ADD/ADHD Treatments: Tips for Vyvanse

Tips for Vyvanse a new, third generation stimulant:

You already know our regular CorePsych theme with ADD/ADHD and emerging brain science: the more we know the more we can have a positive impact. Not knowing can bring years of frustration, missed opportunity and unfulfilled dreams.                              

-And you know that ADD is one of the most misunderstood clinical conditions, as many in this world consider it a belief system not a proven medical condition.

As you also know from these pages, I advocate for what works, what works best, and what works with the fewest problems for patients and families. Vyvanse, in the short time on the market has set some very impressive records.

From a launch date July 1, 2007, here in the States, I have written about 100 new scripts for Vyvanse treating ADD, and the results have proven quite remarkable. Simply put: almost 0 complaints to the reps, and coming back to my office after the first visit. Unusual launch. -But a few slight problems can occur - thus this post.

These easy tips will help you understand how it works here so that you can communicate easily with your medical people. [Full disclosure: I do speak for Shire, the company that makes Vyvanse, and have for years made a considerable effort to teach medical colleagues around the country how to use stimulant meds more effectively. I have presented for Adderall since its launch, Adderall XR, Focalin XR, and Daytrana as well as Vyvanse.]

Tips and Treatment Notes for Vyvanse:

1. It is a prodrug with a slow and forgiving delivery process: No heavy AM hit, no big drop in the PM
   
2. Both studies and clinical experience show that it is more efficacious [post hoc review] than Adderall XR, and Adderall previously held highest efficacy ratings on comparison studies.
   
3. The prodrug delivery system provides a longer duration of effectiveness, with no need for a PM "kicker" dose to complete homework or home chores.
4. Methamphetamine addicts don't like it: as measured, get this, on a "likability scale." Because it is a prodrug you can't snort, chew, or inject it with any buzz success [peak Cmax about 4 hrs post ingestion]. In research they injected Vyvance into a meth addicts arm: their conclusion: this is not "likable" - no fun, no buzz. This is an excellent outcome, not previously reported with any stimulant, and in the package insert. It may be abusable, but it will be nearly impossible.
   
5. Always start at the lower dose: 30mg which roughly equals Adderall XR 10mg. They may be on higher doses, even 40 mg of the Adderall XR, but always go low and slow. It's more efficacious, and if you start at 50mg which roughly equals 20mg Adderall XR, it can give them an unpleasant feeling. Been there. Go slowly.
   
6. If the duration is out at ~ 2PM the dose is one click too low. Move up to the next dose.
   
7. With a medication sensitive child/adult you may want to divide the dose in 1/2 to get started: Take the capsule, pour contents into 2 oz of water in mixing cup, drink 1 oz each of the first 2 - 4 days to start slowly. I have two children perfectly dosed with only 1/2 capsule/AM in this manner.
8. All psych meds are better tolerated and more effective with a protein breakfast,- please review my breakfast posts linked here.
9. Always remember the ADD 3R's, discussed in my first post, in reference to medical treatment for ADD: Right Diagnosis, Right Medication/Intervention, Right Dosage.

Please send along any comments: this is an opportunity to work closely together and let people know how this medication can be used most effectively. -Look forward to our discussions.

Comments

[Dr Charles Parker]

DeAnna -
Remember to separate cognitive reactions from emotional reactions whilst adjusting meds. Yes, they may overlap a bit, but there are several priority possibilities with these
reported problems:

1. Most likely: Vyvanse dose is too high: see the titration strategy and the blog post on the therapeutic window.

2. Aggravation of comorbid depression: This seems likely given the affective character of his reported presentation - see what your doc thinks. But remember, too much Vyvanse can cause mood dysregulation with depression.

3. The dose is too low: I doubt this. Doses are not adjusted by "is 70 too high?" but rather by very specific parameters for each medication. See the post on the therapeutic window linked in other comments below.

4.Specific questions to report to your doc: How long is the DOE for the current Vyvanse? Does he show other indications that it is too much - such as appetite decrease, sleeplessness, anger outbursts, etc?

You are on the right track, I doubt that it is the wrong drug, but rather the correct drug, not sufficiently adjusted.

In closing remember this important fact:

-Brain injury folks with CA or radiation are more sensitive and more reactive to any psych meds.

Hope this helps.
cp

[DeAnna]

Your website and comments continue to be of help. I wrote in previously concerning my eight year old son who is a former cancer patient who received brain radiation. This year, during a time of remission, we began noticing some significant ADD symptoms. Whether new or as a result of radiation, we'll never know. What we do know is that Vyvanse has proven immediately effective. We began taking Vyvanse in January and have dose adjusted once since then (from 30 to 50). Our concern now is that we are beginning to see a downward trend within the last four weeks (about eight weeks since adjusting to 50). His teacher emailed with concerns that reflect what we are seeing at home: increased irritability, mood swings, inability to concentrate, off focus demeanor, off task behavior.... He is MUCH better than when he began Vyvanse (his first ADD medication) in January 08. We think he might need another dose adjustment but we also have been concerned about comorbid depression. How can we really tell if the Vyvanse just needs another click (is 70 too high?) OR if these symptoms are simply depression? Help!?!

[Dr Charles Parker]

Barbara,
Yes, with neurofeedback we have colleagues who see that maintenance "doses" of once/week-once/mo can be helpful with significant mood disorders.

Growth can always provide reason to go up.

Mixing with Daytrana should be done with care... mixing only MPH with MPH, no AMP products, as MPH blocks the metabolism of those running thru 2D6, including Strattera.

Other suggestions come to mind more functionally based: how are is Omega 3 Fatty acids, how is he nutritionally, do you follow a gluten free diet etc, etc. Many more interesting variables to consider.

cp

[Barbara]

9yo son w/Aspergers and extreme ADHD/ADD has fast metabolism and Focalin XR, Concerta, etc etc only last 4 hours, started Daytrana 6/07 and eliminated many problems, lasting all the way to bedtime--great! Huge improvements in everything, no rebound, etc. At the same time we initiated biofeedback (kind of complicates things, doesn't it) and completed 60 sessions in Jan 08. In the last 6 weeeks, we have started seeing the meltdowns and oppositional behavior of old days with rebound and multiple dosing throughout the day. Does Daytrana "wear out"? Are the biofeedback results losing their effectiveness in his daily life now that they have ended? We are adding doses of stimulants on top of a 30mg patch to heo help him until we figure out a better strategy. Help!

[Sarah]

You are very generous with your time; I certainly appreciate your help! I completely understand that you cannot make any real recommendations, as you have not met my son, nor examined him. Mostly, I was wondering if the meds that did and didn't work with him showed any sort of a pattern to you. FYI, he does take Tenex, and has for years. He currently takes 1.5 mg twice daily. Back when he was on stims and getting tics, the Tenex did not eliminate them. My younger son, fwiw, has Tourette's, and has had issues with OCD (handwashing) in the past. His symptoms are not troubling enough to warrant medication at this time. Since my elder, ADHD, son's tics completely went away after going off stims, I have always assumed his tics were med related. There is no other family history of tic disorders.

[Dr Charles Parker]

Sarah,
Hard to take a definitive position with many variables, a few observations and no examination. These comments therefore should not be considered as treatment recommendations.

He does apparently have an acceptable response to AMP meaning he does not appear to have a genetic 2D6 problem - no remarkable agitation on low dose AMPs - "adderall worked."

In our offices we address tics in several ways:
1. we review carefully any metabolic issues with a comprehensive metabolic panel and any other specific testing that appears necessary, see #3

http://www.corepsychblog.com/2006/12/connecting_with.html

2. we have seen significant improvement with neurofeedback with tics even whilst the patient is on medication for the ADD.
3. we treat the tics separately with, e.g. Tenex,
4. we do all of the above

Then there is the issue of comorbid depression, seen in the aggravation of moods with stimulant meds: Depression often does require specific treatment, is easily accomplished while watching for drug interactions.

Your report of exaggeration in moods with Adderall very frequently would respond to an antidepressant such as Effexor XR. Adderall does often aggravate comorbid depression - they can go from Clint Eastwood depression to really affectively unhappy. See:

http://www.corepsychblog.com/2007/04/overlooked_tips.html

Vyvanse, in my experience, is clearly less likely to aggravate comorbid depression, and you may find that you only need that one med. We don't know the reason, but this consistent response is verified by a number of conversations with many colleagues.

On the other hand, if a significant comorbid depression is present, augmentation with a good antidepressant, not Prozac or Paxil [both significant inhibitors of 2D6], will be helpful.

All of this, of course, to be reviewed by your doc there, as these guidelines don't work for everyone, and are directed to general issues you have raised.
cp

[Dr Charles Parker]

Shannon,
One other point since you are expressing a concern, and yours is the only snorting/getting high report I have heard about... in the studies the pK levels, the blood levels measured with the methamphetamine addicts that were tested to review the "likability" of Vyvanse, peaked out several hours after ingestion - the actual blood levels don't show a sufficient hit to catch a buzz.

What the person may be experiencing is "effect" - quite in keeping with our office experience that patients feel a positive effect about 1/2 hr after taking it - without a buzz feeling.

Look forward to hearing from "Anonymous"
cp

[Sarah]

I guess I wonder: do you see any indications of which types of meds might be best, given our history? Wellbutrin and Straterra (both used at least 2 months) resulted in minimal benefits to focus (compared to ritalin or adderal), and definite negative mood issues. Of the stimulants he took before developing tics, Adderal worked best on focus, but was very negative for his mood. Ritalin/metadate cd seemed the best of the remaining alternatives, causing no mood problems, and improving concentration fairly well. After several years, though, we stopped stims, due to tics (which went away completely after the stimulants were out of his system.)We did try focalin in small doses, hoping its "cleaner" profile would be better, but no. We are hoping that Vyvance, which I understand is similar to adderal will not cause his tics to resume and will not cause the mood problems we saw with adderal. I am an optimist!

[Dr. Charles Parker]

Sarah,
Yes, for years the literature suggested the use of TCAs as a primary treatment for ADD, and even now some studies use TCAs as comparators. No disrespect to anyone on this, but the tide has significantly changed regarding TCAs for reasons of safety, efficacy, and the marked improvement of the stimulant med delivery systems.

Naturally some outliers may respond well to TCAs just as a minimal group respond well to Strattera. But if the choice was between a TCA and Strattera, I would definitely go for the Strattera for some of the reasons you mentioned in your most recent comment. Some appear to respond well/better to Norepinephrine reuptake [vs Dopamine reuptake] inhibitors... and the jury appears out at this moment as to: why?
cp

[Dr. Charles Parker]

Shannon-
Your report does sound interesting to me - and I have been watching to see if any of this abuse material began to surface. I would love to do some investigative journalism on this report, and would welcome an anonymous call to my office,- will call back on my nickel if that person would be willing to talk to me about it. Please do ask the user to call my office with the name Anonymous for a more in depth phone review. Office number over at Contact JR under the picture.

Thanks for the input will be watching.
cp

[Shannon]

All of you that are saying it can't be snorted are falling for something you should have done more research on. They're trying to sell it to the parents because they've all clearly discovered that the ADD meds they're giving their kids are the same thing as coke. Take it from me, I work in a restaraunt-you can most certainly snort Vyvance and get high. If you don't believe me..if you think their advertising is true...crack one open and try it for yourself. What do you have to lose if they're right?

[Sarah]

Thank you so much. It is encouraging to hear that the mood issues seem less pervasive with Vyvance. We have known all along that the TCAs are a very imperfect solution, but tics made the stims unsuitable for our son (and he tried all, including focalin, that were available four years ago), so we had to look elsewhere. We have him on a low dose of desipramine, per Dr. Hallowell's interesting article titled Pharmacotherapy for ADHD in Adults, by Jonathan Ratey, Edward Hallowell, and Catherine Leveroni, in which they say, "... Research and clinical experience have shown that the antidepressants Norpramin (desipramine) and Tofranil (imipranine) effectively increase attentiveness and reduce distractibility in children and adults. Tricyclic antidepressants exert their effect by acting upon norepinephrine and dopamine, the two major neurotransmitters in the attention system. They block the re-uptake of norepinephrine and dopamine into the presynaptic neuron and indirectly modify the rate of release, thus increase the activity of these two chemicals in the brain (McCracken, 1991).

In our clinical experience, 40% or more of ADHD adults respond to between 5 mg/day and 40 mg/day of Norpramin. This dose range is considerably lower than that reported in current research reports (Biederman et al, 1985; Biederman, 1988). We see the return to the use of low doses as a significant contribution to the practice of pharmacotherapy for ADHD because we have found the most dramatic responses at low dose levels. Furthermore, most of our patients report that the positive effect experienced at a very low dose range is often lost as the dose is increased. In the mid 1960's, Rapoport reported that the majority of children with "behavior problems" he studied showed marked improvement on 10 mg/day of Tofranil; in fact, a number responded most dramatically to 5 mg/day, and were maintained at that dose without a waning of response (Rapoport, 1965)...."

However, we are planning to try Vyvance soon, once his desipramine dose is lowered to a better level (we think we may have increased it too much.) We do work with a wonderful neurologist, who has helped us since 1999. He is open to new treatments, and multiple meds, when necessary. I very much appreciate your interest, and your willingness to share your knowledge.

[Dr Charles Parker]

Sarah-
While TCA's are within the standard of care, I do not recommend them to anyone for ADD, as they simply don't do the job.

Sounds like your son very well may have a comorbid depression with his ADD, therefore the TCA will look a bit more helpful.

See this lengthy remark about your question here:

http://www.corepsychblog.com/2006/12/kids_and_antide.html

Without seeing him, just from the information here: Vyvanse consistently proves less troubling from a mood dysregulation perspective. But if Vyvanse does bring moodiness, the simple and best solution is a small dose of clean-on-CYP450/2D6 antidepressant such as Effexor XR, tho off label in children, and subject of course to your doc's approval .

Do not use Prozac or Paxil with Vyvanse for the reasons outlined in the above link. Interaction problems occur down the line with these meds, are predictable, and avoidable.

Hope this helps,
cp

[Sarah]

I'm wondering: my now 13 year old son tried Adderal years ago, and the attention benefits were huge, but it made him terribly moody , weepy, and irritable. After years on various stims, tics became a problem, and he has been on TCAs combined with guanfacine for the past three years. TCAs have been good for the behavioral aspects of ADHD, but have not helped adequately with the cognitive issues. Focus and motivation are very poor. I wonder of Vyvance is likely to cause the same mood problems as Adderal? FWIW, he also had mood issues with Straterra and Wellbutrin, which were not as effective on cognitive issues as ritalin/adderal. I very much appreciate any insight you might have. Thank you.

[Dr Charles Parker]

Leigh,
Not commonly appreciated: MPH products like Focalin block 2D6, and I strongly recommend against using drugs that clearly interact - as Vyvanse is an AMP that runs thru the 2D6 pipeline [Google 2D6 on this blog and you will see much about this issue].

Likely the dose is not correct if it isn't working in the AM - at the correct dose it works in .5 hr... and again we aren't looking for "feeling," but for cognitive change.

Look at the DOE as outlined here and titrate carefully with your doc, then if you absolutely have to mix, stay with an AMP product, one that doesn't block that AMP metabolic pathway.

Interesting question- and a reference on this point is in Cozza and Armstrong at CorePsych Books: Drug Interactions in Clinical Practice.

Thanks,
cp

[Dr Charles Parker]

Jason,
First a simple point: You can't get it right with whatever was in the hookah on board - highly unlikely the fall was due to Vyvanse alone, highly likely secondary to meds + hookah, or hookah alone.

If you are in the US you are most often talking *weed/marijuana* with "hookah" use, - and weed, as other addictive substances, should be avoided if you want the true fix.

Often unappreciated is the fact that weed may appear at first to temporarily help with ADD, but is not indicated:
1. It's against the law,
2. It has a very short half life,
3. The incidence of cancer in many reports is 5X CA in the general population,
4. It has not been studied for the ADD application but anecdotally we often note memory diminishes and dementia-like symptoms are increased... so if you want to do well, forget it.
5. And one final emphatic point: Weed makes you *more ADD.* SPECT scans show clear PFC deterioration with weed use. Stimulants are working to correct, weed is working to deteriorate.

Scrap that drug as a treatment plan.

The Adderall dose likely did not reflect the correct titration in the first place because of the "hookah," as titration accuracy is difficult to predict categorically [without that variable], -so will pass on that one.

Tics and such are downstream problems of all stim meds, especially stim meds with comorbid challenges such as one finds when one regularly smokes or uses weed. We always look for a variety of other contributory metabolic issues if tics persist.

Several comorbid issues are present here, and more should be investigated.

Hope this helps,
cp

[Leigh]

Since Vyvanse does not address early am/schoolday ADHD symptomes, would it be safe to add 5 mg Focalin to help?

[Jason]

Hello,

I have a friend who is 27 yrs old and has just been put on Vyvanase after taking 80mg of Adderall for 6 years. The Adderall was effective and she liekd it but it caused intense fidgeting and her family thinks it was affecting her personality (argumentative, insecure, agitated).

I'm not sure the dose of Vyvanase she is taking but I know that she is now taking it twice a day b/c it was wearing off -- is this ok or should the mornign dose just be higher?

Also, she is still fidgeting a lot (although less than the adderall) and has developed a recurring tic with the side of her mouth (new with vyvanase). Is this a normal and acceptable side-effect? I can't find anyone posting about it.

Lastly, the other day she got up from sitting and smoking hookah (same position for awhile) and fainted and had a small seizure. Thought it was just from standing up too fast after smoking hookah but could it be related to the vyvanase?

She is also taking effexor daily.

Thanks for your info.

[Dr Charles Parker]

DrMomKat-
Your main issue seems to be with the loss of appetite, and yes, that can be a problem. I have covered that point quite frequently on other posts including the breakfast post on the front page under the Toolkit and Protein Breakfast.

Bottom line: breakfast of protein first, then any psych med after.

Second point: dosage may change that reaction and the post on water titration may help.

Third point: Some people cannot take AMP meds.

Fourth general observation: Haven't read the post at CyberPsych, but they clearly do know what these meds do, in fact have the specific receptors broken down in some detail, and tag Dopamine receptors and watch them on functional imaging.

On your side of the point: and, yes, we do not yet know *everything.*

So somewhere along that path is the debate, just what is the diagnosis? Neuropsych testing and SPECT tells us much.

What is the dosage? Watch for the therapeutic window at this post [http://www.corepsychblog.com/2008/01/tips-on-medicat.html]
and use, as you say, much caution with any change or increase.

I do completely agree: with significant side effects that may not be the correct med. Side effects usually diminish by 2-3 weeks, and if not, it's gone.

Thanks-
cp

[DrMomKat]

I've noticed a decrease in appatite since starting Vyvanse (prev on Focaline XR). It also makes me nauseated when I do try to eat sometimes. Not so much a prob for me since I'm in my late 20's ( and could always stand to loose 5-10 pounds) but I could see how this would pose a problem for children. Since this is a medication for children wouldn't malnutrition be of concern for most parents (among other things)? I myself would never give a stimulant to a child but then my kids and I aren't hyper-active or out of control either.

It seems to me that if a child develops an uncommom reaction to meds, such as the one noted prev, I would assume she was misdiagnosed and would take her for a second opinion to a neurologist. I think all natural methods of controlling ADD in children should be exhausted before being put on any kind of unnatural medication- especially a stimulant. In a lot of cases, it's the parent's frustration with trying to deal that's causing most of the problems. :) Patiance isn't something we're born with!

My therapist also says a lot of times Bi-Polar Disorder is misdiagnosed for ADD ... it can even be a combonation of both. Besides .. I just read an article on CyberPsych that scientists aren't even sure what these drugs they are prescribing for ADD do or how they work. What gives?

[Dr Charles Parker]

Deborah- from Jan 24,
Thanks for keeping us posted on these kinds of issues. My own policy is too look for weight loss as part of my adjustment parameters in finding the therapeutic window. Without an evaluation, just offering some feedback without suggesting any specific plan... sounds like what we see in my office as too much Vyvanse.

Please take a look at this recent post which doesn't hit your question directly but addresses the dosing/titration issue in context.

http://www.corepsychblog.com/2008/01/tips-on-medicat.html

Thanks-
Chuck

[Deborah]

I can say that i am a 42 year old woman and i was put on Vyvanse 30mg at first and then bumped up to 50mg then 70mg. I started getting a severe backache and noticed it was only when i took the Vyvanse. I also lost 45 pounds while taking this medicene over a period of 6 months. Needless to say it was somehow and my doctor still does not understand it caused my Potassium to become extremly low and I had to be put on Potassium pills. My Thyroid is also not boderline overactive. I am not on it anymore and am trying something that is stimulant free. But for those that may be new to trying this medicene i would like to make sure that people are educated to what happened to myself.

Thank you.

[Dr Charles Parker]

Terry,
Never concern yourself with an "old thread" with me... if what you are doing isn't working, it's new thread everyday!

Having met Joe Biederman on several occasions and reported once here about a year ago:

http://www.corepsychblog.com/2007/01/add_update_from.html

I can tell you he is just great clinically and will likely shed some new light on her difficult presentation.

I strongly recommend John Ratey's book: User's Guide to the Brain

http://astore.amazon.com/cpbks-20/detail/0375701079/103-7756357-1889446

- his work is cutting edge and he also would be a great resource for your further investigations.

Most striking for me in your brief remarks here is the consistent series of remarks that sound toxic or metabolic. -Just back from a meeting with Dr Vojdani in CA, and will be posting about the many interesting immune dysfunction resources - specific laboratory tests - available for individuals like your daughter. See my most recent post on Dr V who is moving offices to work with NeuroScience Labs.

Basic rule, and comment on your post not clearly discussed in previous Vyvanse posts:

If the therapeutic window seems just too narrow and either up or down dosing is insufficient - you very likely have a metabolic problem, or simply the wrong medication for that symptom complex - from a defective 2D6 metabolic pathway [to be measured by genetic testing with either Genelex [used by the Mayo Clinic and available through our office] or Detoxigenomics [also available with our office from Genova] ...or other metabolic testing indicated by our questionnaires and a personal interview.

The encouraging news: it is highly likely that she has something measurable wrong that does need attention that can improve her situation.

In your daughter's difficult presentation Vyvanse may be the canary in the coal mine because the therapeutic window is too small, she isn't getting better with what appears to be good adjustments by your doc, and she has multiple apparent "neurotoxic" symptoms.

-Difficult presentation, hope this helps a bit.

Chuck

[Terry Matlen, ACSW]

Dr. P,

I know this is an old thread but am hoping you still monitor responses here. An update on my "Vyvanse" kid:

We titrated up to 80mg (saw no change from 70-80) and the pDoc is unwilling to go up any further. Though I did see a longer coverage of symptom control, I don't think it was as effective as the Adderall XR-40mg.

So we're back to that.

Another question-
She must be medicated in order to fall asleep, yet though everything we try sedates her, her body/mind fights it and she ends up staying up way too late. She walks around with eyes half shut and looks intoxicated, yet she can't stop her body from moving. That means repeated runs (she does not walk and she's 19 yo) up and down the stairs, grabbing food, items, cat, etc.

I've just consulted with a neuropsychiatrist here at Wayne State U and his thought is to try and get a consult with Dr. Joe Biederman. Her picture is so unique and reactions to meds unusual.
I know John Ratey, who suggested intense exercise, but she is unable to follow formal routine exercise. I do have her skating and bowling once a week via special ed groups but know that's not enough. This is a young lady who can't read her body; who never tires; can't tell hunger from full, etc. Extrememly hyper/impulsive due to her brain injury as a tot.

The only time she is able to sit is when she perseverates on the computer.

Any tips?

Thanks,
Terry Matlen, ACSW

www.addconsults.com

[Dr Charles Parker::CorePsych]

DeAnna,
Thanks for your question about your son with ADD following CA treatment. We frequently do see *ADD symptoms* following medical procedures, from bypass to chemotherapy to treatment for asthma.

Since I have not seen your son, I would, of course encourage follow up on any comments here with definitive work with your treating physician. Having said that, your son presents a finding typical of medical or injury induced ADD symptoms: More sensitivity to stimulant medications than others.

The decision is with you and your doc, but I always shoot for no side effects, and if your son persists with this hyper-talk for more than a couple of days, I would suggest dropping the dose.

You have plenty of time to increase later. If your doc is OK with the decrease plan consider the half dose in this water titration strategy post:

http://www.corepsychblog.com/2007/11/vyvanse-for-add.html

or here at:

http://www.squidoo.com/vyvanse

Low and slow will often make the day better, and if he needs more you and your medical team could consider increasing later.

Best wishes with your guy-
Chuck