleepy- she would fall asleep on the way home from school and want to sleep until it was bedtime and then she would go to bed, she was depressed and highly agitated, irritable while awake and much of the time couldn’t control her feelings. It was a horrible experience for her and scary for me. She has always been a child with stable/balanced moods so this was very out of character. She was removed from the Strattera and we took a medication break for a couple months after the Strattera experience. The child pscyh told us basically her last medication option to try would be Intuniv. She started Intuniv 1 mg and she had the headaches, dizziness and sleepiness at first BUT she has been tolerating it very well but again the acne started coming back on her forehead (this is the only area that gets affected each time). I am just at a loss right now. The doc is at a loss as well. I have her taking magnesium, calcium and zinc supplements along with DHA. Could the ADHD medication be causing something to happen in her body that is producing the skin problem each time? I would appreciate any recommendations or guidance you might be able to give!!! We are not sure where to turn at this point. Thank you so very much! Kristi S.
Kristi,
First look at her periods: Every time I see acne in a girl her age I jump on all the estrogen dominance questions. If she has estrogen dominance she may have some testosterone accumulation – all of these can be measured.
And, in addition, when anyone has all of these clear metabolic problems with the stimulant meds I always look for more biomedical issues such as immune dysregulation with a subsequent bulletproof liver.
cp
Hi Dr. Parker,
Thank you so much for the reply! Her periods are 21 days apart every month. She is a tall and thin girl. I asked her about her bowel movements. She “claims” to have 1 BM per day. It is just very puzzling that the acne/sores appear once the medication is in her system and when the meds are out of her system it clears up completely. During the 2 months of being medication free she did not have any acne issues at all. It does seem her body isn’t removing toxins. I will definitely check into the biomedical issues you discussed. We are pretty much desperate for answers right now. I had thought about a candida cleanse for her in the past. Do you think this would be wise? Also any tests that you would recommend? BTW- she has had a mild case of eczema since she was very young. Thank you again for your time! It is greatly appreciated.
Kristi S.
Kristi,
Her doc could eval for candida, and there are several good labs to do a stool assessment. Find someone near you who does work with Metametrix Labs, they have a very comprehensive stool assessment eval. The eczema does indicate she has something going on with her immune system, and also a look at Omega 3 Fatty Acids, see another comment just sent on this post about a boy with similar problems.
cp
Hi Dr. Parker, my son has been taking 4/mg of intuniv at night and 30mg of vyvanese in the morning. He has been taking these doses since January. He started breaking out in a rash over the last week which seems to get really bad when he goes into the sunlight. Can either medication be causing this ? Thanks, Ricky.
Ricky,
Sunlight rash is not a common complaint of either med, and I haven’t reviewed the full package insert on those details. They are available on the web, please take a look and report back what you find – only time for a brief reply.
cp
Hi Dr. Parker, thanks for your response. From what I can tell, a rash is a less common side effect of guanfacine the main ingredient in intuniv, but never the less it is a side effect. It looks like it starts more from when my son sweats than the sun itself. His doctor is discontinuing his intuniv, but I would like her to increase his vyvanese from 30mgs to 40 mgs but my son doesn’t want to take it at all because he feels it is causing his acne and it hurts his appetite. Do you have any suggestions ? Thanks for your help. Ricky.
Ricky,
Thanks for the update on the rash, we just don’t see it yet, tho it might be an issue. Regarding the dosage of Vyvanse: main issues for everyone – a protein breakfast. If he has a good protein breakfast, takes the Vyvanse after, and completely gets off anything like pop tarts, sugar or any trash carbs, he will likely do much better on the acne side. Do take a look at the breakfast link, take him to the store with you and figure out which one he could do.
If he is constipated, or toxic in any way, get him on Omega 3 Fatty Acids [‘Fish oil’] in the range to 2-3000 mg/day and I think you did say he was on zinc [20mg chelated/day], an excellent multivit would also help – and fiber to go every day.
cp
Thank you for your insight Dr. Parker. One last question: The Vyvanese takes my son’s appetitie away which is why it is hard to get him to take it. Do you have any thoughts about what we can do about that ? Thanks again, Ricky.
Ricky,
Protein breakfast is the first line, but if he has an immune dysregulation with some gastric irritability anyway that item will become first on the to-do list.
Thank you! Hope it works,
cp
Hi Dr. Parker, My wife met with my son’s math teacher this past Friday and he commented how much more alert Mike was in class. This was after we took him off the intuniv (4mg, we were giving it to him at night). The problem now is he doesn’t want to take the vyvanese anymore because he hates the way it makes him feel. He takes fish oil every night made by Nordic naturals, a multi-vitamin, and 250mg of magnesium. I told him if he doesn’t want to take any medication he would have to eat more protien. Do you have anyother suggestions in terms of natural substances for ADHD such as ginko bulba or anything else ? His ADHD is more the inattentive type. Thanks again for your help. Regards, Ricky.
Ricky,
Most kids with this presentation will work with the doc if the doc simply gets more tight with the child, putting the child more in control, and listening more carefully to the child. You guy does not want to participate in the process – the process of listening to him is likely a bit off, and a smaller dose of Vyvanse would likely have some beneficial effect.
Having said all of that, the nutraceutcials , like ginkgo biloba and O3 Fatty Acids are helpful, but often won’t do the job completely. You are on a good mix, could add Zinc, as some studies show problems there, but I would at this moment prefer testing rather than continuing to throw speculative supplements. Neurotransmitter testing is paid for by most insurance companies, and we offer a consult to go over that testing long distance if you wish.
cp
Hi Dr. Parker, you mention in your last response about getting my son’s neurotransmitters tested. We live in Northern, NJ. Where would we find a lab or doctor that does that in our area ? Thanks, Ricky.
Ricky,
Don’t have a name up there – we can do the testing from our office, no problem, and can report findings by phone and suggest considerations for your medical team there.
cp
What about the combination of Intuniv with Strattera
Marc,
Strattera is a 2D6 substrate, just as Adderall and Vyvanse, making it contraindicated with Prozac and Paxil, but doesn’t effect the 3A4 pathway or Intuniv metabolism a-tall.
cp
Thanks again for taking the time to answer my questions.
You seem to have a good knowledge of medications. Have you heard Mesocarb/Sidnocarb? It is a medication that has been available in Russia since the 70s and is used for a wide variety of things including treating ADHD. While doing research on the different medications available I came across it. It seems to work the opposite of amphetamines, and it selectively increases dopamine without increasing norepinephrine. My understanding, based on extensive research is that dopamine re-uptake also happens on norepinephrine transporters, which is why amphetamines increase dopamine levels, and not because amphetamines blocks the dopamine transporter. Its also much less neurotoxic than stimulants. There are numerous clinical trials and studies done on it but much of the literature is old or in Russian.
It seems like a much better option than stimulants but it not available in the United States. I’m not sure why this is but I suspect it may have to do with patenting. Since the drug company’s didn’t discover it themselves maybe it is impossible for them patent it and make money off it. Do you have any thoughts?
Brian,
You got me on that one. I spend so much time writing and seeing folks in the office I really don’t keep sufficiently up with the ‘perhaps’ meds. Interesting point though, and will welcome your further insights on this one as time passes,
Thanks,
cp
Hi Dr. Parker,
I’m a 20yr guy who was diagnosed with ADHD (primarily inattentive) just over two months ago. I’m in college for psychology and when learning some basic facts about the disorder in an abnormal psych class I began to suspect I may have ADD. I delayed doing more research or going to get checked for two years. Finally, I took action and went to get checked at my college health center. The process there is you talk with a doctor, then psychologist, and finally a psychiatrist to prescribe you medication.
The psychiatrist put me on Concerta for the first month and setup a follow up in one month with the original doctor I had seen. I won’t list all the side effects but they were really bad. On the follow up, the doctor decided to switch me to 10mg IR Adderall twice a day. The medication seemed to work for the first week but gradually lost its effectiveness over the next few days. I upped my dosage to 20mg in the morning and 10mg mid day and the medication began working again. The side effects were much milder compared with Concerta, but still high, Dry mouth, insomnia, loss of appetite, jittery, ect.
I started doing heaps of research on different medications. I discovered many patients get better results with Dexedrine because of the purer d-amphetamine. At my next doctors visit I suggested this and he said he won’t prescribe it because it is more abusable. He also said he didn’t believe Adderall could develop a tolerance and put me on 10mg twice a day again, and suggested I talk to the psychiatrist again. I agreed, the psychiatrist also said he doesn’t prescribe Dexedrine but suggested I try Vyvanse. I explained how I was concerned with insomnia because the IR Adderall seemed to create insomnia even when the last dose is taken at 12pm. But he still thought Vyvanse was the best option and placed me on 20mg Vyvanse once a day. Since there is no generic like there is for Dexedrine, the cost was $40 for one month compared with the $5 for generic Adderall.
I tried the 20mg for a few days, but it wan’t effective so I started taking 40mg a day. This dose worked well and the Vyvanse nearly eliminated all the side effects that Adderall had with the exception of the insomnia. I have only been getting around 5-7 hours of sleep a night compared with the 8-9 hours I used to get.
I have found a few studies that show stimulants do not provide any long term benefits and their toxicity also concerns me. I don’t think Strattera would help me because most of the negative side effects I have seem to come from the norepinephrine stimulation. I am thinking about suggesting Tenex at my next follow up, with the psychiatrist again, in about three weeks. Do you think this would be a good idea?
Thanks for your help, Brian
Brian,
You are very close to what many would consider an excellent resolution of challenges.
1. Agree, Strattera has limited benefit and is not worth the time unless you fail everything else.
2. You are responsive to AMP, and they work much better than MPH [Ritalin products], with few side effects
3. Your sleep could likely be corrected with some Melatonin over the counter 3-6 mg, talk to your doc.
4. Disagree with the doc that Dex is better.
5. Your DOE with Vyvanse sounds like it is nearly right on.
6. Tenex may be necessary, but the Vyvanse will do a much better job with fewer side effects if tolerable, – but Tenex is quite inferior to Intuniv and not really effective with all the dosing strategies and diminished half life.
7. You may simply need to go to the Vyvanse 30mg dosage for the specific DOE to meet with your approval and resolve sleep issues. No med will make it completely resolve, but you are very close.
8. In psychology you will come to know that your personal and professional future will likely evolve with the understanding of neuroscience/neurotransmitter imbalances anyway – and down the road testing may be in order to correct your entire sleep and ADHD picture.
In the end the best choice, IMHO, is the Vyvanse, and it is quite likely that your doc will agree – and he/she will have to sign off on any changes.
cp
Thanks for your advice, I was already considering taking Melatonin to help fall asleep so I will try that.
As I’m sure you know, Vyvanse is essentially the same medication as Dexedrine. It is dextroamphetamine with an amino acid added to prolong its effects for 10-12 hours and make it only active orally. Dexedrine Spansules on the other hand last for 6-8 hours but are available in generic, so the cost would be $5/month vs. the $40/month for Vyvanse. These two reasons are why I thought Dexedrine would be a better option.
The half-life of Tenex and Intuniv are similar though, taken directly from the Intuniv prescribing sheet, when taken once daily the half-life Intuniv is 18 ± 4 and 16 ± 3 for Tenex. I would much rather take generic Tenex twice a day (if that is even necessary given there similar half-life) than pay for the cost of Intuniv which is sure to be much higher.
Brian,
No harm in any of your choices, for sure. – Just answered you according to my preferences and so that you would have a clearer idea of what we actually see in the office with these meds. If cost is the issue, the other problems are diminished, and the only issues that do loom are efficacy and and compliance. The Vyvanse lasts 14 hr, that will be a big deal if you take it longer, and tenex will be less likely work than Intuniv, [in the office it’s different, shorter, than the package insert] but it may do the job – people are indeed different in their responses.
Best wishes, thanks for asking the questions, and I do wish you well on your several journeys-
cp
Hi Dr. Parker, Thank You so much for such an informative website. My 14 year old son had been diagnosed with ADHD 4 years ago. He started Concerta at 18mg within a week he was up to 36mg. He was on 36mg for a year doing great then he was bumped up to 54mg which he was on for almost 3 years.I always knew deep in my heart that he was never 100% focused on the concerta and his behavior was still a little annoying, but not anything compared to him without being medicated.My husband and I accepted that this was going to be him at his best.(We tried Adderall but my son had horrible crashes the 2 days he was on it)He has also been going to Sleepaway Camp for the last 4 years and every summer we would start at 36mg but always wound up ending at 54. He Socially had problems because he was “annoying”,but still liked and loveable. In a nut shell he came back from Camp and FaceBook started. Facebook basically ruined him. Because of the things he said you can tell the kids who were in his bunk were starting to cut their ties.Starting in January I noticed his grades slipping and his behavior more defiant.His teachers started to email me that he wasn’t paying attention and was not focused at all. He was never one for doing homework, but he just started not caring at all about his grades. (We have a tutor for him Mon-Fri)We tried bumping him up to 72mg which did absolutely nothing. He actually was much worse.I just found out last week that he his behavior has been horrible in school. Starting with kids, not listening to teachers,instigating, running through the hallways,cafeteria ,etc……He is also going through Puberty, I wonder if that could have an affect on his behavior?So we went back to our Dr. again and our Dr. felt that Intuniv could possibly be a great fit for him. He started 1mg yesterday and he slept for 1 1/2 hours, He also went to bed at 9PM. This morning he got up at 8.30AM. He took the 1mg and again fell asleep for over an hour, except today he was just so tired he didn’t want to move. Finally at 4:30 he played tennis for 2 hours. He complained that he was exhausted, fatigued, and lost his match because of the medication. His mouth today was just shooting off and I was basically verbally abused for hours. I ignored it knowing he cannot control himself. He is 5’5 and weighs only 103 pounds.(Low Weight the result of Concerta) His blood pressure in the morning is only 105/58 which I was told by his pediatrician was fine because he is on the thin side,normal low range. I checked his blood pressure several times today and again tonight when he went to bed at 8:00pm and it was 105 /65. When he was on Concerta he didn’t go to bed until 1:00 in the morning. He is only taking the 1mg of Intuniv. He is not taking Concerta at all. My son is miserable and wants to go back on Concerta which we know doesn’t work that great for him. Does the Drowsiness subside or will this always affect him?Is it possible to tell after only 2 days that this is not going to work for him? I had him home from school these last two days just in case something like this would happen. He doesn’t go back to school for another 10 days. There is one thing to be a little sleepy, but this breaks my heart to watch him take a nap, be exhausted all day , and then go to bed so early .To top it all off we don’t even know if the medication is going to work.Thank You in Advance for any insight. Lauren
Lauren,
Your guy is complicated, very typically complicated however, so don’t despair, you have a number of choices with just what you have written here. These are some thoughts, but because of the challenges won’t provide specific answers without further review at your site – so are just that: some thoughts for more definitive steps.
1. Strongly suggest counseling if not already underway. So many variables, so challenging being an adolescent, and with FB and so many issues in adolescence boundary discrimination and management have so many variables that time in therapy can help discern.
2. Sleep sounds like an issue, sounds like it has been an issue, and without clear attention to sleep, the whole foundation becomes a house of cards. I have one whole chapter in my new book on ADHD Meds [and notes in the Precise Solution White Paper at this link] on sleep.
3. Concerta is fine, but without working hard on the DOE, and too few dosage options, not my favorite.
4. As they say when I visit California: “in Capistrano, one swallow doesn’t mean summer is here.” The trial of Adderall leads me to believe he might benefit from a further stimulant trial of Vyvanse as: – a. it is more forgiving, b. it has less drop in the PM, and most importantly, c. it is an amphetamine capable of more precise dosage strategies – see the link on Vyvanse dosing.
5. The Intuniv appears to, – as does the Adderall, and even these clinical challenges with the Concerta – show underlying evidence of metabolic challenge that can be measured more completely as noted on this page regarding Neuroscience Labs. Immune dysregulation is on the consideration table with the regression during camp – perhaps a stretch, but seen that one before with complete indiscriminate food at some camps. You might try the Intuniv, as some have with your docs approval, at night to obviate over sedation.
6. Finally, and perhaps most importantly, it sounds like your guys is suffering from a comorbid depression see this ADHD and Depression Video and this Video on Anxiety, Meds and comorbid diagnosis with ADHD. Not caring fits my ‘Clint Eastwood’ Depression characterization from High Plains Drifter and Gran Torino.
Hope these thoughts help, and if you get further stuck you an always set up a consult call, and we can evaluate more completely.
cp
Dear Dr. Parker,
Thank You so much for being kind enough to take time from your busy schedule to respond so quickly. Today was day 3 on Intuniv and it was Horrific. My son woke up at 8:30 this morning took the 1mg of Intuniv and in about 30 minutes after taking the pill he had a major meltdown.I saw a side of him today that I have NEVER seen and pray I will never see again. He said things to me that as his mother were unimaginable. It was almost as if he was possessed. This is the only way I could describe it.He started screaming “I hate this medication” “I hate the way this Medicine makes me feel”and That “I was cruel to do this to him”.He was hysterical and crying which was odd because he very rarely cries.To be honest with you , I had a bad feeling about this medication last night when I wrote to you. I immediately called his Dr. this morning and filled him in and he obviously told me to stop the medication asap.He told me my son should take nothing for two days just to see the way he acts. I reminded the Dr. that when my son is off his concerta (I take him off on weekends from time to time)he just acts plain goofy, laughing excessively, acts extremely immature, but never Vicious. Inappropriate yes but Vicious no. I then gave my son 36mg of Concerta (I suggested this) and within an hour he was calmed down and was apologizing profusely.Back to his “Normal” self. He said he was so sorry, that he couldn’t control himself and he was so sad that he hurt me with the things he said and that he loved me.I of course told him I loved him back, but also told him that when he said those things to me; he hurt me terribly. His Dr. was pushing for Risperdal because similar to your suggestion he thinks my son also has a “mood disorder”. I suggested the Vyvanse and he said fine , I picked up the Rx for 30mg.He also let me know that there is a very good possibility he will need “Risperdal” for tweaking if the Vyvanse works.My son is also starting Cognitive Behavior Therapy this week and Counseling(Hopefully I can avoid the Risperdal). After viewing your Video, I realized you hit the nail on the head again! I think he definitely has Avoidance ADHD. I Just want to let you know again how much I truly appreciate all the time you have spent informing myself and others and giving me the powerful gift of knowledge to help my son further.I will be in touch and will definitely keep the phone consult with you in mind. In the Interim , I will be telling all my friends and family about you ,your informative website and all about your research.Thank You.
Sincerely, Lauren
Lauren,
You are very kind, – I very much appreciate your remarks and forwarding to your friends.
Time will tell with your guy – the important thing: more options are available if these next steps prove insufficient!
Best,
cp
Hi again Dr.Parker,
I started my son on the Intuniv (1mg) Saturday, and he has been very tired ( a side effect I am aware of), and now as of today, he is complaining of dizziness (another side effect I am aware of) and also feeling a bit listless. He could barely get through his karate class tonight and he is complaining that he does not like the way he feels on the Intuniv. He has had 4 doses so far and I was wondering how long this will last. I know it takes a little time for the body to adjust, but he wants me to take him off already. Will these feelings dissipate by the 7th day or will it take longer? I am just a little frightened of it lowering his blood pressure and then having to increase his dosage to two tablets per day by this Saturday. Will this make his side effects worsen? Any info is greatly appreciated.
Thank you
Roxy,
Tiredness is different than BP, and tiredness doesn’t mean that he has an associated BP problem. Side effects should slow in 7 days, or you might skip a dose and give it that night. Some have had better response to night dosing.
cp
Hi Dr. Parker,
My son has been on 2 mg. of Intuniv for the last two months or so. He seems so tired and irritated when he gets home from school around 4 in the afternoon. We have been consistently giving him the 2 mg. of Intuniv around 8 in the A.M. along with 25 mg. of zoloft. I think the zoloft has been helping with anxiety and an overall happier mood. But, we do get concerned about the sleepiness after school. I have read that some of the parents are giving the Intuniv in the evening. I am thinking of trying the switch where I would still give the zoloft in the AM and the Intuniv in the evening. Can I ask how I would go about making the change? He did take his 2 mg. of Intuniv along with the 25 mg. of zoloft just this morning. Therefore, should I not give the Intuniv tonight nor tomorrow morning and wait until tomorrow evening? Any feedback would help! Thanks in advance for your thoughts! Sue
Sue,
Since he is only on 2mg, you first check with your doc about this, as he is the responsible party. Either way will work, and agree with keeping the Zoloft in the AM. Likely more able to maintain function and not skip a day if takes it that night, rather than waiting an entire day, as any ‘Top of the Window’ side effects would occur whilst sleeping.
cp
Dr. Parker,
My son is totally off the Intuniv now (due to severe fatigue) and back on 20 mg. Adderrall in the a.m. with an added 5 mg. Ritalin in the p.m. We have dramatically increased his protein intake and he has begun self-restricting sugars and dyes. This is the first time he has used a short acting in the p.m. and we are seeing improvements but not sure if this is due to the medication or nutritional changes. Any thoughts?
Susan,
Would have to talk more about the details to render clear opinion – but hey, sounds like it’s working. I never use MPH with AMP as MPH also blocks 2D6 – however a small dose of Adderall IR in the PM, even 2.5 mg [1/2 of 5] can be helpful, if not too close to 6PM – as will cause insomnia if too late.
cp
Hi Dr C,
My daughter, 16 with significant ADD and NVLD, is doing ok but not great on Strattera and Abilify (the latter is to help with irritability, some of which is likely organic and some created by the Strattera). Stimulants (even Vyvanse) are not an option as they eventually make her so angry and paranoid she looks practically psychotic. So… how would you characterize the clinical differences between Strattera (when it works well) and Intuniv (ditto)? Also, might they be used together to any benefit? And finally, for something completely different — any experience using Amantadine for ADHD and/or people on the very mild end of the ASD spectrum? Thanks as always! J
p.s. before you ask — she is a great eater in general, including protein breakfasts!
J,
Copy on the protein!
Amantadine can be helpful in some of these complex presentations… but, hate to sound repetitive, she needs a workup for neurotransmitters and immune dysfunction, no doubt. I would just get-it-done. Evidence beats speculation no matter how well trained we are. You can set up a time with Deborah, we can do it long distance, and I can tell you some specifics of what-to-do from that testing, for sure. Both NT imbalanced, and Immune system is rusty from these brief comments. If you have a doubt, read this book by Dr Laponis.
No interaction with Strattera and Intuniv. Haven’t used them in combo myself, as I use Strattera so infrequently, because I get the job done without it.
cp
Hello Dr. Parker and thanks in advance for all the insight you offer on your site, each ADHD case is so unique and it helps to be able to find a situation that matches your own and discover what is working, what is not and often what still needs to be investigated. That being said, my son 6 1/2 yrs, 58 lbs was diagnosed with severe ADHD last year with real impulsivity problems. Thru pediatrician, then physchiatrist, tried stims inlcuding Ridalin LA and Focalin and became very emotionally aggitated, weepy, hyperfocused and the pyschatrist thought he was one of those ADHD kids who could not tolerate stims. He was started on Intuniv before Christmas with amazing results, but he seems to keep progressing, over time, out of the therapeutic window and our great results begin to dissipate. He is currently on 1 mg at 7am and 1 mg at 7pm to combat afternoon sedation he was having in class. I feel he clearly needs to titrate to the 3 mg a day dose, but want to combat the sedation while yielding the greatest efficacy. What do you feel would be the best dosing strategy?? staying at bid dosing and having one dose be 1 mg and the other 2 mg for a total of 3?? and where would you add the increase, morn or eve?? He does get a good protein breakfast every morning as well. The Intuniv worked amazingly well in the beginning, I’m just trying to get back to that therapeutic window. Thanks again for your advice.
Patricia,
You are making the point exceedingly well about comorbid metabolic issues. Often, as you can see here and in the other Intuniv posts, the real challenge is for those with metabolic issues. I am certain that your guy has some of those issues, in spite of your excellent supervision and planning with the meds. Bottom line: he needs the testing to identify the underlying cause of the challenged slowing.
His situation does present with too many questions to jump in with a specific rec – but having said that, I would seriously consider just working within the framework of his Therapeutic Window, and actually lowering the dose to see what his response is now that he is reacting this way. Not my first choice, but something to consider with your doc prior to obtaining the more precise information.
cp
Hi Dr. Parker,
I am hoping you can answer a few questions for me. My 11 yr. old son diagnosed ADHD was prescribed Intuniv. But before I actually get the RX filled, I would like to know what vitamins and spplements should not be taken with this medication. He takes 1000mg Omega 2x a day, 200mg L-Theanine 2x daily, 100mg DHA, and 100mg VitC 2x a day as well as a multi vitamin. He was on medication (Buprorion, and Celexa) but I took him off over 6 months ago and he is on vitamin therapy and organic foods. His symptoms have improved tremendously, but his impulsiveness is still a little too much, hence the Intuniv Rx. Can I continue with the vitamin therapy and give him the Intuniv? Thanks for your advice.
Roxy,
Absolutely continue with the vits, organic foods, – and you didn’t include exercise [see the review of Spark by Ratey on this CorePsych Blog post]. As you correctly hinted, the treatment for ADHD covers more than one dimension, and these amino acids and vits don’t interfere with meds. Only cautionary note is 5HTP with serotonergic meds as they might encourage a serotonin syndrome – but with a measured, low serotonin, that concern becomes less significant.
One of the regular observations we witness at CorePsych is the significant need for mixing a variety of supplements with traditional meds – as traditional meds often have limited value in the context of significant metabolic and nutritional issues.
cp
Sorry, I forgot to include his exercise regimen! He has been doing karate since 4 years old – he currently has 3 classes per week/ one hour each class/strenuous workouts!
Roxy,
You are on it!
cp
I have a 16 y/o diagnosed ADHD/ODD. He takes Straterra at 138mg daily (hes been at that dose for about 2 years now)..he reports increased difficulty in school lately, orgazination issues, trouble concentrating, remembering etc…Also, he can be very moody, angry, and at times violent. He just finished a round of partial day treatment and IOP for anger issues and is in one on one counseling. We have an appt. with the psychiatrist in a week for medication review and was wondering if you think Intuiv is worth mentioning? We have tried EVERYTHING over the past 11 years (Diet, stimulants, etc..). The straterra used to work great, but the bigger and older he gets (5’11” 220lbs), the less effective it seems to be…and we’ve run out of room to increase his dose (obviously). My main concern is how much of a role is adolescence/hormones contributing to his behavior? I used to be able to tell the difference, but not lately, and I don’t want to overmedicate him, but at the same time, want to help him “take the edge off” so he can function. Also, lately he’s been complaining of being unable to fall asleep or not sleeping at all, and I thought this might be contributing to his increased inattentiveness/moodiness during the day? I started him on a Melatonin regimen, and now he seems tired alot..but I’m still trying to find the right dose I think…any suggestions? Thanks in advance!
-Stephanie
Stephanie,
Last, first: A ‘melatonin regimen’ should not make him tired. If it is the dosage is too high, or there are other mitigating factors – such as metabolic issues noted in this post on Intuniv.
Strattera response usually occurs in those with other metabolic compromises. Barring the possibility that he is one of the 5-7% with inability to metabolize AMP due to CYP 2D6 polymorphic [genetic] changes – because Strattera also passes through 2D6. Said another way, I’m certain that he can metabolize AMP because he has metabolized Strattera at relatively high doses for > than 2 years. Conclusion: The AMP was likely too high or too low when first adjusted, either too quickly topped out or not sufficiently dosed, and Vyvanse would definitely be indicated for the stimulant side of matters.
Regarding the Intuniv: There is no drug interaction with Intuniv and Strattera, – Strattera runs through the 2D6 pipe, and Intuniv, as outlined in this post, runs through 3A4 – so no interaction of competitive inhibition.
So many of these questions overlook the most important part of the equation: Is he eating a protein breakfast? Is he a picky eater? What are is bowel function patterns -times/day #2? What is his diet – too many carbs? More information on sleep. Does he exercise? etc. All of these require more thought for the proper connections and conclusions that available here.
Hope this helps a bit with your team out there. If you remain stuck schedule an hour with me and we can cover the details.
cp
[…] CorePsych Blog by Dr. Charles Parker http://www.corepsychblog.com/2009/11/intuniv-for-adhd-dosing-details/ […]
Dr. Parker
I too am very happy to have stumbled upon this website. I don’t want to take up to much time but I just want to give a quik history. at 2.5 my daughter started displaying extreme rage. I mean just all of a sudden. She was kicked out of a childcare facility at age 2.5, 4, 6, 9. Suspended from buses. Basically after she spends so much time anywhere, eventually she isn’t welcome to return. I was against the use of Meds before I exp this with my own daughter ( I would like to say I have birthed 4 children and she is the only 1 that is medicated. Maybe you can give me your opinion on this. She is the only 1 of my children I had to take medication with while I was pregnant. I was already contracting at 3 months so I started taking tributaline (sp?) (which might I add the year she was born, was the year whomever makes the decision, made the decision to no longer give pregnant woman that med) for about 1/2 my pregnancy. At 6 months I moved and had to go without for a couple weeks and started dilating so they had to give me double dose to stop the labor, so obviously she could have been stressed in the womb for the preg, do you think that or the meds could have something to do with it? She seemed depressed at birth and always very easily agitated, but not rageful) . I always figured parents were prob giving there kids to much junk and not enough balanced meals, and most importantly not enough structure, and and not enough sleep. But I am glad to say I take pride in sleep, balanced meals, and not to much junk food, and still my daughter has been very hard to figure out (bio/neuro needs) She tried Concerta originally (in the 1st grade), it was a Godsend for the teachers, because for the 1st time since she started school she actually could be part of the class, not entertainment for the kids, and a complete distraction as well. Then after a couple months she started displaying more rage then she naturally displayed prior to the start of the med. So i took her off it and we tried Focalin, same results, then we tried tenex (alone), no real change maybe a bit more friendly. I started seeing a diff Dr. and mentioned that according to what I have studied my daughter exhibits many symptoms of pediatric bi-polar, I do realize that there are similar symptoms off ADHD and bi-polar, but that umbrella where ADHD ended and Bi-polar continued my daughter fit those. The Dr. didn’t want to label her with that to young, but I did request maybe something other then a stimulant or maybe a combo, so that was how we got with risperdone/vyvanse. It really is good, but as you know the hormones effect the meds, and needs change. My daughter is 12 about 5’1″ 115 lbs, and today the Dr. increased her Vyvanse dose from 50 to 70mgs. She currently takes .5mg of Risperdone in AM and 1mg of it in PM. My daughter’s behavior, impulsivity, agitation level, and lack of empathy has just down-spiraled. She started Vyvanse at 10 (4th grade) at 30mg and only .5 mgs of risperdone in AM and PM, in the middle of 5th grade we needed to up the dose to 50mgs. and added another .5mgs of risperdone in PM. Now another year later, and 3 suspensions (in the last 5 weeks) and about 7 detentions (which usually weren’t served due to the suspension that came), we are again raising the vyvanse, not the risperdone, and now adding the Intuniv. 1mg for 1st week, 2mg next week, then the 3mgs, and the Doc said thats where the increase will stop. She did say we are starting her with the 3 but working her off risperdone. She didn’t say when (considering she gave me another script for Risperdone I am thinking not soon), I just don’t like all these chemicals really, but I do accept the fact that as of right now my daughter lacks what she needs naturally, and the meds def make life more livable for her and ALL around her. My concern is the risperdone and intuniv will create alot of lethargy, especially considering the 77 comments I have read now. I do realize you are limited to only the info I share and it’s hard to really give the best answer. But if you could please let me know what your general recommendation would be regarding the combo that would be great.
Ingrid,
No drug interactions with Risperdal and Intuniv, so that part is covered. I do think the doc is on the right track, have gone up to 4 mg on Intuniv, but don’t think any of these meds should be given in some kind of protocol, as you can see from these many remarks. All need specific targeted titration strategies.
On sensitive kids with a history of medication unpredictability, I would have been slower on the increase from 50 to 70mg, as every time I scoot up too quickly, problems arise. I only increase with the specific criteria for Vyvanse DOE as seen in this video, and when they are close to perfect I always go more slowly. Yes, I would have gone to 60, but not having been there and not knowing the specifics I can only tell you my patterns, not recommend specifics for your girl.
The CD on Brain and Immunity, on the 4th or 5ht disc by Dr Laponis has a great deal of info on Immunity and the intrauterine experience. It is highly likely that she has some other biologic imbalance, not as visible as ADHD symptoms, and would absolutely do further testing to find out what is going on with Neurotransmitters, Endocrine function and IgG [immunity] testing for other sensitivities including foods. It is quite unlikely that a simple, even very careful titration strategy with Intuniv will completely turn the tide – based upon her complexity and history.
cp
I just have a quick question. My son (13yrs old) is diagnosed with ADHD/Biploar/Seizure disorder. He is on 450mg of lamictal, 15mg abilify, and was on 4mg of tenex a day. His dr wants to take him off of the tenex because it may cause an anueurism(not sure how to spell it). His heart rate was elevated according to the last 2 EKG’s. He wants to start him on Intuniv 4mg in the am asap and stop with the tenex. I was looking at Intuniv and it seems to have the same side effect. Do u think that there will be the same issue as far as his heart rate being elevated with intuniv as well? His is getting A’s and B’s in school and currently has an F in math. He dislikes his teacher and math so we are slowly working to correct this problem. He recently started seeing a counseling and that seems to be going well. Let me know what you thought is on this situation.
Jenn,
Complicated case, not an easy shot with such a paucity of information – but briefly to the point: I do agree with your doc in that Intuniv appears to have a much better side effect profile than tenex. The slow release provides a markedly diminished roller coaster effect on the blood concentration values thru the day. Regarding the aneurism comment – not at all on my radar, never heard of that concern, and it hasn’t come up in any of the meetings with my research colleagues.
On a deeper note, my ears burn on the metabolic issues: heart rate elevation and whatever else may be contributing. Is he a picky eater, does he eat a protein breakfast. Without neurotransmitters you can be shooting blanks whatever your team does with the meds. And check out the Brain and Immunity reading list at the neurotransmitter link for more possible information.
cp
cp
Dr. Parker,
I am a 16 year old girl diagnosed with ADHD (inattentiveness), depression, and that’s it for now. When I was diagnosed with ADHD in October (4 months ago), I was started on 27 mg of Concerta every morning. I was already taking 10 mg of Lexapro each morning too, and no bad side effects were happening from the Lexapro. However, when I started the Concerta, I would crash every day around 1 PM and become extremely fatigued. My heart rate and blood pressure were also very unstable- There were times where my heart rate spiked to about 300, or my blood pressure would be fine one day and 170/100 the next day. My doctor then took me off of Concerta and gave me a Daytrana patch to wear every day, so the medicine wouldn’t wear off and I wouldn’t crash. However, I was and still am sick every day in some way since starting the Daytrana. My blood pressure and heart rate readings are still crazy, although my blood pressure has become consistently around 160/90. My heart beats very rapidly at random times of the day, even when I’m just sitting in a class at school. I also randomly get dizzy or lightheaded, or extremely fatigued. It’s strange how fatigued I am, because I am exhausted mentally and physically, but I can’t sleep. I am usually feeling like that every night. There are also times where I can be wide awake for 24 hours straight. There is no pattern at all with this that I or anyone else can find. I am still on Daytrana and Lexapro, but I’ve just started taking Guanfacine (for both blood pressure and ADHD) at night before I go to bed. I am still extremely fatigued and I don’t see a difference in my attention span- The Daytrana has helped that quite a lot already. But no doctors can find what exactly is causing this, or how to solve it. My doctor who prescribes my medication is very quick with appointments, and she usually doesn’t let me talk or explain anything correctly. I am really at a loss at what to do, because getting sick every day is interfering with my school work and life. Do you have any solutions, or suggestions?
Danny,
Whatever you do girl, just keep writing. Your note here is excellent, well written, and clearly shows you have much promise with your communication skills.
I am going to guess a few points, because I see them all the time:
1. I will bet you have significant problems with not eating a protein breakfast.
2. I also bet that you have significantly increased transit time on your bowel activities, probably one every other day or every 3rd day.
3. In addition I also guess that your menstrual periods are challenging, but you are toughing them out, and everyone has said, just hang in there girl, this is what it’s like being a woman. Listen to this estrogen dominance podcast if I am right.
4. You might also be a picky eater on top of all of this.
Now because your are 16, and this is the Internet, I am not asking for specifics on the reply. Bottom line if I am correct on any of these your immune system is likely the problem, and the neurotransmitters are unbalanced downstream, so the fix will be deeper investigation of your metabolic issues before you will be able to get it all together.
Again, keep up the good work!
cp
Dr. Parker,
Your site is very informative, Ithank you for that. My son will be 5 at the end of April, and has been put on Intuniv about 5 weeks ago and are now up to 3mg. in the a.m. with little or no changes. He has been diagnosed with PDD-NOS with severe ADHD tendencies. The preschool teachers see only a minimal change in his impulsivity and at home I see a little more focus but am not even sure at this point if I am only “hoping” to see a change. My concern is that the drug is FDA approved for 6 year olds and he is really only 4 (although he is 54 pounds) – what are your thoughts on this? In the beginning of taking Intuniv he finally slept the night (first time since birth) but now is up again – either complaining of stomache or nightmares although he does not appear to be in distress. Would you recommend giving him a pm dose instead or adding something for sleep? Thanks in advacne for your help!
Jean-Marie,
Complicated and off label situation, not one to deal with over the internet as kids this age are particularly challenging to balance in the first place. My best recommendation is to get on the real testing for neurotransmitter imbalances as soon as possible. See the NeuroScience Testing available here, and look at the webinars on this link, and consider Brain Immunity as discussed on this same page by Dr. Laponis
Reasons:
1. Age
2. Refractory to meds, often associated with immune dysfunction
3. PDD often associated with immune dysfunction
4. Severe ADHD, often associated with immune dysfunction
5. Stomach aches are essential to F/u, – immune dysfunction until proven otherwise
6. Nightmares can indicate several issues with unbalanced neurotransmitters and are often associated with immune dysfunction.
To guess at any one of these with this complexity would likely prove ineffective. Having said all of that, yes some docs are using Intuniv with this type of child at this age and have been having some success. The best strategy: take a look at the evidence first to discover the underlying issues.
Take a look at this post on Celiac and chase down the links there to consider next steps.
cp
Hi Dr, thanks for this amazingly informative site. My son is severe ADHD, he is on Concerta 54 AM, daytrana 10 mg AM, Risperidal 0.25 BID and Depakote ER 250 qHS. He is eight years old and in the third percentile for weight (very thin kid). He still presdents with morning anger which disturbs the whole household. We would like to start him on Intuniv. What do you think, and whcih medications should we take away from his regimen???
Perel,
Definitely would consider adding Intuniv with your medical team. Far more information needed to take a shot at which one goes first. Mixing the Daytrana and Concerta is one way to help with after school duration… does that system work for the evenings as well?
cp
Follow up question for your below answer:
My daughters DR has her taking Concerta 54mg in the morning and 4mg of Intuniv at night before bed. She has night terrors and so far the intuniv at night along with Klonopin 1 or 2 mg has helped with this. My biggest concern is that the DR is giving her too much for her body. Should I be concerned? She weighs 75 pounds almost 5 feet tall and has a very high metabolism, always taken the highest dosage for her body weight.
Thanks!
Wendy
Wendy February 17, 2010 at 4:02 PM
I have a 12 yr old daughter who has been on intuniv for 5 weeks now 3mg. She is ADHD, we came off of Conerta for the Intuniv but it seems to not work for her hyperactivity but works well for her moods. Can this be combined with Concerta?
Reply
4 Dr Charles Parker February 19, 2010 at 5:57 AM
Wendy,
Yes, no problem, no drug interactions with Concerta, only caution is dosing strategy for best ‘Window’ placement.
cp
Read more: http://www.corepsychblog.com/2009/11/intuniv-for-adhd-dosing-details/comment-page-1/#comment-4187#ixzz0gHUlSVpj
Wendy,
Sorry to be repeating a bit, but in complex situations the real complexity lies in watching the side effect profile for each medication in question. “Too much” will show as a side effect, oversedation, decreased ability to manage feelings, anger – and too many more symptoms to list here. That’s why it would be very important to keep your eye on the Therapeutic Window with each medication, with your doc, and do share your concerns with him/her. If you think the meds are too much, you must have a reason.
cp
(I’m 27, diagnosed ADD from Spect Scans, but also diagnosed Bipolar 4 years ago…on Abilify, Lamictal, Welbutrin, Klonipin, and just started Intuniv…hoping to replace some of the first 4 meds.)
I started taking Intuniv at 1mg for a week, and didn’t really notice much improvement in executive center (PFC) function…and I had major sleepiness, which seemed to go away after a couple days (after my doc switched me to PM doses). So I went up to 2mg the second week. After day 2 though, my BP felt quite low all day (checked it at 7PM, and it was 91/56) and I felt like crap…very tired and dizzy. I went back down to 1mg, and used Licorice Root to stabilize my BP. After a couple days, and with the Licorice Root on board, went back up to 2mg. Now, after 5 days of still feeling so tired and sleepy, I’m frustrated and discouraged. Should I try going down to 1.5mg to see if the tiredness goes away?
Also, my doc said it wouldn’t interact with any of my other meds, but not sure I can rule that out. Thanks for any insights you have. My Dad told me to comment and see if you had any advice…he’s on it too, and didn’t experience anything like this, so we’re both confused. Thanks again!
Karin,
Intuniv does hit a different neurotransmitter system [specifically glutamate], and very well may be creating a positive response that increases the side effects of all the other sedative bipolar drugs. I have seen this using neurotransmitter precursors when the correct imbalance is identified, and the other neurotransmitter modifiers [that missed that specific pathway] have been cranked up to cover it by default.
A good example of this phenomenon: I have seen literally hundreds of folks given Prozac for ADHD – and many claim that it works!! The original comorbid depression was identified correctly, the cognitive anxiety, however, was misidentified as part of the depression, rather than seeing it as a manifestation of the comorbid ADHD, . To cover the cognitive anxiety Prozac was increased, with the result: they become ‘Prozac Stupid’ – and simply can’t think. They think they are better, and indeed they are with that ‘unmanageable cognitive abundance,’ – but their ‘operational ADHD’ is flaming, and they can’t concentrate on anything, even ordinary conversation. Duh! What were we talking about?
The Prozac appears to effect the initial problem, but does so in a secondary rather than primary way, by cranking the serotonin to such a level that the brain becomes relatively toxic. The symptoms appear to resolve, but the underlying ADHD problem continues to proliferate in an different way.
Another less obvious possible interaction, not commonly appreciated, is the possible drug interaction between Intuniv [a 3A4 substrate] and other meds traveling up through CYP 450 3A4 by competitive inhibition, specifically Klonipin. You may, and this is quite speculative – but worthy of consideration, be toxic with Klonipin secondary to that possible interaction.
Honestly, your question has many more variables, including the original reading of the SPECT, and the formulation of treatment from the SPECT images and your history in the first place. Having seen many second opinion “Ring of Fire” conclusions, I am concerned that far too many have gone off with that new, evocative diagnostic label, only to find that the subsequent intervention strategy proves limited in the long run, because the underlying neurophysiology is assumed from the hyperperfusion and hypermetabolism, rather than understood completely on a cellular-metabolic level. That discussion is considerably deeper than this response, but if you have had SPECT scans with a Ring of Fire ‘diagnosis’ you will surely understand what I mean.
The problem of missing the underlying neurophysiologic complexity can still exist even with good SPECT evidence. SPECT, in spite of it’s obvious contribution to the search for real functional evidence, rather than just labeling folks by external appearances, is still a ‘macro look’ at brain physiology, and almost completely overlooks all of the underlying causes such as basic immune dysfunctions like gluten sensitivity, for example.
Hope this helps,
cp
I have a 12 yr old daughter who has been on intuniv for 5 weeks now 3mg. She is ADHD, we came off of Conerta for the Intuniv but it seems to not work for her hyperactivity but works well for her moods. Can this be combined with Concerta?
Wendy,
Yes, no problem, no drug interactions with Concerta, only caution is dosing strategy for best ‘Window’ placement.
cp
Hi Dr. Parker,
My 8 year old son has been taking Intuniv since mid December. He started at the 1 mg. dose and then we increased to the 2 mg. after about 10 days or so. We definitely saw some improvement with his behavior which is ADHD and ODD. (He also has a lot of anxiety). The hyperness completely slowed down and he was less frustrated and irritated then usual. However, he was so tired and quiet that we felt his personality was not shining anymore. He didn’t seem interested in anything and was just kind of robotic everyday. On a plus side, he seemed to some improvements in his schoolwork. He always had horrible handwriting and all of a sudden, it was almost perfect! He just started taking his time and thinking his homework through more etc…. But, we were concerned about his lack of interest in anything and his complete quiet behavior. So, the doctor put him on 25 mg. of zoloft along with the 2 mg. He didn’t want us to go any higher because of our concerns. ( Sometimes, I wonder if he isn’t on a high enough dose of the Intuniv) We have seen his personality shine again and has shown a lot of interest in things and playing with kids more. So, the zoloft has been great in that respect. However, it seems to pump him up and make him hyper. And, we are also seeing a lot of the ODD symptoms again. So, my question is do you think the zoloft can be masking the effects of the Intuniv? If the zoloft didn’t make him hyper and doesn’t affect the Intuniv, we would like him to stay on it as it helps tremedously with anxiety and makes him way more outgoing. Any feedback would be great! Can you recommend something other than zoloft thay may work well with the Intuniv that may not cause the hyperactivity? Thanks in advance for your feedback!
Sincerely, Sue
Sue,
Your doc will always treat each side effect differently – and in the contest of this limited info I would suggest just dropping the Zoloft to 1/2 of 25 mg with your docs approval… sounds like he hit the ‘disinhibition’ side effect seen so often with SSRI, even on low dose. See what your medical team things of that idea, and do keep us posted.
cp
Thanks so much for this very informative site! My dear son (DS) is 8 years old and weighs about 75 pounds (he’s about 5 ft tall as well, fyi). DS is diagnosed first with PDD in 2005 and HF Autism in 2007. We started on Tenex in April, 2009 and Intuniv in early December, 2009 (titrated up to 3 mg). I saw less succes in how DS fell asleep with Tenex than with Clonidine (which he was on previously). From here, wow, how to make this brief: DS has been faling asleep in car to and from school since about First Grade. About a year or so ago DS fell asleep for 15 hours and had a BM which did not wake him up. Called ER for help, advised to pinch and use cold rags with eventually woke him up – no follow up from Pedi. DS continued to be occasionally lethargic. DS experienced significant behavior changes through 2009 (aggression, distractability, ADHD increase). I noticed one or two episodes of staring and blinking in 2009. In Decemeber, the Intuniv seemed to help somewhat…..but then….
In January 2010 I began to notice DS was much harder to wake (like, 45 minutes to an hour – kept falling asleep). Previously, it took about…30 minutes to wake him. DS falls asleep several times a day at school and is awoken by his teacher. I have found DS asleep at day care in a cold sweat and pale. DS falls asleep from school to day care and is difficult to wake up. DS has had an increased in bedwetting and does not typically wake during it. DS has also started jerkstremorsspasms in his shoulders, legs, arms and head when going to sleep and waking up. EEG has not caught this behavior. When you shake DS’s head while asking him to keep his eyes fixed on you, his eyes bounce around like a pinball machine. When you ask him to walk heel in front of toe, he crosses his legs over.
I have spoken with his psych and while he suggested syncope, he thinks the other symptoms aren’t really adding up. I would tend to agree, but the timing of the change to Intuniv and the increased sleepiness and movement makes me wonder. We’re scheduled for a brain MRI next Wednesday…..
Any thoughts?
~C
C-
‘Wow’ is right… this is far more than syncope, – your guy needs a medical workup ASAP, brain MRI work up will be helpful, but he needs a complete medical workup from top to bottom – many thoughts come to mind from ‘toxic’ and heavy metals, to immune system dysregulation with something as simple as gluten, and nutritional evaluation is important as well. Take a look at the Metametrix portion of this Neuroscience page, and consider a consult with a provider who can read the *Triad Profile* outlined there. First the acute workup – for the most serious obvious challenges, then on to the cellular and molecular measurements – My take: your guy has a biologic condition, with a psych presentation.
The clinical keys here are cold sweat, pale, lethargy, BM whilst sleeping, tremors, jerks, spasms, eye rolling, – this is most likely not an Intuniv reaction – if that is a question for you. If concerned about Intuniv simply wind it down and off to eval response to going off it – if your doc approves.
Please keep us posted. Hope this helps a bit.
cp
I have an 11 year old son who has been diagnosed as many things. He started having rages around age 2, which were initially put down to terrible two’s. Over the years they have increased in severity. In first grade he was diagnosed ADD. I disagreed with the diagnosis as I believed he had more of and anxiety issue then an attention issue. He was put on several ADD medications, the majority of which increased his rages but didn’t affect his focus. He finally ended up on Concerta. When he was 9 I took him to a behavioral specialist to see if I could find out what was happening. She rediagnosed him as ADD but added on an anxiety disorder, put him on Zoloft, and I started him in counseling. His focus has never improved and his rages continued to worsen. He reached the point where he was taking things like pencils and threatening to stab himself in the neck, telling us we all hated him, and saying he wanted to move in with my mom. He also experiences what I assume is mania in that he is happy – but it’s out of proportion and is just as frustrating and hard to deal with as his rages. Several months ago I had the chance to talk to his birth mother (he was adopted as an infant) and she told me his birth father was bi-polar. His counselor got us an appointment with a psychiatrist. While we were waiting the six weeks for the appointment his behavior was so bad his pediatrician increased his Concerta to 72 mg from 36 mg. This had the effect of calming him down considerably, but didn’t change his focus. The psychiatrist said with the family history and the information I gave him pointed to our son indeed being bi polar. He put him on Risperidone with instructions on how to slowly increase it to the right dose. He ended up at .50 mg in the am and .50 mg in the pm. He also has been slowly working him off the Zoloft saying it can cause worse problems in kids like my son. He took his last Zoloft this evening. He is a completely different child as far as his behavior goes. He is still able to get angry but he doesn’t rage and can get himself under control. He is still able to be sad without withdrawing from everything and going into depression. He does still have his mania moments, but they have decreased. He still can’t focus and he still “picks”. He picks at or chews on everything. His fingernails are still nubs that sometimes bleed he’s chewed them down so far. His psychiatrist would now like him to start on the Intuniv. I’m extremely stressed about this. He is already taking the Risperidone twice a day and two Concerta 36 once a day. I’m very concerned about how much medication is too much medication. I would love to see his focus improve the way his behavior has, but not at the expense of putting him at risk. Is it safe for him to be on 72 mg of Concerta once a day, .50 mg of Risperidone twice a day, and then up to 4 mg of Intuniv? Since the Concerta affects only his behavior and not his focus does he need both the Risperidone and the Concerta? And most importantly, do you think the Intuniv has a chance of doing what no other medications has and allow him to focus?
Susan,
I am completely with you regarding your consternation with your guy’s diagnosis, and find interesting the most recent NPR reports about changing the diagnostic coding in psychiatry to cover these kinds of complex presentations. In a word, the new coding does absolutely nothing to address brain function, and adds on more superficial observations and speculations than the previous set in DSM 4r. The new angles are somewhat less political, but do very little to improve office practice.
Most perplexing to parents is the fact that we diagnose problems in psych by external appearances, and appear to have no real science, no facts, to turn to to point the way for improved care. This unhappy circumstance is changing, – too slowly, – but is changing. We do have more evidence available and brain and body function, IMHO, should absolutely be measured in any person with complex presentations. The outside labels just don’t work as predictably as biologic measures, period.
So on the biologic diagnostic side, he could be gluten sensitive, casein sensitive, high glutamate or PEA, mold neurotoxic, candida infested …etc, the list is much larger and the complexity requires more in-depth analysis.
Bottom line on the multiple variables: Complex presentation do require more meds, more supplements in the short run, and better evidence. As to your basic question regarding Intuniv with your guy, it is very hard to predict – as kids like this can go significantly either way – Big improvement, or surprising regression.
Why? Because the specific neurotransmitter imbalances are not on the table, and without that solid info we are completely in speculation. Do discuss with your doc, it certainly is reasonable to try, and there are no contraindications with the current med mix.
cp
Dear Dr. Parker:
We are about to go to 2 mg of Intuniv with Tristan, who began with 1 mg two weeks ago. His moods are even and he gets his work done when he sits down to do it. No mood swings and he is cheerful; his old self. I am concerned because he is complaining of feeling depressed. It runs in our families and he has commented on it over the past few years. I never thought it was a real concern until now as he has been mentioning it more frequently. While I am pleased with the results of the Intuniv, what options or direction should I take to address his depression? I’m worried to go up to 2 mgs as it might make it worse.
Janis,
Interesting question, appreciate it! Tristan may simply have a comorbid depression that was hiding behind the ADHD behavioral presentation. As the Intuniv pulls off the covers, the depression becomes more obvious. At this moment I see no indication from any reading that the action of Intuniv downregulates 5HT, serotonin. Take a look at the many answers on this CorePsych Blog post on Intuniv if haven’t been over there [now 155 comments].
Simple solution: try low dose antidepressant if your doc thinks that is reasonable.
More predictable outcome solution: Neurotransmitter testing.
cp
A little over a month into the Intuniv our 15 year old seems to be back were he was before we started. Things were looking so positive for several weeks and this is so frustrating for our son! We tirtated to 4mg, which made him tired and went back to 3mg for about 9 days now. I’m wondering if we should try again with the 4mg or is this drug just going to continue to be ineffective for him no matter what dose? He didn’t eat well this week and I’m wondering if that may be adding to the ineffectiveness. I understand the importance of the protein breakfast but what about protein all day? Incidentally, we have an appointment for allergy testing coming up in a few weeks due to a rash that doesn’t ever quite go away. I also sent a request to your patient coordinator for a phone consultation. Fortunately, we live close enough for a trip to Va Beach if necessary and I understand you have an office in the DC area. Is that correct?
Thank you so much!
Susan,
Used to have an office in Reston whilst working with Amen for four years, but now only at Va Beach. Hard call on the meds, sounds like he is a guy that clearly needs a more complete look at all the variables. Often Intuniv simply turns them around, even with a bit more time than at first expected… but sounds like going back up may not be the solution. Without asking the specific questions and without knowing many other details it’s hard to take a shot.
I do look forward to meeting you in Va Beach, even tho we are in 6″ snow right now, will likely be quite gone on Monday!
cp
Dr. Parker,
I am new to your website and I’ve been very impressed with your knowledge and what I’ve read so far. I have three children, two who have been diagnosed with moderate ADHD. My daughter who has it is 13 now and was diagnosed over a year ago when she suddenly started getting poor grades and not doing her work in middle school. She is an honors student and always performed at the top of her classes, so this was alarming. She also became very irritable at home and resistant to parenting, both of which had never been a problem before. She is now on Straterra, which helps her to focus and has helped with the intensity of her moods, but she still has her ups and downs with school. Her moodiness has increased as she has started to go through puberty and my doctor suggested that we put her on the pill to regulate these moods (along with other issues regarding starting her period that required that measure). The psychologist thought she was sinking into depression, which comes and goes. We started her on the pill and she seems to be feeling somewhat better and it has only been a week that she has been on it. If this doesn’t work, I’m considering asking the doctor about adding Intuniv for her. I have had both of my kids in therapy with a wonderful child psychologist for the past year or so, and we have a reputable child psychiatrist as well.
As for my son, who is 7, he has always been a very intense child. He gets frustrated easily and growls when doing homework or something he doesn’t want to do. He sleeps 11 hours per night, yet wakes up tired. He complains now that he hates school. His teacher has said how distracted he is in class, but he is so bright that he seems to absorb the work anyway. We tried Straterra since we had some good results with it for my daughter. However, we had to take him off of it because he became very aggressive and his anger was way out of control. He is normally a very sweet boy, even with his irritability and temper flareups, but Straterra turned him into a completely different child. My doctor suggested trying Intuniv and my son, who has become tired of struggling so much with school and homework, has agreed that he would like the help. I am about to try it and I’m worried because of my previous experience with the other drug.
Do you think NT testing would be a good idea for both of my children? Should I suggest it to my doctor? We cannot use stimulants because there is a case of Tourette’s in my family and my son had a few ticks last summer and it scared us. Depression also runs in my family, but those family members didn’t have it until after menopause. I am also giving both children Attend by Vaxa, a natural aid for ADHD (what do you think of these?) which seems to supplement well but doesn’t take care of the whole problem.
I would appreciate any advice you can offer.
Thank you for your time,
Gail
Gail,
Each of us had our own practice preferences, and from a psych perspective I always wait on BC pills for anyone as they are, IMHO, not the way to start life as a young woman – bad precedent [this point is emphatically supported by all of the writers on this page at CorePsych Books]. Yes, they [BCs] might help, that is not the issue, and, yes, they may be indicated from the surface of matters, but for those having any problems with starting menses a simple sputum test to assess hormones can significantly help out – evidence matters on that end, for sure. I worked with a great girl in my DC office who started showing hair at 8 yo, had significant gluten sensitivity, and when tested was estrogen dominant pre-puberty! She did very well with carefully administered bioidentical hormones, needed gut healing, off of wheat, and all of that was years ago before NT testing. Short answer NT testing does help, your doc will likely not know about it, and yes I can tell you more with specific evidence by reviewing your materials. One final point with your daughter: so many have simple ADHD and need a stimulant to turn them rapidly around – but I need more info to discuss that point specifically. She would benefit from NeuroEndocrine testing for both NT and Hormones [the latter with sputum].
Your son is almost a poster child for those children that seem to benefit most from Intuniv. Every one of these psych meds is completely different and, tho they may have similar actions, often behave differently based on a variety of metabolic variables. I discuss all of this in my new book in detail: Patient’s Guide for ADHD Meds. Strattera is the least effective ADHD med out there, agreed upon by all of the many researchers and speakers, and a failure of Strattera mean next to nothing for a good prognosis. Your son’s sleeping problems suggest more comorbidity that deserves further evaluation with NT testing.
cp
Dear Dr. Parker,
Thank you for your previous response. I did put my son on Intuniv, which we started this past Sunday at 1mg. The first thing we noticed was how beat up and exhausted he looked. He had bags under his eyes and his eyelids were at half-mast. After two days this got a bit better, at least in the morning. He seemed chipper and his teacher commented that for the first time, she saw him buckle down and get busy first thing in the morning. This wore off as the day went on, though, and he seemed very tired to her and less focused. The first afternoon after school, Monday, he came home angry and frustrated and spent the evening exploding at everyone. The next few afternoons have seemed better initially, although he is definitely tired, but then he wears down by about 7pm and starts in with his anger and frustration again. I’m wondering if this is a response to fighting the tired feelings. At any rate, it has been awful for this family and I’m getting worn down myself.
I’m supposed to increase his dosage to 2mg this Sunday, and I’m thinking that he may need more time to adjust to the 1mg first. I’d love your opinion on this. Also, I’ve read that Intuniv can cause mood swings…is that what I may be seeing and will that wear off?
As for my daughter, we are weaning her off the Strattera since it was not showing us any benefit. Her grades are plummeting as she is not handing in work again, and she is very snappy most of the time. She has similar anger issues as her brother and they rub each other the wrong away constantly. Our house is becoming a war zone filled with temper blowups. Do you think she would benefit from the same medicine?
As for the stimulants, I believe that they would help my daughter at least, but I’m concerned about trying them because of the Tourette’s that runs in my family. My son already experienced some tics last summer, which have since passed, but they made me very nervous. I don’t want to tap into the propensity for my family to develop tics and/or Tourette’s.
Please let me know what you think.
Thank you,
Gail K
Gail,
Wouldn’t worry about tics unless they came up, and if they do, that argues for a more metabolic review as noted in the most recent comment over on this CorePsych Blog post.
Gotta run to work, agree that you should slow down the titration and check with your doc on any changes.
cp
Dr Parker,
I am a new subscriber and and already learning so much, thanks!
My son is 11 this week, diagnosed with ADHD at 6 and BD (I have truly wittnesed mania if that is worth anything and its definetly in the family) at 8. Many medications later we are presently on Depokote 125 in the AM, with Vyvanse 30 and Intuniv 1-2 mg (still playing with this one) and Depakote 250mg in the PM, we succeeded this year in getting him off Abilify, it took 2 years and I believe I owe it to the Intuniv because we could not succeed before. He weighs 63 lbs.
Her are my 2 questions; (1)When I go up to 2 mg on the Intuniv I initially get good results, that turn into sedation about mid morning, so I cut back, he becomes used to 1-1.5mg and the effect wears off, I attempt to creep up to 2 mg and he is sleeping in the nurses office at school for 2 hours, I cut back and he has detention for throwing pencils. Ive been at this now for about 2 and 1/2 months, any reccomendations??? Also, I have noticed irratablility along with the sedation, a moodiness, he is winy!! Is this realted to the low BP?? She I be giving him folic acid?? Thankyou, Mary
Mary,
First: the folic acid thing…. it’s a Deplin thing, not a folic acid thing, please see the Deplin link on the other comment with the Stahl article.
Regarding dosing: Not recommended by the pharma company, but seen here at CorePsych Blog and in my office: some do better with night dosage with oversedation matters. BD is a tip of the iceberg diagnosis, not wrong, just incomplete because it only deals with moods on the surface, not what the underlying issues are. Multiple comments here deal with the issues, and you might wish to attend the Holistic Health Virtual Conf… the entire conference will give you ideas of ways to approach the significant background noise, and the underlying issues there. Whiny could mean many things including serotonin challenges, side effects, sleep issues, too complicated to rush off a response here.
The recurring theme in these posts: more evidence will help answer more questions.
cp
Dr Parker,
I am giving the Intuniv at night to my 11 year. we’ve worked it up to 2mg, the ADHD is still not completely controlled we get the tiredness and over sedation between 9-1100 PM. I am writing to ask you what you think about giving it too him mid afternoon, this way the sedation would occur while he was sleeping. He needs to be increased, his ADHD is not controlled, he appears at mid morning impaired because he is still fidgetting up a storm, but his eyes are droopy.
I would really love this to work for him and am doing everything possiable because the stimulant drugs trigger the mania in his BD and this would require us to place him on an antipychotic. Thanks to the Intuniv so far we have been able to discontinue the Abilify.
My son states he becomes depressed at times, this is new. Will see psychiatrist tommorow and will discuss changes in Intuniv time and discuss deplin.
Thanks for all your help, Mary
Mary,
I always listen to informed Moms such as yourself, and accept suggestions like the mid afternoon dose as not in specific conflict with the 24 hr standard, and only looking at adjustments that might prove helpful. Your guy is more complex, as every BD child is, and I suggest a very careful look at this comorbid immunity issues: IgG food panel would be in order. Neurotransmitter testing is completely in order and will tell you more about why meds are not predictable… and I predict a high histamine on that panel.
cp
My sons blood pressure was very low this week and he was very tired in the evenings. We went back down to 3 mg on Thursday night. I wonder how low is too low for the blood pressure? He had no other symptoms besides being tired in the evening but the pressure was 80/40 and that scared me. He was fine in school and was able to participate in sports after school and reported that he was only “a little tired” during the day. Apart from that, he is trying to catch up in school from a quarter of doing little to no school work and was able to focus enough to complete most of his assignments. A very positive sign which makes us want to stick with Intuniv. I haven’t heard of Deplin before now. I assume you think it is preferrable to Folic Acid supplements?
Thanks again!
Susan,
Good plan, intuitively correct and I’m sure your doc will agree. Follow this link for the Deplin info, and yes, far better than folic acid for the reasons noted. See this S Stahl link for even more detail with the tetrahydrobiopterin (BH4). Deplin has been a remarkable med for those non responsive to meds – a pre-pre synaptic intervention.
cp
Good Morning Dr. Parker,
My son is 6 1/2 yrs old 52 lbs and was diagnosed with ADHD with severe impulse control defecit. He is a very bright little guy. He was on Ridalin LA and Focalin, both at different times, but became extremely emotionally aggitated and weepy. In consultation with our psychiatrist, he determined my son is on of those 20% of ADHD children who can not tolerate stims. So we started Intuniv 1 mg about 1 month ago. We actually started to see results immediately. He was happy, could focus, complete his work,etc. Peers were a able to socialize with him without his constant touching, singing, grabbing, jumping, etc. Then at about day 8 we lost the therapeutic effect and were back to ground zero. We titrated to the 2mg and we were back to the ‘lovely child’ withing 48 hrs, this time with the sedative effect mostly in the afternoon…..fell asleep on the bus home, etc, but not unmanageable. We are 2 weeks into the 2 mg qd dosing and the last couple of days I see the therapeutic effect waning again. We have had some physical impulsivity issues at school, etc. The tiredness is also decreased though. I will also say that his appetite seems to be more healthy on the Intuniv, not something I’ve heard mentioned before. Will we just have to keep titrating up?? I’m worried that everytime we do, in time, we will lose the AMAZING result that we were having. There are so many things I love about this drug, the 24 hr effect, the non stim factor, the non control factor, etc. I just wish it would keep working!!! What are your thoughts?
Patricia,
As you will see from this CorePsych Blog post, it could be that he suffers from comorbid depression in the first place, aggravated by stimulant meds, less likely to be aggravated by Intuniv. My experience is simple here: Stay with the program on the Intuniv, but watch for the side effects and slow down as needed. He may need the higher dose, even at 52#, only a trial will tell.
Another thought if he were in my office: Sounds like he is out the Therapeutic Window in the PM and crashing, often see with Focalin, not seen with Vyvanse in the PM. My next augmentation strategy would likely be Vyvanse, sounds like you haven’t tried it, and it could fix the focus whilst the Intuniv corrects the agitation and assists with the focus.
You’re right – you are actually chasing different neurotransmitter systems, and ADHD is not so simple as many suggest – treatment often involves more than a simple dopamine intervention.
cp
A lightbulb going off here, after reading the above post and subsequent links to folate deficiency and links to depression. Garret, as an infant to 3 yrs of age, as per blood test was low on folic acid and required supplements. (He was also allergic to peanut treenut and milk which he as grown out of verified by testing) He seems to metablolize drugs very quikly….whatever effect we saw initially when on the trial of Ridalin LA only lasted about 5 hrs, on the Focalin, maybe 2, but as stated before became extremely emotionaly agitated and unmanageamble, etc.hence our move to Intuniv….. I am going to re- introduce a supplement to his Intunive 2 mg before considering him titrating to 3 mg…..which do you recommend? Deplin?
Patricia,
Deplin is a good choice for you, and as you know Intuniv is not cleared below 6 yo, would be off label, and certainly could be used by your doc. Short and best rec for young children, a standard in our office: measure, and measure. Why twice? I predict he will have a significant histamine aberration, and will need enteric food testing [not patches on the skin] after you find the histamine elevated.
Looks like you have read enough here to be asking the tough breakfast questions. Make sure you do the absolute best job of helping him choose the right protein breakfast – he will thank you years from now!
cp
Dr. Parker-
My son is 8 y/o. He was dx at age 6 with having SPD. Shortly after finishing his OT/ he was additionally dx with having ADD/HD. After a variety of meds (all which seemed to exhasberate his SPD symptoms) the only med we seen work with him is Focalin XR (20mg) Very successful for him – however now that he’s entered the 3rd grade and the pressures that come with it for him (FCATS fast approaching) We are noticing that he exhibits a lot of the following – aggression,temper tantrums, irratible, extreme frustration, minor defiance) Our family has been walking on egg shells; any little thing he wants/doesn’t get – can set off lots of grunting and frustation from him. It is very unlike him, even on his worst of days (until now) At school they’ve noticed even on the focalin his focus lately has been diminished. I am concerned about where this is going for him. We visited his dr this past week who gave us a script for Intuniv on top of the Focalin XR. I have reservations about giving him 2 meds and the fact that intuniv is a ‘new’ med. He always seems more sensitive to side effects of any med he’s tried (most of the time, it’s increased his SPD side effects – to the point he has been known to pull at skin on his thumbs – will spare the details 🙂 With the focalin, that has resolved itself.
All the signs point to he’s stressed/frustrated at school. My questions are 1) Do you think this combo will work from your experience? 2) Have others been on this since September seen good results
Thanks so much,
Michelle R.
Michelle,
Combo works, but I think you do need to dig deeper and will do well to review the comments over at this other post on Intuniv. You definitely need more clear evidence.
cp
Dr Parker Thank you so much for the reply and the link to look into the families on Intuniv. I’ve already started to look over them. Amazing the stories and the different successes. Just a thought, the comment “you need more clear evidence” is that to ease my mind or do you think that I need it for that particular combo? Thank you very much for taking the time to respond to my post – I so appreciate a blog such as this to help ease any fears/reservations that I might have regarding this (excuse the fact I’m not internet save either 😉
mr
Michelle R,
When I don’t have enough info to make a clear statement,, I simply bow out of speculation. I don’t like cookie cutter medicine, don’t like guessing games, and have big problems with platitudes when true complexity is the hallmark of many of these questions.
cp
Hi,
My 16 year old son started on Intuniv 3 weeks ago during the Christmas holidays. He is Growth Hormone Disordered, ADHD (inattentive), and has OCD. He responds well to stimulants but developed tics and says his OCD gets worse. He says the Intuniv has not helped focus at all and we added Adderall 20mg back for school. He also says the Intuniv makes him very drowsy at school. I want to give it a chance but was wondering if he should take the Intuniv at night because of this. Any thoughts.
Thanks, Jamie
Jamie,
Some have noted a decrease in tiredness with night dosing, the jury is still out on that process, and it certainly isn’t a first line recommendation – tho no harm in trying.
With the several tidbits of info you have added here, I would take the next step to figure out the background noise, as I have regularly recommended on several other comments here. Could have a simple problem with only neurotransmitters, but I suspect it is more as he has tics and need for Growth Hormone – when I see those two signs I would look at food sensitivity testing, immune dysregulation, picky eating as a possibility, and of course neurotransmitter review. He will show an increase on excitatory neurotransmitters, – just don’t know which one, and each needs a different approach.
cp
Dr. Parker,
We are on week 4 of Intuniv with our 15 year old son. We went down to 1mg and titrated more slowly as we discussed earlier on this blog.
He’s done great with few adverse events. We’ve attributed his mood the last seveal years to normal teenage behavior but we ate rethinking that since Intuniv–he is pleasant, happy, and much easier to get along with! It is still unclear as to how/if he is doing better with attention/focus at school. My question is about the half life and DOE expectations of this drug. We are giving him Intuniv in the evening and we aren’t sure this is the best way but it’s just plain easier to make sure he’s getting it on a regular schedule, especially the weekends.
Thank you so much for sharing your knowledge. Your sight is wonderful!
Susan,
Thanks for your kind remarks.
The Intuniv DOE runs about 24 hr, so if compliance is an issue, no harm giving it in the PM. I’ll bet he will improve, and AM compliance with the absolutely essential Protein Breakfast will become easier. Remember Intuniv also works on neurotransmitters, and neurotransmitters are built from protein. Some of these kids can use Deplin a drug [actually a pharma nutraceutical used for refractory depression, but which actually works to build neurotransmitters out of the protein in the diet.
cp
My 11 year old daughter is bi polar we have been through many medications through the last 3 years , with some real nightmares . Dr. had tried tenex and my daughter had more anger and began raging . Do you think this will have the same effect ? I am willing to give it a try but I am very hesitant . She has been on seroquel and wellbutrin for a while now but still very angry and outbursts often. Thank you
Pat,
I am with you on the hesitancy. Bipolar for me, thinking from an informed biologic/neurotransmitter perspective, begs for a more complete work up to actually see the real neurotransmitter options. The question for your team: What is the clinical objective for the Intuniv?
If the objective is ADHD treatment, and you absolutely want to stay away from stimulants, you might be pushed to give it a very conservative dosing try. My take: stimulants do work well if bipolar if the bipolar is managed first.
Having said that: Intuniv and tenex are the same parent compound, and it quite possible that you would have a problem with Intuniv as well – the significant advantage of Intuniv is the time release quality which clearly shows evidence of less of a peak and valley effect.
cp
Hi Dr. Parker,
We have a 7 year-old boy, with extreme hyperactivity and impulsivity. He has been on Concerta since age 4. He is about 48 pounds and was up to 72mg daily plus 1mg of Clonidine for sleep. His psychiatrist started him on Intuniv over the xmas break as his symptoms weren’t really being managed with Concerta and he had also become very OCD and rigid. It seemed like he was getting worse in many ways, and he was so hyperfocused and intense he looked like he could snap at any moment. Intuniv has been fantastic as far as we can see so far. he did 1mg for one week with 63mg Concerta, then 2 mg for one week with 54mg Concerta. Now he is at 3mg Intuniv and still 54mg Concerta. We are off Clonidine as well. However, when we dropped to 45mg Concerta over the last two days (with 3mg Intuniv), he got very loud and hyper again (but happy and not at all anxious). Question- does it seem OK to go to 4mg Intuniv, or is he too small? We are really trying to get lower on Concerta as he has dropped from 95th percentile in height to the 25th over the last 2 years and looks so skinny. He really won’t eat much more than Ensures all day- hates food.
I guess the bottom line question is whether it’s safe to put a 48pound child on 4mg of Intuniv and whether it’s ok to combine with Concerta at taht level. His EKG was normal so I was told not to worry about the old reports of combining those meds. Any advice would be very much appreciated. Thanks. Stacy
Dr Hunt,
I have to confess that as soon as I saw the narrow therapeutic window phenomenon I guessed either bowel or diet… and then there it was: “hates food!” Your guy is a quintessential picky eater, and honestly I could make suggestions from my experience all day with meds, but the first, absolutely first thing you have to do is read this post on Breakfast Protein, and sign up for my book in the upper right hand corner here, as I just finished the discussion there on the narrow window, immune dysfunction, and breakfast. It will be out in about 2-4 weeks, just have to get it in pdf and set up right for readers [footnotes need attention – will add links to every footnote for usefulness].
But back to your bottom line: He is hyper not just with Concerta on the Top of the Window, but his window is so narrow, due to metabolic challenges, that just a small drop down takes him out the Bottom. His main problem is that his excitatory neurotransmitters are just blasting away, likely glutamate and PEA, and without correcting that balance you can mess with meds for the next many years.
I just rebuilt this page on Neuroscience testing we do here, and, though I don’t know your PhD interest, bet you would find some interest in those papers on Neurotransmitter testing. Getting it precise is the way of the future… and I added some interesting work there this weekend on other sites, including great work done by Metametrix – just down from the Neuroscience materials on that same page. They are a bit harder to understand with the biochemistry on the front end, but deeper into the nutritional side of matters.
I have no prob going up with Intuniv [see additional comments regarding adjustments here] as he does not appear to be hitting his Top with that med from your explanation, but will leave that to your team.
BTW, with proper testing, and intervention, I am sure you will be able to significantly diminish the visits and worries about all the titration woes, and will likely be able to significantly reduce ADHD meds.
cp
Dr. Parker,
My 11 year old daughter is currently doing fairly well on her medications. She is an ultra rapid metabolizer for sure, and this is what we have to do to get through the day:
6am as she wakes up crazy hyper–20 mg Focalin (IR)
7:30 as she steps on the bus–120 mg Vyvanse
4pm as she gets off the bus and is very hyper–20 mg Focalin (IR)
6pm–.1 mg clonadine
She also takes Trileptal 600 mg at night and 600 mg in the morning for intense anger, and that has helped alot. We went through several antidepressants before arriving at the Trileptal solution, but settled there about 2 years ago.
All these medications work reasonably well. The transition times when the meds have worn off are hard, but we have learned to just get through. The main problem (other than all the ups and downs in her hyperactivity at medication transition times) is that she is swallowing pills SO often just to get the coverage she needs! (Plus, the insurance company battles with me all the time, but that’s another story!)
So, my questions are these:
Might Intuniv help her? Could we at least reduce some of the stimulants if she had Intuniv on board? And what would I do about the Intuniv-Trileptal interaction problems?
Thanks so much for your blog–it is invaluable!!!
Gretchen
Gretchen,
As noted elsewhere on Drug Interactions With Intuniv [second paragraph of My Reply] – Trileptal is not contraindicated – it will just diminish the effectiveness of Intuniv for the reasons noted. If you were in my office I would be very interested in doing a full Neurotransmitter panel, would ask very carefully about picky eater issues and bowel function as with the metabolic problems with the fast burning array she likely has clear, correctable underlying immune dysregulation issues.
BTW: Focalin can block the metabolism of 2D6 the Vyvanse pathway, and I make it a rule in my office not to use MPH together with AMP for that reason… it can artificially increase the Vyvanse levels, blow the patient out the top of the Therapeutic window [see the EzineArticle link there for more].
Do keep us posted!
cp
Dr Parker,
My 8 year old daughter (53 pounds) improved with tenex (1mg in the morning and 1 mg in the evening). We titrated her off tenex, and gave her 1mg intuniv for week 1, and then 2mg for week 2, all in the morning. She did not show any affect so we increased her to 3mg during week three. We have just completed week 3 at 3mg, and on one hand, she is calmer, less volitile and more attentive, but at the same time she is very tired with little energy and seems down in mood due to her low energy. Do you recommend we reduce her dosage back to 2mg (although there was no visible theraputuc effect) or keep her at 3mg?
Also, as with tenex, she awakens a few times throughout the night which disturbs her sleep. Do you have any information about how this medication affects sleep, and any suggestions on how to give her intuniv so that she can sleep through the night?
Thanks very much.
Lisa,
Naturally it’s not appropriate for me to offer specific medical advise for someone over the Internet – but I can tell you what I am seeing in the office and as you can see from these comments, and comments on the other posts about Intuniv [this post in July has ~ 78 comments] this problem is not uncommon.
My experience in the office has been to simply evaluate the seriousness of the side effect, and if it is incapacitating I drop back down. If not, we stay with it and it slowly resolves over 2-3 week, but I don’t go up. Actually in the studies the researches noted a specific improvement in sleep with the AM dose, again over time. The rule appears, on this one to be patient, back off when necessary, and put some time into the equation.
cp
Since my prior post, I thought it may be helpful to share our experience with intuniv. After 3mg for two weeks, my daughter had very low energy and we learned from her doctor that her heart rate went down from her nornal range. It was significant enough that it was agreed by all to reduce her back to 2mg, but there was no theraputic effect. Consequently, we stopped intuniv. Since we had a positive experience with tenex, we resumed giving her 1mg in the morning and 1 mg in the evening (the dose she took before taking intuniv.) It has been one week since she has been taking tenex. The tenex appears to be taking longer to show its theraputic effect as before but we are hoping that this will straighten out.
I am interested in any thoughts you have.
Lisa,
Without looking back to find your previous history I would quite easily suggest that you consider with your doc a stimulant med – my favorite is Vyvanse, but it doesn’t work for everyone. If she has a problem with stimulant meds, she is clearly atypical and should have an easy evaluation of neurotransmitter and immune dysfunction to discover the underlying metabolic challenges.
cp
We have a 17 yr grandson who has been diagnosed with everything from ADD, BiPolar, ODD, Mood Disorder NOS, ED and Asperger Traits. Stimulants cause tics and adversion to food but Vyvanse has been the least troublesome although after noons and evening can be very aggressive physically and verbally. He takes 2000mg Depakoke, 40mg Vyvanse, 75mg Effexor and Seroquel for sleep at night. He is also on a low dose of thyroid for hypothyroidism and Soma at night for muscle spasms from rapidly developing Scoliosis. His mental, emotional and physical age is about 14 d.yr and the orthopedic says his skelital frame is also about that of a 14 yr old. We started Intuniv three weeks ago and is now on the 4 mg dose. The first week was wonderful! Like a miracle. Since then things have really gone back the other way. We don’t get it. Could some of the medications be interacting somehow? Is there a way to get him off of some of this and start from scratch or further testing that can be done? We are slowly losing this battle and there is stil the Scoliosis ahead of us. Do you have any suggestions or ideas?
Kay,
Your guy has multiple metabolic and developmental issues:
1. Asperger traits
2. Tics
3. Aversion to food
4. Thyroid problems
5. Muscle spasms
6. ‘Developing’ scoliosis
7. Mental developmental delays
All of these require more investigation, not from the purely ‘psych’ side with more meds, but from the metabolic side with complete evaluation of cellular and molecular physiology. Your guy has a set of chronic medical problems not available through regular Lab Corps reviews. That review should include multiple immune, metabolic and neurotransmitter precursor reviews – my recommendation for a start: Triad Profile over at Metametrix..
His ADHD is likely only the tip of an iceberg… connected to much more going on below the surface.
And, yes, Depakote is a mild inhibitor of 3A4, and could contribute to the issues with Intuniv. Depakote is notorious for complicating matters with any kind of liver challenge – it could be contributing – but the other medical evaluation is much more to the point of the other underlying issues.
cp
Dr Parker,
My son is 6.5 yrs old, and has done 1 week 1mg, now has been on 2mg for 2 days. first week, napped every day, with 2mg, he was zonked day 1, and great day 2, then asleep now on day 3, we changed from am to pm doseing, and still same sleepiness.
Does it subside as time goes on, or stay the same?
By the way, day one on 1mg, teacher said he had completed first piece of work, by himself, in 15 mins. with everything in it , that was needed!! i figured day one was too early for results!
so, does sleepiness get better, and whats with the puffy eyes for a few days?
Thanks, I decided to post as I feel with a new drug, we all need to compare notes, and help each other.
This ADHD path is a lonely one sometimes.
many thanks for being there.
Kay,
Yes, thanks for posting, – all of these new drugs do require some field testing to fully understand the treatment expectations.
Your guy sounds like he is having a pretty typical start, perhaps a bit too much sedation. If you are concerned at all, just take it more slowly with your doc on the titration up to the next click. Sleepiness does get better over time. With this one it simply is not like the stimulants with big results right out of the box. Shire is very interested in not building false expectations, but rather suggesting deliberation and patience with Intuniv – it really is a different med and we will all take some time getting used to the specific parameters.
Bottom line, if in doubt, slow down, breath deeply, and hang in there. Many take 3-4 weeks to get it right. As you can see from some of these comments others take even longer.
cp
Dr. Parker, we started my son on intuniv almost 3 weeks ago. 1mg for a week, 2mg for 10 days and 3 mg for the last 2 days. He is 14 years old and weighs 143 pounds or 65 kgs. I have not noticed much difference in his behavior or concentration and when I went to the intuniv web site it showed the results kicked in at .05 to .07 per kgs or around 3.25 mg minimum for my son. My question is should we just go to 4mgs in week four or wait until we see how 3mgs go ? I went back to giving him 30 mg of Vyvanes along with the intuniv. Thanks, I find this blog very helpful.
Ricky,
Glad CorePsych is helping you review matters. In specific planning I always defer to your doc there. The researchers who did the studies did agree that slow is best and that if 3mg is not sufficient, you should go to 4mg. The weight relationships are guidelines, not written in granite, and are simply there to help find the correct dose more easily. Those weight relationships appeared ‘post hoc’ – after the studies where completed, and are suggested as a grid to titrate, based on the fact that most fell into those response ranges.
But please remember, titration is always, always, customized for each person. Customization during the titration will provide the most accurate results with the fewest side effects. Stick with watching and moving slowly with your doc there, and set specific objective criteria that your son can respond to as well.
cp
Dr Parker, thank you for responding to my inquiry last week. My son is still on 3mgs of Intuniv and 30 mgs of Vyvanese. He is complaining he is starting to stutter in school. Is this a common side effect when combining both medications ? He has been on the 3 mg dose of intuniv for about 10 days now and we started him at 1mg for a week followed by 2mgs for 10 days. My son’s psychiatrist does not want him on stimulants but we want to wait until after his exams to take him off the Vyvanes. He takes 100mgs of Risperidone at night. I would really like him to just be on the intuniv as I think that it is the safest medication. Thanks, Ricky.
Ricky,
The dose of Risperdal is likely 1 mg not 100 [just checking! ;-)] and I do try to stay away from that one as a long term solution. It works, works well on the front end, but I just saw a girl in my office the other day in the 7th grade who is lactating, and have seen similar probs with some boys.
It does sound, and I am completely leaving this to you and your doc. that he might be developing a tic secondary to the Vyvanse, not at all likely with the combo or Intuniv alone. Waiting to complete exams is reasonable, the tic is reversible, some take longer than others.
Do stay tuned for more posts here on neurotransmitter measurements and tic disorder correction with targeted amino acids. Our medical team has had some significant positive results with tics here at CorePsych.
Hi Dr. Parker, just a quick update. We had been giving my son 3mgs of intuniv in the morning along with 30mg of Vyvanese. He also got 1mg of Risperal at night. His teachers were complaining about him being lethargic all the time and not being able to focus. His doctor reduced his Vyvanese to 20mg,and his risperdal to .5mg. We started giving him the intuniv at night along with the reduced dose of risperdal and the vyvanes in the morning. The result has been great. He is not lethargic anymore and his tutor said yesterday was the best she has ever seen him focus. Thanks for your help. Ricky.
Ricky,
Super! Can’t go ‘by the book’ with every situation, glad your guy is coming around!
cp
Dr. Parker,
My 15 year old son (130lbs) started Intuniv two days ago on a 2 mg starting dose. I noticed you recommend 1 mg with titration of 1 mg each week until the target dose is reached. Since he’s already started on the 2 mg would it be best to leave the dose as is or go to 1 mg and then titrate to 2 mg next week? I’m also wondering if we can administer this med in the evening as it would generally fit our schedule better espeically on the weekends when my son enjoys sleeping in late.
Thank you for your blog!
Susan,
No absolute need to go back at this moment – but since he has been with it only 2 days, it would be quite reasonable to go back to the sample pack and start as recommended. The reason: slow starts bring fewer Adverse Events, pure and simple. Now you may, as some likely will, get away with pushing the dose, but why bother? Every mistake I have made in my life with meds has been made in the context of trying too hard, too much enthusiasm, the zeal to heal.
I don’t consider ‘no effect’ a mistake, but, rather, in the case of Intuniv, a proper expectation at the outset – as all the researchers with whom I have spoken, every paper I have reviewed, says go low and slow on this one. Most do best with a two to three week titration strategy as you accurately outlined.
Be well,
cp
Jennifer,
Sorry to get back so late – just had to post the Christmas story, and can tell you his situation is more complicated than a single fix with which ADHD med. Yes, trying another med like Intuniv might help, but I would encourage you to go much deeper with a more complete food sensitivity review – Celiac is often associated with other sensitivities, but more than that he may be malnourished and needs to be measured precisely for which downstream effect is troubling him. The anxiety side effect is but one part of what sounds from this distant outpost like a significant metabolic problem yet unresolved.
cp
Hi
I have a 19 yr old son , he’s still in the finding the right medication period . Doctors don’t want to put him on a stimulant because of his age and possible addiction. He has tried Strattera , that didn’t seem to work well , he seemed to be moody.
We are trying Intuniv tomorrow , at first because of his age I wasn’t sure , age says from 6 to 17 , but I am trusting the doctors , are there any studys of younge adults who have taken it , I know its new .
I am also going to start a protein shake of 8oz of coffee and 20g of protein powder with it , so hopefully it will work.
Rose-
You are on the right path. Intuniv is clearly indicated with folks who have some measure of medical concern about abuse… it just isn’t abusable period. An indication not mentioned in this post are those in recovery from substance abuse, e.g. medical professionals in programs who suffer with ADHD and are standing before licensing boards.
As you point out adults don’t have a specifically approved indication through the FDA, but the safety with children does encourage an Intuniv intervention if any abuse concern does exist. Older adults on antihypertensive meds, with blood pressure problems or any specific cardiac conditions need a medical review – in spite of the fact that in the ‘flexible-dose’ titration study [customized for the person based upon symptom resolution, rather than the 2 ‘forced-dose’ titration studies] the hypotensive side effect was nearly the level of placebo.
On the other hand, it is my frequent concern that too few docs understand the diminished abuse potential of Vyvanse, documented throughout CorePsych Blog and elsewhere. Yes, Vyvanse is an amphetamine, but is the only full on stimulant with peer reviewed studies in the package insert regarding diminished abuse potential.
Stay with the protein, well done, and very likely you will have a positive outcome. It’s never to late to treat ADHD.
cp
Hi, you mentioned that Intuniv can be used with Vyvanse and I was wondering if you could elaborate a bit on that. My son (8-years) has been taking Vyvanse since May and is currently on 50 mg. It is actually working amazingly well for him for his focus and attention. He is doing great in school – his report card was fantastic an his teacher (as well as others at school) have told he that he has done a 180-degree turnaround from last year. However, he never wants to eat and has gone from the 100th percentile to 50th percentile in weight in 6 months. And, we still struggle greatly with the oppositional and defiant traits. He had a follow-up today with his Pediatrician and we decided to try Intuniv to see if we’ll get a better outcome regarding appetite and the ODD symtoms. We’re using Intuniv instead of Vyvanse and I was wondering in what situations you would want to use both….?? Thanks.
Tracey,
Your guy would certainly be a candidate for the mix of the two based upon your info here with the defiance and oppositional traits.
The only concerns would be:
1. Is the current dose of Vyvanse given after a protein breakfast?
2. If it is, is the dose too high? [may need to go down to 40mg?]
3. Encouragement to do that breakfast would be primary here, as the wt loss over time could be problematic.
Mixing is not problematic, I will have a specific reference up soon for studies on that subject. Reports from the front and experience in my office indicate that the same slow titration would be indicated as is described on this post.
Hope this helps,
cp
Dr. Parker,
Thank you so much for this post. I’ve already read through it a few times and learned a lot from following the links. I listened to all of the cinch recordings as well. Here is what caught my eye:
You wrote, “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 is 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.”
As I told you in another post, my son DID have neurotransmitter testing, and he was low on seratonin but had elevated levels of glutamate. How does Intuniv modify/facilitate glutamate transmission in an individual who has elevated glutamate levels? I’m concerned because you had mentioned someone in your practice that did not do well with Intuniv because of a nuerotransmitter issue. My son will be on Intuniv (2mg now) 3 weeks tomorrow. We are still having emotional outbursts and anger issues. Although we did have friends over for dinner last night and they actually commented on how calm our son was.
Just a side note. Our Doc suggested that we give him the Intuniv at night due to the sleepiness issue…I noticed you talk about giving it in the AM.
I’d really appreciate your thoughts! Thank you so much for all the information you provide!
Denise
Denise,
Glutamate findings here are only one child with a deep n of 1! Jury is still out here with that situation, it just makes common sense, but much of what we see, as you know from the testing, is not directly related to only one neurotransmitter. Conservative guy that I am I just raised the flag to see how that glutamate information flies with others.
I would love to see his neurotransmitter testing, and compare it with my guy out here. I had to stop the Intuniv [only one I had to stop] just because he became so agitated – and he is better with inhibitory neurotransmitters, probably EndoTrex, an L-Theanine product with affinity for glutamate receptors and produces alpha waves in stressed brains.
Intuitively your doc may be right on the PM dosage, makes common sense, time will tell, just watch for that top of the window.
cp
Dr. Parker
Thank you for your reply! I did raise the question because I saw your response to Anji on a different post re: high glutamate levels. I would be more than happy to fax his neurotransmitter report to you, I do believe it’s the same lab that you use. The report is about a year old I would guess. We started with the naturopath shortly after that and he was working, through various supplements, to bring things back into balance. We have since stopped the supps..but would be interesting to get a current NT test and see if anything has changed. I was thinking about adding a salmon based fish oil in. We’ve just started with this current Doc. I would love to combine the Intuniv with a neurotransmitter supp. When we were with a bio-med Doc, she had him on a supp called Neuro-T, based on the NT test results. I will have to explore this further with my Doc. I have found that Bio-med Docs don”t generally prescribe meds, and Psychiatrists will prescribe meds only…I’d love to find a Doc who does both. Not sure if this is the norm but has been my experience so far 🙂 Oh, I’m not sure what a “deep n of 1 is.
Thank you Dr.Parker,
Denise
Denise,
We use NeuroScience, but it doesn’t matter. Do send the findings along and look forward to further discussions. One small glitch – my right hand person, Caitlin is out for this week, so exactly how and when we discuss is open. I will send you a note off line.
Deep n of 1 is a self sarcastic remark regarding the paucity of numbers. Pharma likes to do larger n numbers [number of people in the study to form a conclusion] to significantly improve the ‘effect size.’ An n of one is not a study, and could simply be a fluke. It’s a shallow conclusion, reported as an informal case study with not enough parallel evidence to form a conclusion even on that one.
cp
My son is Aspergers and tourettes with ADHD and anxiety. Stimulants do not work for him. We were on tenex and then switched to intuniv. He also takes Risperdal and Prozac. The issue is the Intuniv at 3 mg is not enough to control his impule and attention. However 4 mg makes him fall asleep at school everyday after a month. He takes 4 mg of Risperdal (1.5 mg x2 at 8Am,4PM and 1 mg at 8PM) He takes 10 mg prozac at 8AM, and was taking 3 mg intuniv at 8AM and 1 mg tenex at 4PM. The psychiatrist switched him to 4 mg intuniv when he was having alot of inappropriate behaviors. How should I give the 4 mg Intuniv? 8AM, 4PM, or 8PM? Can I divide the Intuniv? 2 mg in the AM and 2 mg in the PM? Or could I give 3 mg in the AM and 1 mg in the PM? What do you suggest? He is very sensitive to meds. The Risperdal is helping his rage and opposition, the prozac his perceverating and anxiety, the intuniv his ADHD and tics. I have researched this and there is little info out there on the best way to give intuniv. The psychiatrist says to play with it but it is expensive and he gets very sleepy on it and I really don’t like the feeling of playing with dangerous meds. Thak you!