ADD/ADHD Treatments: Tips for Vyvanse

by Dr Charles Parker on August 29, 2007 · 177 comments

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:
It is a prodrug with a slow and forgiving delivery process: No heavy AM hit, no big drop in the PM

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.
The prodrug delivery system provides a longer duration of effectiveness, with no need for a PM “kicker” dose to complete homework or home chores.
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.
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.
If the duration [DOE] is out at ~ 2PM the dose is one click too low. Move up to the next dose.
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.
All psych meds are better tolerated and more effective with a protein breakfast,- please review my breakfast posts linked here.
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.

Shire beats forecasts as new drugs plug gap left by generic competition (telegraph.co.uk)
VYVANSE – new ADHD treatment option – now available in Canada (worldpharmanews.com)
Holistic Reviews At CorePsych (corepsychblog.com)

Digitally available now at Nook, Kindle, Barnes and Noble.
ADHD Medication Rules – PDF For Your Desktop
ADHD Medication Rules | Paying Attention To The Meds For Paying Attention – Kindle Version

Tagged as: ADD, ADD and ADHD, Adderall, Adderall XR, ADHD, amphetamines, Attention-deficit hyperactivity disorder, Daytrana, dextroamphetamine, Diagnosis, duration of effectiveness, Lisdexamfetamine, Medication, metabolic challenges with ADD, methylphenidate, prodrug, Vyvanse

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Fightlikeagirl2011

Hi Dr. Parker,

Wow, you are brilliant. Wish there were more out there like you. I recently started Vyvanse 40mg and have taken Effexor XR 150mg for close to ten years. So far so good! My question is:

My doc’s only concern is that combining Effexor and Vyvanse has caused alarming weight loss in SOME patients. Is this likely as I am a recent chemo recipient and their concern is secondary anorexia? Of course, I could afford to lose about 100 lbs., but don’t want it done due to meds.

God Bless!
Bethany

http://www.corepsychblog.com drcharlesparker

Fighter,
Thanks for your kind remarks! – Not a problem with the two, strictly anecdotal on his part. I have used that combo as my primary combo for many years, probably around 15 years, and don’t find wt loss an issue.

If wt loss occurs then I use it as a side-effect marker for either dosage adjustments or an indicator for metabolic challenges that need attention. Those metabolic challenges can occur over time with a shifting/roving therapeutic window based on other comorbid issues.
cp

http://www.corepsychblog.com drcharlesparker

Deb,
Highly likely best bet would be to redo Vyvanse, dial it in more effectively and consider comorbid depression with a depressive/anxiety subset that will likely respond to antidepressant meds.

If that proves counterproductive she very likely had a metabolically stimulated “roving therapeutic window.” http://www.corepsychblog.com/2011/06/psych-meds-time-titration-tachyphylaxis/
cp
http://www.corepsychblog.com drcharlesparker

Hillsz,
Sometimes those symptoms dissipate, but often they don’t – see my video on Anxiety and ADHD on YouTube – at about 5 min there you can see some info on the seesaw with depression/anxiety and ADHD. Stimulants can and often do aggravate depressive symptoms that are often there before, but are aggravated by the AMP.

Bottom line: easy fix would be low dose antidepressant for a quick fix and measurement of neurotransmitter imbalances for the longer term fix data.
cp
Hillsz

My 7 year old daughter has been diagnosed with ADD/ADHD. Doctor has prescribed 20mg of Vyvanse. While drug is helping with school and focus issues, it seems to cause her to be overly emotionally sensitive and weepy. Is this a common side effect and will it dissipate after she has been on medication for a while?
http://www.corepsychblog.com drcharlesparker

Darrius,
Vyvanse dosage, as is all stimulant dosage, metabolism and genetics related, not based upon size, weight, sex or age, period. There are some studies that encourage a more weight related response with Intuniv [described in detail elsewhere on CorePsych Blog], but with the stimulants, not so.

Having said that, Vyvanse, when correctly adjusted, should work for ~ 12 hr in adults, sometime up to 14 hr without side effects, without coming out the top of the Therapeutic Window. Adjustments up or down from 40 mg, in attempt to find that Therapeutic Window, will move most often by 2hr/10mg – meaning 10 mg more = 2 hr longer duration of effectiveness DOE.
cp

Read more: http://www.corepsychblog.com/2011/05/adhd-medication-dosage/
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Darrius Jenkins

how long does vyvanse 40mg would last
http://pulse.yahoo.com/_SCZ32YFZN32OZJ3CVM7YVHV5DQ Amber

Dr. Parker, I have a common situation. I have no health insurance. I have been on vyvanse for 4 years. I have been diagnosed 2x for add/adhd. My situation is that even psychiatrist has problem with giving over 70mg. I am 31 years old. I have patient assisstance through shire to cover cost of vyvanse. Switching me to other meds is a concern due to cost. Even trials done on adults for vyvanse is a joke. They were given max dose of 70 mg. The child trials were given at 30, 50 and 70 mg and titrated by 20 mg until reaching assigned dose at four weeks. Help please.
Amberstarted at 30,50 s

http://www.corepsychblog.com drcharlesparker

Hey Amber,
Not much this single guy can do with all of that very challenging stuff. You are clearly correct, but so many are completely ruled by the research, frighted to work with the metabolic details. On the other hand I see folks downstream for very significant overdoses and absolutely no awareness of metabolic variables on that completely opposite end.

Sorry, not much I can do on that one, except report on the standard of care as witness from this office.
cp

Amy

Dr. Parker,

I ordered your book and I really love it. I have a couple questions about drug interactions. I have fibromyalgia along with cronic infections on top of the ADD and high anxiety. I got off of my Vyvanse for about 4 months when I was first diagnosed with the fibro. because I am on so many medications I was scared. Now, my concentration is so bad I started it again, but instead of the 20mg I was on before I started out with 5 and am working up that way. My question is they have me on strong pain medications Norco and Percocet (when the pain gets to bad) and Clonazapan for anxiety. I have also been on and off of Steroids, anti-biotics and hydroxyzine for all the Sinus Infections. My doctor says that these drugs do not interact, but after reading your book I am not so sure. Should I be concerned?

http://www.CorePsychBlog.com Dr Charles Parker

Amy -
The clinical fact that you have so many immune dysfunction situations going on in just this brief note encourages me to suggest that you might be best served by looking more deeply into the underlying cause of the anxiety and the refractory response to well adjusted, carefully adjusted meds – esp Vyvanse. All of that pain, all of the steroid and antibiotics… you just aren’t healing well, which means your body is fighting off so many intruders it can’t do the repair. Strongly suggest IgG testing even though they will tell you it’s pointless – and if you can’t find someone to do it there we can consult and send you a test kit long distance – easily.

Regarding the interactions: the pain meds are often 2D6 substrates, and if you are loaded with everything at once, could cause the Vyvanse to back up a bit thru competitive inhibition [they are both competing for the same exit] – you can imagine. And BTW, don’t settle for a useless macro quantitative assessment, you want total qualitative and then you want the measures on that specific food group in qualitative amounts.

Glad you liked Rules, – don’t know if you have seen this new video page that I did as an ADHD Med Tutorial
review. Remember this, you are very fixable, you just don’t feel that way. – And BTW 2: I will suggest the culprit is milk… see what the testing says.

One other point: you may be interested in this CinchCast audio on finding that PM drop on the Vyvanse.
cp

Matthew Picardo

Dr. Parker,
I am finding that Vyvanse has been much better than the other AMP meds I have tried in the past. It doesn’t exacerbate my impulsiveness or cause such emotional disconnectedness. My question is I still experience low frustration and impatience, along with anxiety. My wife and I just listened to your blog on drug interactions, particularly Prozac and Paxil. I would like to know if you find that the Effexor XR, Lexapro etc, can help with anxiety and low frustration? I want to be able to address these other issues and my psychiatrist doesn’t want to interrupt with my therapeautic window by increasing the Vyvanse as I am on 50mgs and she feels an increase would only lead to more problems, not solutions. I would greatly appreciate your thoughts.
Sincerely,
Matt Picardo

http://www.CorePsychBlog.com Dr Charles Parker

Matt,
This is a CinchCast spelling out the details with the different antidepressants – the ones you mention here are the best. Think DOE, read my Special Report on DOE and you will become more informed about the details so you can respond better to your doc.

And take a look at every one of these videos on this ADHD Med Tutorial page for easy details,

This will work!
cp

Adele

Happy First Official Day of Winter Dr. Parker,

Dr Parker,
Dec 11, 2010 was my first day on Vyvanase. I had taken too much that first day (10mg) You are probably right that I have a slow metabolism even though I thought I had a fast one since I walk and talk fast and can eat like a horse and remain fairly thin. I do have low blood pressure. Anyway, what I’ve been doing is I titrated one capsule of 20 mg in 8-9 oz of water – just a little over one cup. I take 3-4 Tablespoons in the morning, This equals about 1.5 to not quite 2 oz per day. I keep the medicine in a bottle in the refrigerator. I shake it up and pour 1 T. and then shake it again and pour another and so on because I notice that the medicine falls to the bottom of the water quickly. So far, I have no side effects other than increased irritability towards the end of 8 hours. The irritability seems to be declining. I’m going to stay on a low dose for a while until my body gets used to it. I feel a little more focused. In addition I think it’s important to note that I have been experiencing increased stress in my life and I believe this can affect medication. So, I”m going slow and paying attention to how I feel all day. I am saving up my pennies and nickels to purchase your Rules of Medication Book and to have a phone consultation with you. Of ALL the Doctors and literature I’ve experienced, You are the ONLY ONE right on target with my ADD life experience. I am telling everyone, including Doctors about you and your website. I really believe the time is now for a Campaign on educating the public and health care providers on ADD. Can we start by changing the Acronym? AAD is much more accurate – Attention Abundance Disorder. Thanks again Dr. Parker for all you do. Your website has helped me start life anew!

http://www.CorePsychBlog.com Dr Charles Parker

Adele,
You, my friend, are very close to the most precise titration strategy of anyone I know at this moment… but you clearly are “doing it correctly.” My speculative remark about your presentation is simple: you have a metabolic imbalance and it is corrupting your drug metabolic system with a relatively bulletproof liver. The 8 hr DOE does mean that you might go slowly up, but based upon your liver slowing you should move ever more carefully.

Love the AAD idea! More in keeping with the predominant presentation by far!

And thanks, you are very kind – I really appreciate your supportive remarks… and don’t forget that Complimentary White Paper at this CorePsych Blog Page it might help you with those 23 pages of additional info and links.
Best for the Holidays!
cp

Matthew Picardo

Dr. Parker,
I have been taking Vyvanse for rhe past two months and am happy to report that it is helping my ADHD w/o the horrific side effects that I experienced with Adderall and Ritalin. Issues of anxiety and low frustration continue to be problematic and my doctor has prescribed Buspar for the anxiety. My wife is still convinced that these issues are related to serotonin defeciences and has asked the doctor to look into an SSRI in combination with the Vyvanse. Though the doctor is open to this combination, she has stated that SSRI’s like Prozac can exacerbate symptoms. I would like to hear your experience in dealing with ADHD and issues surrounding the need for SSRI’s. Thanks again
Matt Picardo

http://www.CorePsychBlog.com Dr Charles Parker

Matt,
After more than 14 years of speaking and teaching about the interactions between Prozac, Paxil and Amphetamines I am very pleased to hear your doc is spot on! Your doc will likely appreciate the following links and combination suggestions:

Furthermore, I do agree with your wife that an SSRI might be helpful and often is with associated anxiety and depression… only need to watch the 2D6 pipeline and several antidepressants are completely clean in that regard – specifically Effexor, Pristiq, Lexapro, Celexa, Zoloft.
Be well!
cp

Adele

Dr Parker,
Thank you for this website. I just started on Vyvanse yesterday. I titrated 20 mg and drank only about 1/2. I was flying high all day. I noticed at the exact 8 hour mark the vice on/in my head, my rapid heartbeat and my sweating (I usually never sweat) ceased. I am very sensitive to medication. I was paying attention to how I was feeling all day. When the medication kicked in, I noticed I could focus, there was less resistance to stop and pick up something on the floor – I felt I could actually stop and organize without the usual fear and resistance. Because my job does not require a lot of organizing and focus I probably did not need to take medication at work yesterday. I did not like the rapid heartbeat and head vice feeling which lasted almost the entire 8 hours. It felt like I had overdosed. Intuitively, I feel I should try about 3 mg in the morning and maybe 3 in the afternoon, I will see how I feel. Maybe I only need the 3mg in the morning for the entire day. Any thoughts? Again, thank you for your weath of info. I look forward to reading all the great info on your website over the next few days. Happy Holidays. Blessings to you and your family. Adele

http://www.CorePsychBlog.com Dr Charles Parker

Adele,
Your metabolic rate is quite slow, could be genetically based [slow 2D6] or metabolically [slowed liver turnover for a variety of reasons]. Your conclusion is a good one, but to my mind premature. I would simply try a 1/4 dose [5mg] for the next 4 -6 days, go more slowly and then firm up on your DOE measurements. Often the first day goes out the top… the second and third days usually tell the tale on the acceptability of the dose.
cp