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.
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Grace-
Word finding problems can arise from several feeds, and can be associated with the meds.
1. The Vyvanse can be slightly too high in dosage, see this article for details on the Top of the Window:
http://ezinearticles.com/?ADD-ADHD-Treatment—7-Tips-on-Finding-the-Elusive-Top-of-the-Therapeutic-Window&id=1257427
2. Another frequent problem, without outright asking you about bowel function, is the increased sensitivity seen with increased ‘transit time’ = less than 1 BM/day. No, I won’t be asking you for feedback, but many don’t know about this connection. The ‘metabolic issue’ seems to be more a function of relative liver compromise than medication dosage per se, as once proper frequency is established, the Vyvanse works at the same dosage without side effect.
3. Stimulants in general can at times increase anxiety, and if the anxiety is secondary to a comorbid depression, and the antidepressant is not correctly adjusted, then anxiety will be increased.
4. Sleep is a big one. If you aren’t sleeping well you can feel quite demented, and word sorting can become more obvious.
5. If you are taking Prozac you must ask your doc to change that one out. Prozac and Vyvanse do not work together as noted here:
http://www.corepsychblog.com/2008/12/add-adhd-medications-amphetamines-2d6-drug-interaction-update.html
- and Prozac can cause an increase in frontal lobe, executive symptoms all by itself – with Vyvanse on top of it you might have trouble remembering your best friend’s name.
This are a few quick thots, more there if we have the opportunity to chase down the details.
Hope this helps!
cp
Can Vyvanse cause severe word-finding problems? This was not experienced before taking Vyvanse. Seems to happen more in stressful situations (presentations, conferences, etc.). Would combining with an anti-anxiety med help? This is a real dilemma for me … the need to be focused, alert, and articulate.
Dr. Parker,
I am currently taking Vyvanse with favorable results compared to Adderall. However, with both, I find the duration of effect to be quite less than the typical estimates. Long story short, I am also taking 75mg/day of Effexor XR, and I cannot find a conclusive answer to whether or not the Effexor could be affecting the stimulants. I would ask my doc, but I don’t see him for another month.
One more thing… Would switching from Effexor to Wellbutrin be a wise change in anti-d’s and possibly curb the issue with my ADD meds as well?
Thanks for the help.
Lisa,
No prob with throwing it away, no prob with using only a portion of the capsule… my main bias in the water titration strategy is simply penury – saving every last bit for the next dose-
Glad it’s working for you – and on fine tuning the dose don’t forget the *breakfast policy* mentioned elsewhere here – meds often will feel like too much without breakfast-
cp
Hi Dr.
Thank you for your response to my question about changing from Metadate CD to Vyvanse. You suggested that I could also mix the contents of the capsule with water and use a portion of the water mix. Could I, instead of mixing with water, open the capsule, dispose in the trash some of the contents, close the capsule and take the remaining contents? that is what I used to do with Metadate CD when originally the 30mg capsule was too high of a dosage, but the 20mg capsule was too low of a dosage. Please advise if opening and closing the Vyvanse capsule impacts its ability to be correctly processed by the human body. Thank you.
Lisa,
I did the math for someone on another of these comments and can’t immediately find it – bottom line: it does not work mg/mg – Vyvanse has a completely different mg dosage pattern that MPH products.
20mg is a good place to start, and for me I am even more careful depending on a variety of variables – and will use 1/2 of the 20 in water titration if I have any doubts at all.
Seems reasonable to me-
cp
If a person takes 30mg of Metadate CD in the morning only, what is the equivalent of Vyvanse? The doctor is changing the medication. I was surprised that she ordered only 20MG per day of Vyvanse to replace the 30mg of Metadate slow release. Does this seem correct to you? Thank you
Julie,
Even a big guy can get toxic and it sounds like better off than on… do need to check with your doc.
I never give Vyvanse 2X/day, duration is just too long – have seen many who don’t appreciate the simplicity of the DOE, but he surely sounds like too much.
- BTW this is not a rule out for Vyvanse, just work with your doc to go down… most folks just don’t want to try a lower dose after all of that – thus my admonition to stay so low at the first.
Good luck, and do check with your doc,
cp
I need help As soon as possible, David has used Vyvanase , but after about 1 1/2 weeks he becomes very aggressive Ht 5 foot 9inches 180 pounds and he also on on Buspar and Resperidal, and Tenex
When he is on the Vyvanase he is more focus for the period of 1- 1/2 weeks then gradually he becomes aggressive. He has had a couple trial and last trial was 30 mg am and 30 mg 12noon . When Vyvanse was stopped he slept very hard for 3-4 days and immedicately the aggression stopped …now off this medications he is having aggression but not quite as serious as before
Help me please, the school has suspended him and he my have to go into resiential home. I do not wish that for him Thank you
Rebecca,
Challenging questions – my best shot: The onset seemed to have too many side effects. Appetite, over focus and racing thots are all signs of too much. See some of the Therapeutic Window Posts [top] I have been writing over at EzineArticles on the badge on the right here.
Sounds like it was too much, going down on dosage was a great move, but my take at this moment is that you were at first starting [in hindsight, no disrespect to anyone] too high, couldn’t accommodate, and then went too low and are simply trying too hard, too quickly moving the dose to get it right.
I agree with your suggestion: Start all over at 20, expect that is likely not enough, but take it there for about 10-14 days, then go to 30. This will give your metabolic pathways an adjustment time, and you won’t be hitting so hard at the outset. Then when you go up to 30 watch for the ‘cognitive’ changes on the PM drop, not the feeling changes. The cognitive changes are more subtle, and if you actually ‘feel it’ for ~ 14 hr – likely too much.
Also sounds like you might have an associated metabolic issue with your atypical reaction to Ritalin. Big question: Did you eat your breakfast girl?
You are thinking exactly right, need to slow down on the expectations… not easy in law school, but he wait should tell the tale.
cp
Hi there, I have found your website to be extremely informative and helpful. I am a 26yr old law student who was just diagnosed with ADD about 1.5 mo ago (after taking phentermine for a few months) and have been looking to your blog for guidance re meds and info ever since.
I started out on 30mg Vyvanse and for the first 2 weeks, it seemed to be working wonderfully with DOE of roughly 12 hrs ( maybe less) with an onset at 45 min after taking it. Mental cognition and verbal expression were sharper than ever, the ability to focus and pay attention in class were through the roof. I did however experience racing thoughts, mood elevation, intense motivation, and suffered from lack of hunger most of the day. It also seemed as though in the evening I would have onset of anxiety and depression.
The following two weeks however were a completely different story. It was sort of like I was slipping into a fog with no ability to focus. I had very little concentration or clairity and sort of just wanted to sit and stare. I wouldnt feel an onset until roughly 3 hours and ( it would only feel as though it was sort of working)then I would have a terrible crash after 6 hrs of taking it. I would become completely ravenous and want to eat anything and everything. I had become extremely exhausted with an overwhelming desire to just sleep. There was one occation where I became sick and feverish, nauseous with a terrible headache and left class early to go home and sleep.
I stopped taking it for about 3 days and then started up again to see what would happen… and it was slightly working although not very effective as it had been when I first started and seemed to feel as though it was wearing off quickly.
There was one incident where I took the vyvanse as well as some liquid vitamin B and suffered from chest pains and shortness of breath for several hours. I stopped taking the vitamin B and that seemed to get rid of the problem.
I also tried to cut the does in half (15 mg) using the water tritration method and it seemed to be somewhat effective in terms of increasing self expression. Although I was tired and suffered from lack of motivation, anxiety and depression.
My doctor thinks that my reaction to the meds is strange and he took me off the Vyanse and put me on 5 mg of ritalin – which is completely awful! I just suffered from crying bouts for no apparent reason and bouts of aggression and hostility with very little changes in mental cognition. He thinks that my body does not like the method of delivery the vyvanse offers and he said we may try adderal if the ritalin doesnt work out.
I would like to stick with the vyvanse and am convinced I just have to find the correct dose. It seems as though the benefits of taking it outweigh the negative. Do you think that possibly the does it too high and maybe I need to decrease to 20mg or maybe the does is too low? Its difficult to figure out since the top of the window can look like the bottom.
Ste,
As noted previously, buried in the many comments here, that sounds like too much to me.
The deal with Vyvanse is no side effects, no nervousness and a reasonably good appetite…
Hit the breakfast with protein hard and suggest talk to your doc about the 20 mg size, sounds like it will be just about right,
Please let me know if we hit the mark!
cp
My child has been taking Vyvanse for 3 1/2 months she is losing weight like crazy. I can never get her to eat more than a bite or two at a time. The last month I have noticed that she has been really unhappy and acts very nervous. Her self esteem has dropped. She complains with her stomach most of the time. My child is 9 years old and started and still taking 30mg 1 time a day.
Helen,
This is a typical reaction to too much, check with your doc – what I do in these situations is stop the med and go down to 1/2 the dose as described in the titration strategies on this and other posts…
Or you can see it at http://www.squidoo.com/vyvanse,
The lower dose will likely correct, if not, and a down affect continues, look at augmentation with low dose antidepressant with your doc.
cp
My daughter has started vyvanase 30mg for one week now, and has been crying and ready to give up on life. could this be a reaction to the new medication and will it pass as with the dry mouth?
James,
When it comes to thought disorder and bipolar, yes, your doc was exactly on with her thoughts about dosage – and since we now can review the game plays, two thots:
1. Vyvanse could still be too much, so watch the top. It can be unpredictably better, using less med than anticipated may be still necessary.
2. I have seen no atypical findings with mood or thot disorder. It’s still an AMP molecule, and the only elaboration of symptoms will come from the differences in dosing strategy – may need more in some cases.
Yes, could mean more or less… likely not the drug, and always take with breakfast, preferably one with protein,
Please get back to us and report your experience, it could be quite helpful to others.
Thanks
cp
Hello Dr. Parker.
I have a question with regards to your experience in treating ADHD when it coexists with thought disorders.
My primary diagnosis is Schizophrenia, Paranoid type. I also have been diagnosed with ADHD since age 14.
I currently take Abilify and Klonopin for my thought disorder, and although when I was first DX’d with Schizophrenia I was removed from stimulants, my condition deteriorated without them and for the past 8 years I have been taking one of the available ADHD meds. Currently that medication is Adderall 30mg BID @ 7AM and 12NOON.
Today I went to see my psychiatrist and she recommended I switch to Vyvanse. She prescribed a 50mg qam dose.
From what I have read in the past this seemed low to me when compared to how quickly I metabolize Adderall — but she insisted that 50mg was a good starting point. I have been reading your weblog entries on this site for an hour or two now so I can see at this point that she made a good decision in not starting me at 70mg. She suggested I call in to report with her in 2 weeks as to my progress and experience with the drug.
My concern is exacerbation of my psychotic symptoms. I already know that Adderall @ 60mg / day does not hurt or worsen my symptoms. In fact, and this may sound quite strange, it seems to quiet the hallucinations a bit. On days I do not take the Adderall I experience more difficulty with my core condition.
I am very interested in hearing what experiences if any you may have had in using Vyvanse for ADHD in patients with a psychotic disorder.. I am concerned to try a new med when the previous one was working fine.
I don’t consider myself to be a cynical person, but I feel a bit like Vyvanse was pushed on me for reasons not exclusive to my benefit alone. Seeing tons of Vyvanse paraphernalia at the office (just recently arrived I assume from the reps) made me a bit uneasy.
It would calm my fears quite a bit if you have knowledge of others who have my condition, are also on stimulants, and have made the switch to Vyvanse successfully.
Thank you so much for your input and interaction with the community. It is invaluable.
Karen,
You are quite right all around and suggest that their specialist is absolutely correct… when the dose is inadequate!! My DOE target is 12 hrs and often we get 13-14… somewhere around 15 hrs seems to often become too much, with sleep and appetite problems and *top of the window* challenges.
-Have no *specific recommendations* on the school policy… just clear that they don’t understand the issues, and are quite uninformed about several aspects of the metabolism/delivery process. My thot: they should simply give it to earlier and consistently, not inconsistently.
Both the morning and weekend issues seem small to the uniformed who don’t live with these problems.
Are other kids having the problem? Perhaps a parental petition would awaken the sleeping giant.
Only other quick note for your daughter’s consideration: coffee for breakfast – it’s short term, not harmful and could close that open window just a bit.
cp
MY DAUGHTER IS 15 AND TAKES VYVANSE. SHE LIKES IT BETTER THAT CONCERTA. SHE IS AWAY AT BOARDING SCHOOL AND THE NURSE OF COURSE HAS TO GIVE HER HER MEDICINE EACH DAY. SHE TAKES IT AROUND 7:30AM THEN GOES TO BREAKFAST AND FROM THERE TO HER FIRST CLASS AT 8:00AM. SHE SAID IT DOESN’T REALLY START TO WORK WELL UNTIL THE MIDDLE OF HER MATH CLASS (@8:30). IS THERE ANY WAY TO GET THE MEDICINE TO WORK QUICKER?
ALSO, ON THE WEEKENDS THE NURSE ISN’T AVAILABLE TO GIVE HER THE MEDICINE UNTIL 11:30AM. I TAKE MEDICINE FOR ADD AND SO DOES MY SON. TAKING IT LATER ONLY KEEPS ONE UP LATER. THE NURSE TOLD BOTH MY DAUGHTER AND MYSELF THAT THEY HAVE SPOKEN TO A SPECIALIST AND THE SPECIALIST TOLD THEM THAT THE MEDICINE WEARS OFF IN 5 HOURS. I TOTALLY DISAGREE! IF I WANTED A DRUG TO WEAR OFF IN 5 HOURS I WOULD ASK FOR ONE NOT TIME RELEASED. AM I RIGHT? ALL THE RESEARCH I HAVE FOUND SHOWS IT LAST 10 – 12 HOURS. IT JUST THROWS HER SCHEDULE OFF AND THEN THEY EXPECT HER TO BE ON TRACK FOR MONDAY. PLEASE HELP ME UNDERSTAND IF MY THINKING IS WRONG. THANKS SO MUCH!
Lee,
Sorry on the skin problems, don’t have an easy answer.
-But can tell you what I would do: I expect that you do have some associated metabolic problems – could be bowel transit time, could be diet, could be nutritional, and the stimulant is only aggravating the underlying problem – I would chase all of those multiple questions down in detail, too many to review in this brief note.
This is a post I did some time back on transit time:
http://www.corepsychblog.com/2007/10/recipe-for-brai.html
And don’t forget the basics: a dermatology consult.
cp
Mitzi-
As you can see from this post the comments about Vyvanse and the multiple issues with long term stimulant use for ADD/ADHD medication management are remarkably abundant.
First: Do go up on the right hand top of this blog site and sign up for that *ADD Book* notification. There you will receive two goodies, one now and one later: The one right now: a pdf of the 10 Biggest Problems with ADD/ADHD Medications – not a lot of answers but good information for the multiple issues involved.
The other, soon to become available to all the early interest folks: a 1 hr MP3 Audio report on the !0 Biggest Problems – My book will tell you how to solve those problems… most of the time. If you are already signed up you are on the list and will receive a link as soon as I get it recorded.
Second: Without an evaluation, and subject to a complete review of the evidence only hinted at in your question: Sounds like a *comorbid* depression from the fact that the Vyvanse and others aggravated the affective side of his presentation – the feelings of I don’t care – and the suicidal feelings. See this post for further review of these issues about the frequently missed Clint Eastwood depression from *High Plains Drifter.*
http://www.corepsychblog.com/2007/04/overlooked_tips.html
In my new book I have a whole chapter devoted to this very problem you appear to be describing – seen so often in everyday practice.
The treatment: Consider, if your doc agrees, adding a small amount of an antidepressant. Stimulant meds all aggravate depression, and antidepressants aggravate ADD. My favorites for this presentation, not approved by the FDA, but excellent if watched carefully: Effexor XR in the AM with the Vyvanse after breakfast.
This is a start, hope it helps, please do keep us posted on his progress,
Thanks for asking,
cp
Hi, My 13 yo son has been treated for about 6-7 years. Started out on Straterra, did not work. Went to Adderall XR 30mg & XR 10mg for a few years until very bad moods and threatened to kill himself. Went to Focalin and maxed out without it helping. He is now on 70mg Vyvanse and it helps some but we still have many non-focus and anger issues. New insurance doesn’t prefer Vyvanse and wants to try Concerta or something generic, etc. What side effects come with this family of meds. and with his history should I just keep him on Vyvanse and maybe see if he can have a higher dose?
I have been dealing with an increase of oil production since I have been on Vyvanse (30 mg) for the last couple of weeks. I use to be on adderall (10 mg x 3 a day) for nearly four years and I went off of it a year ago due to the side effects of tender skin and breakouts. My skin improved significantly once I went off the medication. Why would vyvanse and adderall cause such skin reactions? Is it because they are a stimulant, is this why I have had an increase in oil production?
I would appreciate your feedback and any suggestion you may have on how I can continue medicating myself for ADD without having to deal with the skin issues.
Thank you so much
Kendra,
The description of “isn’t working” sounds like it may be the *bottom of the therapeutic window* – see this post:
http://www.corepsychblog.com/2008/01/tips-on-medicat.html
For the important answer to the question of *Duration of Effectiveness* needed to get the dose dialed in most precisely see this post:
http://www.corepsychblog.com/2007/11/addadhd-treatme.html
As noted in several posts: weight, age, gender, level of hyperactivity… none of these characteristics will help with the dosage individuation necessary to get the right dose for the specific rate of metabolism with any person. No groups have specific characteristics – so his size and age are truly unimportant. Each person, each dose pattern must be customized.
What is important:
1. Even though no “studies have been reported” we have experienced in our office, and heard many reports from colleagues that 100 mg Vyvanse is not “too high” a dose – if it is titrated correctly, as indicated in these previous posts. I have several folks on 140 mg, all are adults, but they are the exception rather than the rule, and only arrived at that dosage after much care with titration.
2. Your doctor is the final common pathway… I can only report what is working, and add this common sense point: 100mg Vyvanse = about 40mg Adderall XR – 40 mg of XR is well within the standard of practice.
3. Vyvanse tends to work consistently better than Adderall, but there are some exceptions wherein individuals [for reasons I have not yet heard reported or understood myself] actually need a bit more Vyvanse than the expected dose based upon the previous rate of metabolism with Adderall.
4. Always remember the theme here at CorePsychBlog: ADD is almost always more than *just ADD.* Metabolic differences occur for many different medical, nutritional and biological reasons – so if your medical team is having a problem always look for other factors rather than simply chalking up problems to the medication itself.
5. With other concurrent *metabolic problems* the therapeutic window narrows, and until the associated conditions, from gluten sensitivity, to brain injury, to heavy metal intoxication, will create a situation wherein “nothing seems to work right.” The only solution: complete analysis of comorbid conditions.
Hope this helps-
cp
my 14 yr old son has been on Vyvanse 70 mg. of about 3 weeks. He was on adderall xr for a couple of years and it didn’t seem to be working as well as it used to, so the dr. switched him to this vyvanse and he has been more irritable and his sensory issues seem to be more pronounced. I upped the Vyvanse to 100 mg. for a couple of days and he seemed to do better. I called the doctor and she said to stay at 70 mg. for a little longer, that there are no studies that have been done over 70 mg., I called Shire and asked about 100 mg., they also said no studies over 70mg.
Do you think it would effect him in a neg. way, by taking 100 mg.? There was such a difference in him those couple of days that I had him on 100 mg., but if it’s not safe, there’s no way. He’s 6 feet and weighs 128 lbs.
I sure would appreciate your input!
Thank you,
Kendra
Saundra,
Please do sign up for my new book in the box there on the upper right of the front page here – to get the free article on *The 10 Biggest Problems with ADD Medications* to get started.
Then answer for yourself the following questions:
1. When does he get angry?
2. Is he eating a protein breakfast?
3. Is he sleeping well?
4. Was he whiney and fussy before and the Vyvanse is only aggravating it?
Answer these questions, look at the *Problems* article and consider the answers – the answer to your question is very likely in that mix.
cp
My 5 year old has been on Vyvanse since mid- May of this year. His behavior has been improved until recently. He’s had anger outbursts of throwing things and kicking and screaming that appear to be unprovoked. When asked why he is so angry he just says he doesnt know. I don’t know how to help him and I’m starting to feel that impulsivity is a lesser evil than uncontrollable anger.
Julie,
Do please reread this article:
http://ezinearticles.com/?id=1257427
*Word retrieval* is not precisely addressed in this article, but I always review DOE and the top of the therapeutic window if someone complains of word retrieval problems.
My first guess is that you are not sleeping as well, and may have some weight loss issues – and might be just a bit on the cranky side – all signs likely associated with a mild “overdose” of Vyvanse or any stimulant medication.
If I’m wrong on those items you should look more carefully with your doctor at other metabolic issues such as hypothyroid for example.
I wouldn’t want to add another drug until I had a much more clear view of the specific target.
Hope this helps!
cp
Hi,
Thank you so much for this informative blog. I am a 43 year old female, have been on Welbutrin for 8 years for depression and mild AD. It’s worked well for the depression, but not for the focusing My psychiatrist first added Straterra — LOVED it, focusing and word retrieval were great. Due to significant weight gain, I chose to go off. Since then have tried Concerta (very bad mood issues), Adderall and now Vyvanase. I feel good mood wise and physically, but I’ve noticed lots of memory issues and great difficulty with word retrieval. Is there a way to combine the great effects of Straterra with the positive aspects of Vyvanase (70mg)? Thank you!
Jess,
Thanks for your gracious remarks and interest – I will cover some of your questions here, and give you some links to chase down some other points that might help your father and others with an explanation for what is going on:
First start with my podcast series of 4 different .5 hr presentations on ADD the Media, the Meds and the Madness – these will cover a lot of your questions and explain things more cohesively: This is the first in the series @:
http://docparker.typepad.com/corepsychpodcast/2007/01/add_the_media_t.html
Look at the previous comment response for details on dosing,
For depression and ADD:
http://www.corepsychblog.com/2006/12/kids_and_antide.html
I think BorderlinePD is a wastebasket term which is almost clinically useless. Like ODD it is purely descriptive, and may be caused biologically by many different biological adversities… Description alone is on it’s way out, as descriptions of office findings [labels] do little to direct treatment – and often are more pejorative than constructive – giving the feeling to the team that *we have named the problem* now we have a reason to stop trying. Reductionistic thinking is out, comprehensive thinking is in, – because including the many variables proves more clinically effective than simply finding a label.
Depression is often aggravated by stim meds, but stim meds can fix the ADD and the subsequent secondary depression.
Do sign up for these email updates here at CorePsychBlog – as I will soon have a book out which covers all of these questions in more detail – and have another planned shortly after which will go into the biologic diagnosis of ADD.
Hope these help,
Tnx
cp
Hey, thanks for being so helpful– I think it’s really cool what you are doing with your blog and quick answers to comments. In my experience it’s been really difficult to find people who are both knowledgeable and unbiased and can maintain some semblance of objectivity.
I have a couple questions for you, if you wouldn’t mind answering. First of all, I am a 22 year old college student, and have been taking Vyvanse for just about a year now– I have found it to be unbelievably helpful; it has completely changed my life, allowing me to reach potential that I always suspected was there, but never thought was possible. My dad is hyperrational and overprotective and does not believe that ADD is a real disorder– he sort of sticks to what he knows. Immediately assuming that I have “addictive tendencies,” he-unwaveringly-would not allow me to go on medication…until Vyvanse came out.
I have always had extremely classic ADHD– but though I was very hyperactive as a child, I am much less so now, although the pure volume and disorganization of fleeting thoughts I have on a constant basis could definitely be described as “hyper,” though strictly in a mental sense, as opposed to both mentally and physically. My mom also has severe ADD–So much so that it is difficult to even be in her presence for long periods of time (she is not medicated).
In addition to ADD, I also have Borderline Personality Disorder (BPD), which manifested itself visibly in about 9th grade..but maybe even as early as 6th grade. In case you are unfamiliar, BPD is characterized by extreme mood cycling and black and white thinking, as well as patterns of unsteady relationships and impulsivity. Which I suppose leads to a sort of depressed lifestyle.
Since taking Vyvanse, not only have I been able to focus for the first time in my life (as well as listen to other people on basic things, read books, etc), but my symptoms that I’ve felt were associated with BPD are also almost entirely gone. I understand that ADD and BPD might overlap a little bit, and that ADD also deals with impulsiveness, etc, but I am wondering if Vyvanse works as a mood stabler– I have felt pretty heavy depression most of my life, although I would never admit it to myself, but now that I am on Vyvanse I feel great, and all traces are entirely gone unless I forget to take my pill, or run out of my prescription…. in which case it is hard to motivate myself to do anything at all, and sometimes I don’t even make it out of bed. Is it possible that Vyvanse is acting as an anti-depressant/mood stablizer in some manner? and if so, why is this? Is it because of the affect it has on seratonin levels? Or could it be that I was mainly depressed as a result of my inability to get anything done or motivate myself. I am not sure if the change in me is purely and directly neurologically based or if it is more of a reaction to positive thinking spurred by my ability to motivate and make progress, and actually get things done for once. (I understand that dopamine and norepinephrine work by stimulating reward centers and also attentiveness through adrenaline).
My final question is.. is it possible that Vyvanse could have an effective off-label use as an anti-depressant or mood-stabilizer? For example, in abuse victims, the symptoms are commonly similar to those of ADHD people. Obviously the underlying issues are completely different, and medication would never be sufficient without the appropriate counseling, but if someone is suffering from serious ADD-like symptoms, and their life is absolutely impaired by it… could something like Vyvanse work to help a person correct negative behavioral patterns, so that in theory, they could finally deal with the underlying causes? I ask because I have a friend who has been on numerous anti-depressants, but nothing seems to help, and they only seem to deaden her emotions or make her feel worse. It’s hard for me to see behaviour in her so similar to how I used to be, or how I am when I run out of medication, yet know that I have this pill that can help me, but she has nothing…just because she does not have classic “ADHD.” Does it really matter what the underlying causes are, if the symptoms themselves are so impairing?
I am sorry that this is so long and complicated. I understand if you don’t have answers to some of these questions, but I really appreciate your time, and your blog here. I can’t seem to find these answers anywhere.
Thanks so much,
Jess
Mary-
Package insert is clear on the top at 70 mg, but anecdotally I can tell you the adults have *generally* done better with higher doses. If your doc is not a psych it will be difficult for him/her to go into an area of unfamiliarity and discomfort.
Since 70mg = 30mg Adderall, then my next move up is to not double the dose, and *never* give a dose after 12 Noon as the predictable excellent half life will do just what you said, – keep you up. It will often burn past midnight when dosed after noon.
Do dial the dose in using the DOE here and at this post:
http://www.corepsychblog.com/2008/01/tips-on-medicat.html
and this one;
http://www.corepsychblog.com/2008/06/addadhd-medic-1.html
Best to get your doc on board, and if uncomfortable, find someone like a psych who is more comfortable with increasing the dose.
And be careful – as you can see also at this article – you can get to much:
http://ezinearticles.com/?id=1257427
Hope this helps,
cp
i am a 38 yr. old female and have recently begun taking vyvanse. first at 50, then 60, now 70. it works fairly well but fades by mid-afternoon. i then added a second dose around 3pm. this helped but i had significant problems falling asleep. have now tried taking a double dose in the morning. this gets me through the day and evening with no need for trazadone to sleep. however, my doc won’t prescribe a double dose because of the recommended dosage being only 70mgs. i have a friend who is prescribed 100mg daily and has no problems either. is it really unsafe to go higher than 70mgs a day or is it just that there are no studies for a higher dose? i feel great when i double the dose but, of course, i run out before i can get my next script. any info would be greatly appreciated.
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
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!?!
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
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!
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.
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
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
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