ADD/ADHD Treatment Notes: More on Vyvanse

by Dr Charles Parker on November 12, 2007 · 41 comments

Vyvanse Benefits

Vyvanse appears to offer considerable benefitsover the best seller Adderall, but you must know just a few points to get it right:

puzzle brain ADD/ADHD Treatment Notes: More on Vyvanse

Brain Complexity

  1. Vyvanse is an amphetamine, so it is, in essence, the same molecule as Adderall, though not the amphetamine salt mix with some of the adrenergic side effects. No one knows at this moment, but could it be the norepinephrine [NE] in the Adderall? I think so – NE is the only variable other than the  rate-limiting step with the prodrug discussed in the previous post on Vyvanse.
  2. Since the basic molecule is the same, switching is easy, – just don’t follow the *forced dose* titration schedule as noted in the research on the run-up for FDA approval. We don’t do forced dose titration, only researchers looking for the effective parameters should attempt that kind of aggressive titration strategy.
  3. Practical suggestions for titration strategy with some subtle nuances that will help you get it right if you simply think about these easy details:
  • NB: We do not look for a “feeling” that it is working as we did so many years with Adderall – instead we look for clean cognitive changes. Patients will do better, can think better, have better concentration and thinking skills, but don’t “feel that it’s working.” If the children who use it continue working, it’s working.
  • They, generally speaking, don’t have the same amount of unpleasant side effects: the emotional drop in the PM, the jitteryness, the “squirrelly feeling,” the jumpiness, – to use a scientific term.
  • The drop in the PM is predominantly cognitive, not affective [emotional]. They may mentally stop, – just can’t work.
  • If the dose is too high they may go out the top of the therapeutic window as noted below.

More on the specifics->

So just how do we figure the DOE – the Duration of Effectiveness, – that excellent dosage parameter we have been using for >10 years with Adderall?

Simple: We always ask the question about DOE, because that tells us about customizing the dosing to the individual’s specific metabolism. Remember from previous posts: size does not matter, weight does not matter, only metabolic rate matters. This point is essential and must be understood completely by the entire team.

Look for the top and bottom of the Therapeutic Window [which also helps spell out the DOE]:

  1. The top of the window – simple: too much – with racy side-effects and can’t sleep.
  2. With too much, the person feels buzzed and agitated, and, most importantly, experiences other side effects – that don’t occur for the most part unless the dose is too high. -Doesn’t mean they are bipolar.
  3. Too high means more than 14 hr duration. You give it at 7 AM and it keeps them awake past 10 PM, – often a sign of too much. Stay with ~ 13/14 hr as the objective for the DOE, and do record DOE for every office visit.
  4. With too much, they feel their mind is racing and they actually can’t concentrate.
  5. The bottom of the window, also simple: not enough… it doesn’t work at all, or…
  6. It quits too early, at about 2-3 PM with a drop in cognitive/thinking skills.
  7. The main focus for all of us – not previously appreciated without another PM dose of another short acting med – are those bewitching hours between 4 PM and 8 PM when the goblins appear.
  8. If the dose is right: the PM is covered quite consistently. Interesting… and easy.
  9. Always go slower and lower than you might expect based on the published research numbers, and take a visit or two to get the dose right, about 2-3 weeks later – let it settle to discover it’s metabolic rate.
  10. The redeeming feature: you will get it right faster, it will last at that level. Recent studies show that when adjusted correctly it needs no more attention during the entire following year. Predictability is all about that rate-limiting step that activates the prodrug, peels off that lysine binder,- it actually digests it into action with an enzyme that keeps it from running into your system all at once.
  11. The exemplary outcome… even more predictable action than our previous favorite. This third generation stimulant medication becomes an excellent addition in a sea of unpredictability and constant working with outcomes and side effects with other stimulant meds.

Interestingly, as mentioned in a recent previous post, the adults [off label] have had an excellent experience with Vyvanse as well, with very little titration and fewer office visits to get it right.

And nobody has to feel like they are a drug addict to take it. No buzz, no hype unless they pop out the top of the window based on the dose being too high. One slight exception to this is starting up, so use the slow titration outlined in that same previous post if the person is sensitive to meds. Expect they may be jittery for the first 3-4 days, just hang in there, or divide it in 1/2 with water titration strategy noted in that post.

Remember the study mentioned before with those poor, beat-up methamphetamine addicts in Baltimore…  – they voted on the likability both by mouth and IV quite clearly: “We don’t like this Vyvanse stuff!” It is an amphetamine without many of the amphetamine properties… this is a good thing.

And an important, quick side note: I wonder how many of those amphetamine addicts have ADD? – and even more importantly: how many of them are now treatable because they can’t abuse the drug? This is a very big thing. ADD/ADHD challenges always effect the recovery process and must be identified. If untreated they remain a significant relapse trigger.

-Said it before, will say it again, Vyvanse will change how *the uninformed* think about ADD – but I still recommend you keep your ADD/ADHD diagnosis a secret.

I will keep you posted as understanding regarding Vyvanse use for ADD/ADHD evolves here.

Please send any comments out on this post as you may have some different experiences that will add to the discussion.

cp

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Tagged as: ADD/ ADHD, Adderall, addiction, ADHD Medications, amphetamines, Attention-deficit hyperactivity disorder, duration of effectiveness, Psychiatric Medications, Recovery, relapse trigger, stimulant meds, Titration, Vyvanse

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Rock-imran8

Why has my motivational feeling for vyvanse disappear. I used to have this feeling that would make me want to do things and take challenges but now it has gone away. I feel even worse taking Vyvanse when I dont get that feeling i used to. Help? 

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Dr Charles Parker

Could be a number of things, dosage may need adjustment, and do SEARCH "Roving Therapeutic Window" here at CorePsych Blog.... your window is roving and the details are too many to adequately cover in a brief comment! The good news: it's entirely fixable! cp

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Dr Charles Parker

Wendy, My clinical experience, and the experience of hundreds of physicians across the country, as well as peer reviewed research is that daily dosing works better by far for the large percentage of patients. Most especially forming the habit, indeed the correct perspective, that ADHD is not only an academic problem is a key to understanding the life implications of ADHD. The doc you describe with the different opinion, was provide only that, an opinion, not confirmed by research or the standard of care. In my own experience those who suggest only school most often are pediatricians who, as a group, have been educated by other pediatricians working from that same limited perspective that meds are bad for children, especially stimulant meds. Stimulant meds are, as we regularly report at CorePsych Blog, bad if they are given whimsically and capriciously, which, on the other side of the coin, happens very rarely in my experience with well trained docs at any level, especially pediatricians. cp

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Dr Charles Parker

wnd, Thanks so much for your articulate and pleasant note, in spite of your obvious consternation. Your remarks do take you into the realm, increasingly found in the pubic as well as some corners of medicine, of the frustrated-informed. I've been in that club for years so know a fellow traveler - and am determined next year to take the conversation further down the metaphoric road with anyone who will listen to me and the experts I have lined up over at CoreBrain. There I plan to create a medical-knowledge community for global consults. [Interested professionals: pass the CoreBrain tests there and we send you folks wherever you are.] 1. First you need a doc with more ADHD experience, someone who understands the essential fact that on the liver metabolic 2D6 side of things, that genetically-based rapid metabolizers are alive in the lit [~ 7% as I recall at this moment], and just that fact alone often requires higher than ave doses. More experienced docs understand that basic clinical finding, and can make that med adjustment without hand-wringing and patient guilt. 2. Your history strongly suggests that do have additional metabolic challenges, possibly immunity related, possibly hormonally related [adrenal], possibly nutritionally related - all of those challenges are easily measurable [see the /neuroscience page here] - we can do that long distance - information isn't treatment - wherever you are. Those answers can guide treatment, and on the phone we can often help doc shop to find the right person, even in Possum Hollow. If you want to come in to Va Beach, it might be the ticket, as once we jump on it and get with you those details are on the table, rather than in the speculative ethers. These are more complex questions - you can call and set up a brief complimentary *doc shopping* call with me to see if we fit. 3. Vyvanse often does work better, but if you have either 1 or 2 above, then your outcome will remain regrettably unpredictable. Vyvanse certainly is worth a shot, you are ok on metabolizing AMP products, titration is the only issue and that's spelled out repeatedly in many of my how-to articles, websites [Squidoo/Vyvanse] and posts here at CorePsych - just *Search* here. What I'm saying is perceived by some as radical, by a few head-in-the-sanders as quackery, but by the most conservative and well-read docs, as common sense. The less the doc knows about ADHD Meds, the more they are inclined to not listen to the literature or the patient, but be directed by the posturing of academic institutions, who in my lifetime have been repeatedly behind the experience curve by at least 5-10 years - as they are so awash with tenure, group and institutional thinking. I can site specific examples of Paleolithic academic thinking right at this moment from here in VA to CA and MA - it's absolutely ridiculous - intellectual clubs with a big initiation fee and serious clubbery up there in the tree house, - and girls are allowed. I have to be careful here, as you write so well you seem like you might be over in that community - even though you aren't on the med side of things ;-). The good news is that *Rules* has been well received, docs are listening, the ADHD med world is moving forward, and others are singing my same tune, including ADHD coaches, and such esteemed research colleagues as Russell Barkley who, of all clinicians in the world, is more conversant with the fresh cellular and neurophysiologic research for ADHD than anyone. Thanks for your support and kind remarks in that regard, and do feel free to find a local doc and share *Rules* with them - books are for sharing. Best wishes for a restful Holiday wherever you are [metaphorically or geographically!], cp

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wnd

CP, Thanks for your timely, practical response. Evidence, I take it, of your underlying convictions that each person’s case is as unique as the person who happens to be attached to it. Tempted to chime in on the running debate regarding the possible root causes behind chronic paleolithic psychosis , which afflicts so many among the esteemed medical community…  better for me to ponder a little bit more upon the refractory nature of the human intellect - i.e.  the phenomenon of a mind already made up -  before commenting too freely; though I do have a few observations perhaps for another time.   Alright, maybe just a single comment: I do think it's all symptomatic of something greater and more fundamental – that is, more universal than just the medical profession & academia – the word ‘systemic’ seems to fit as a descriptor. If true, then there certainly would exist more counter-inertia compared to what one would otherwise expect, if it was merely a phenomenon within the medical profession alone. Maybe that’s the reason for such resilient objections being made to any suggestion of re-consideration and re-thinking, when you’d expect the opposite reaction to come from the very groups of individuals who are purportedly representative of wholesome change for the common good, whether in the area of medical science or otherwise. Foregone conclusions are hard enough to deal with and dismantle on their own, but add to that the social construct of professional reputations and accolades…. Forget it. Reputations that are earned this way are more akin to 401ks than they are to any pulse of scientific inquiry. It’s part of club membership bennies, just as you have suggested… and moreover, it’s exceedingly pandemic; all b/c, I shall continue to assume, it must be somehow woven into the fabric of our culturally-conditioned expectations, in the form of social standing and dividends yet to be paid out. I’m being overly opinionated here – it’s merely a speculation. So that kind of strikes me as being a big statement coming from one of so little stature… that’s o.k. by me – and it’s probably just the kind of statement we would all expect to come from a ‘languishing ADD patient’ who just so happens to be an outlier, unfortunately, along the bell-curve of what is otherwise ‘successful ADHD treatment’... which precisely illustrates my point. A bell-curve-thinking society promulgates bell-curve-thinking clubs and bell-curve-thinking industries, medical being just one of the many. Since our economics are quite naturally, then, bell-curve dependent - there is real economic reward to be had by those who utilize bell-curve methods for attaining the standard bell-curved objectives.  Not wanting to eschew bell-curves here – rather, the bell-curve-thinking that we, as a group, seem so prone to continually follow. That has got to be forced into the oblivion of extinction. So it’s encouraging to see individuals taking a different posture than the above, such as yourself. But if I can turn aside now from the topic of our refractory culture.... I’d like to ask of you further advice re: my refractory ADD. I have the info packet from your office. Quick field guide types of questions:      1. Found someone willing to give it a go here… Tried for Vyvanse @ 50mg/day – too low. But as an addition to the Adderall IR 60mg/day, one Vye 50 at 6 am, and another Vye 50 at lunch… the evenings have never been so smooth, w/ no sleep issues, actually sleeping better. But the a.m. is constantly slow to start, no matter what I try to do about it. Like a couple of hrs. Less so if I take more of the IR. The Buddhist-monk-eggs-&-oats has been a great suggestion, btw. I conclude that: 2. I need to test, for sure. So which tests are the most critical? As in, if available funds so required that the testing be done one at a time, what’s the sequence? 3. How would the test results affect titration, generally speaking? 4. Is it possible that, given an extremely fast metabolism, Vye just won’t be a viable option? Or more positively, what is the most viable option for super-quick metabolizers? 5. How long does it take to repair, say, an obliterated immune system, once it has been confirmed? 6. Is an immune dysfunction generally caused by an IgG problem? So are they, in real-life applications, usually one and the same? 7. What does one do in the mean time, if immune dysyregulation is a real problem, while waiting for it to be treated correctly... go higher on AMPs temporarily? 8. Re: the question of transit time – my answer here is that I’m waiting until I run across activated charcoal… sounds way cooler than corn. 7. If many of these questions are answered in the lit. somewhere, just point me to it. Thanks, wnd

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Dr Charles Parker

wnd, Sounds like your significantly high dosage does reside downstream from 'metabolic problems' which could be IgG related, and could also swim directly downstream from toxic pollutants, genetics, and other medical challenges. Not everyone has only IgG problems, it's just a high percentage place to start on the complexity. Genetic testing for the D2 receptor coming to CorePsych in Jan. Stay tuned for that important science. Dosages can be adjusted with your doc as you have been on DOE. That varies so much it's almost pure speculation to guess what one should do, especially with all of your cellular medicated background noise. IgG correction is first, and then if we hit a wall there we do go to toxic elements which you can look at: toxicelements.com if I recall correctly. Parallel to toxic elements is Metametrix findings - they do a fantastic job on a variety of other indicators, check out their website. Higher on the AMP while waiting: I do it with folks in the office but only guided by the specific needs and careful adjustment on the Therapeutic Window. IgG is elevated as an expression of the immunity - the ones we test are food, but some can be seriously disturbed with common metals, toxic elements, nutritional deficiencies... all of which confuse PFC circuitry. cp

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wnd

Great. Thanks for the orientation on sequence of tests:     Step 1:     IgG -  food-related immune reactions     Step 2:     Toxic elements - 'other'-related immune reactions     Step 3:     person-specific testing, if req'd? (other hormones, etc. ?)     Step X:     the upcoming 'D2 receptor test', which is independent of the above testing sequence. This would be important info. for every on stim. meds, actually - since it would take away the guesswork for how fast meds are metabolized by the individual; that would be really good to know, so as in my particular case... it's unclear to me if a rather high dose of AMP w/ short DOE is b/c - 1) I'm toxic with too much, or 2) hitting the sill (bottom) of the window with my head everyday. If this proves to be a reliable test (D2 receptor)... then, wow. Do you think, then, that drug cos. will want to include that info. on their labels, asap? Seems to me like they would... that could really change how docs. in the office think about meds. and the PERSON sitting in front of them, while writing out that prescription. If the label itself were to incorporate that kind of d2 clinical data, who knows?... it could crack the ice just a little bit more. Its just one more thing to cause everyone to give pause and think about what they are treating, and why. Good news for people like me... kind of tired of drinking the dregs of ADD [misdiagnosis], esp. if one doesn't  have to. That gives me the rough outline that I was looking for. wnd

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Thomas Dahdouh

Hi, Dr. Parker, I have an eleven-year old who has been on Vyvanse for one year.  He has been diagnosed with "sluggish cognitive tempo" which I think you would view as ADD -- Primarily Inattentive.  We have two issues.  First, the Vyvanse helps him on his focus, but he has a tendency to become "fixated" on something (an eraser, a mechanical pencil) and lose focus during class.  The fixation We have seen this at home too.  We recently increased his dosage from 20 to 30 mg, hoping that this might help.  The teachers report some increase in his focusing, but, oddly, his tendency to become fixated inappropriately (an eraser, a pencil) has increased too.  Is there any way to prevent this?   

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drcharlesparker

Thomas, Without asking many more questions, simply taking a quick shot at the surface presentation, I would like to explore several different contributions: Diet - protein breakfast, Sleep - at least 8 Total Ave Hrs, Nutrition - B vitamins and others, and the likely possibility that the med is simply the wrong med [AMP vs MPH]. It sounds like he is very slightly coming out the top of the Therapeutic Window, discussed in many other posts here at CorePsych Blog. When someone has more side effects, I always back off and/or completely restart with another level of intervention. As you know from these pages I would expect metabolic noise, would want to know Transit Time, and would definitely chase down IgG function with specific neurotransmitter measurements. cp

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Angela

I'm currently on 60mg of Vyvanse daily. I've been on it for two months now and I'm finding that the DOE is only 7.5-8 hours max. I'm completely unable to function after it is out of my system. At the same time, I'm concerned that taking an additional dose is going to cause sleep disruption. I'm visiting my physician later this week. Any suggestions?

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Dr Charles Parker

Angela, Very few have sleep disruption, most will grow their DOE about 2 hr with each increase of 10mg in the AM. cp

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Dawn

Dr Parker: My son was dx wih ADHD September 2009. He takes 30 mg of vyvanse. He did mildly stutter and it seems since December his stuttering has increased. Their is a family history of stuttering, could his medication be the cause of this increase? Dawn

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Dr Charles Parker

Dawn, I don't have specific references to document downstream effects of stimulant meds re: stuttering. Some studies do exist regarding downstream seizures, and certainly tic disorder, so it does make sense that stimulant could aggravate stuttering. My take on these matters at this point, and I predict will soon become the standard of care: why not measure what the neurotransmitters are, take a look at the various metabolic factors present, and make some specific corrections to those likely imbalances. cp

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Kim

Dr. Parker, We are new to using Vyvance for our child. We are on day four, starting with 1/2 titration. He has no problem going to sleep but is waking up at around 4 A.M. and now has difficult time returning to sleep. Sleeping was not a problem prior. This is of course catching up with him at school being sleepy at end of day. Is this temporary? Any suggestions?

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Dr Charles Parker

Kim, Sleep can be side effect at the outset - and whenever that happens I drop back to a diminished dose - use the water titration to go to 1/4 the dose by dividing the single cap into 4 oz, and then 1 oz/day. cp

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Kim

DR. Parker, Thank you for your reply that confirms what we thought was correct. Today my child came home and told us he experienced anger like he has never felt before and it scarred him. We are aware that the depression medication being taken could have this side effect and should be reported . We are concerned and want to know if it should be continued?

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Dr Charles Parker

Kim, Hard call without more info. Yes, your observation could be the case, and if the antidepressant was recently raised that could be the issue. However, in addition review the DOE as all stimulants when topped out tend to cause irritation, esp. AMPs. cp

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aviv

i suggest to all the first time u taking a pill is to take it very small bit from it and see what happened and then a bigger one cos i did take the smallest Ritalin pill [10mg] and got over-focus for 4 DAYS! and then 2 weeks with lite effectiveness from it

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Dr Charles Parker

Aviv, Yes, always low and slow with stimulant meds. No harm, better, more predictable outcomes, awareness of metabolic rates, better titration accuracy using the DOE. cp

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Kati

Dr. Parker: My son was put on Vyvanse by our pediatrician, which we are considering leaving, after having discussions with her, to get her advice with input I was getting from teachers at school on my son who was in the 4/5 grade. His grades were honor roll grades, always, but I was told continuously that he was distracted, couldn't concentrate, and was distracting other student due to him not sitting still and wanting to chat. My pediatrician prescribed Vyvanse without any suggestion of seeing any other for a diagnosis. We've seen her for years and I had a significant amount of trust in this doctor. My son seemed to be much "calmer" on the medicine, but also seemed to go into a "dark" place after being on this medicine for 4 months or so. We went from the 30 mg. to 20 mg. Shortly after switching, SUDDENLY, he developed a motor tic and then some facial tics. NEVER, in is 11 years had there been any signs of any tics at all. NOTHING! He was a great athlete, full of energy, and literally, one night, I hear him upstairs in his room saying a cursing over and over. I was beside myself. I had not heard from school, I assumed nothing was happening. Turns out, that same day, his teacher said he yelled out in class. Something he had never done. Needless to say, he has been taken off the medication, and has been off of it for some 5 months now. Most all tics FINALLY went away. However, now he has a motor tic that has resurfaced as well as a motor tic, no cursing this time, just repeating things over. Our pediatrician indicated that it was likely caused by Vyvanse and that it "should" go away. Any thoughts on how long we can expect these tics to continue? It has not effected his grades at all, but his has effected is confidence and also his athletic ability as he is unable to adequately focus due to his head tic, which often times causes SEVERE headaches. Thanks so much for your thoughts.

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Dr Charles Parker

Kati Very unusual, as your ped says, that it would continue. Some tic reactions do occur, are not common, and his appears to be most unusual in severity. Testing before treatment would very likely not have turned up any indication that would warn anyone that this tic disorder was a possibility. Other contributory, mitigating circumstances might be picky eating, poor breakfasts, immune system dysfunction [bowel issues], depression and possibly genetic predisposition. Re intervention possibilities: 1. Neurotransmitter precursor measurement and targeted treatment - not a med, amino acids, I would jump on this right away because of the safety factor and some reports that severe tics have responded after years of poor response. 2. Tenex [guanfacine] and the new drug coming out by Shire: Intuniv, [a time release Tenex] has been helpful in tic disorder with some people - [more than simply for oppositional folks - doesn't sound like he is oppositional]. Intuniv is indicated for treatment of ADHD in children and will likely be launched this fall. Tenex is available now. 3. Neurofeedback: Exceedingly good outcomes - in our office we have regularly seen complete resolution of tic disorder with NFB. In complex presentations I would expect to use all three of these interventions. This problem is highly likely to be resolved, - just a matter of getting on it. cp

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Jennifer

Dr. Parker, my 7yr old son was just diagnosed with ADD. He has a difficult time listening, focusing and daydreams a lot. His Dr. started him on 20mg of Vyvanse. He has a hard time swallowing pills so I put the contents of the pill into a small glass of water. He drank the water and had a healthy breakfast. Within, 30-40 minutes he complained of having "weak legs" and was and looked very tired. He soon fell asleep for one hour. After waking, he complained of a stomach ache and headache for the next 6 hrs (still looked like he didn't have any energy). This is the first med. we have tried for ADD. I only tried it that one day b/c of his symptoms. I was not sure if his reaction to the vyvanse was b/c it was too low or too high. What are your thoughts? He is not on any other medications. Not sure if it is unusual or important to note, but my son gets very talkative/hyper when he takes Benadryl. I was nervous to start ADD meds in the first place b/c he is such a worrier and didn't want to see him get anymore anxious. One more thing, my son also is disfluent(stutters) with some secondary characteristics (blocking). It runs in the my side of the family so most likely it will be a on going struggle for him. He is in therapy, but was wondering how the stimulants might affect the stuttering. Thank you for your time. Jennifer

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Dr Charles Parker

Jennifer, This reaction was likely secondary to the med, but the play has just begun: 1. Make sure that he has protein for breakfast - some consider toast and peanut butter "healthy." 2. Divide the dose in 1/2 following my titration schedule elsewhere here, 20 mg in 2 oz water, 1 oz=10mg - cutting the dose in 1/2. 3. He may simply be a child who can't take it but I would stay with it until you get 3-4 days into it... most probs are the first week. The stuttering problem can go either way, I have seen them improve, and sometimes get worse - if worse I really look hard at all the other variables from immune dysfunction to nutritional status etc. I would do all this latter anyway with the stuttering - we used to look at that process only psychologically, then only behaviorally, now full on biologically. See the immune testing information at Useful References and look around on the LRA by ELISA, the Perque.com site. cp

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Rebecca

It is worth noting, as I've read through some of your other posts, that my son also takes 75 mg of Bendryl per day. It's something we started long ago to encourage sleep when Melatonin didn't touch him. Our psychiatrist said it was okay to continue to give it to him as it seems to calm him through the bewitching hours (after 6 pm), but does nothing for his sleep, hence the Clonidine. However, I read more about the 2D6 problems with Vyvanse and antihistamines on another page, and am wondering if that's why we've seen such poor response to the Vyvanse? The effectiveness we saw is about 4 hours total, at which time he is back to full symptoms. Is it possible that the dose of Vyvanse we started him on (30-45 mg) is too high, as is suggested in some of the posts above, when it seems to be completely out of his system within 4 hours, or that the Benadryl inhibitted its absorption? Finally, if we are to start him at a low dose of Vyvanse, like 30 mg, how do we cover for the rest of the day if the first few weeks he's not at a therapeutic dose? At this point, there is no way he could make it through a whole day of school on just the Vyvanse. Thanks so much for your feedback!

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Dr Charles Parker

Rebecca, In a word, all of the above... are possible, but unlikely: 1. If the dose is too high the DOE is simply too long and sleep is diminished with bad dreams, assuming no sleep issues before, and appetite is compromised as well. 2. Sleep: Hard to tell without better questioning... Benadryl may help with sleep, most commonly we see sleep hangover and tiredness until 9-10 AM, a reason to start with other products, - but, in truth, it works better for some people. I do like Clonidine, again if it works. Sleep medications should always be adjusted just as the Stim meds, to cover ~ 8hr. If Benadryl was the culprit he would become obviously toxic with all the problems of out the top of the window - don't think that's it, and further he's off Benadryl now. 3. Overview: Using DOE sounds like the dose is too small, even at 45mg. Notice the DOE difference between 30 and 45 and that will give you a clue about next dose with your doc... 50 sounds like it's unnecessary, already too low, and 60 would be the next step to see if corrected somewhat. You cover the rest of the day by sticking to the DOE guidelines and slowly increasing to cover the bewitching hours, usually 2 week intervals, and usually each 10 mg Vyvanse will increase that DOE about 2 hr - 3 hr. Over 14 hr DOE almost always too much. If you go slowly you will find the sweet spot, remember breakfast is the deal, and engage your son in the process, with him on board on the objectives, piece of cake, getting him on board can take months depending on many factors. I had a young girl I started with about 11, she hated me all the way thru HS, sneered every visit, embarrassed her mother [father an MD] - just didn't need the meds, fell on her face every time off. Now is a molecular and cellular physiologist at a prestigious academic site, smiles is grateful, and is well versed in the process. Only at in her Sr year at a strong academic undergrad did she see the light. Everyone has their own time. Hope this helps, cp

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Rebecca

Hi, Dr. Parker-- My son has been on the Daytrana Patch for about 2 years with pretty good response for his ADHD. We decided to try Vyvanse after an appointment with our Psychiatrist where our son demonstrated a complete lack of linear thought processes. He is on a variety of other medication for Asperger's Syndrome and anxiety, including short-acting Focalin in the morning to cover until the patch becomes effective, Invega for the autism, Clonidine for sleep and Clonazepam for anxiety. In the couple of days on Vyvanse, he has been completely sedated, almost unable to stay awake, for about 4-5 hours, then the meds seem to completely wear off and he is back to full symptoms of ADHD. He is usually a very quick metabolizer who requires relatively high doses for effectiveness--was on 50 mg of Daytrana, following 20 mg of fast-acting Focalin. We started on 30 mg of Vyvanse, then added another 15 after 2 hours when it seemed ineffective. Please advise.

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Dr Charles Parker

Best quick take: Start all over with the Vyvanse- These symptoms are quite different than described in the previous comment wherein, if the guy is the same guy he appears to not have enough on board. This set of symptoms sounds like he is on too much. I always start with the assumption that tiredness and sedation ["complete sedation"] - in this post comment the 4 hrs is sedation in the other seems to work for 4 hrs, each question leaves different implications. With ASD and Asperger's I always look for immune dysregulation, unpredictable metabolic rates with relative liver metabolic rates slowing leaving toxic and unpredictable outcomes. Don't know what you have done in that regard, I find the LRA/ELISA very useful, does cost, but provides consistent excellent answers regarding immune dysfunction. Info over on the site on ELISA under Useful References under Browse. Focalin and Daytrana both use different metabolic pathways, and are not metabolized thru 2D6, often discussed elsewhere here. He may simply be reactive to a genetically slow 2D6, and AMP can't get thru properly - quickly enough causing problems. Final note: Best way to work with Vyvanse, just increase the AM dose, don't try to give other times later in the day. It isn't built that way, - later doses = big problems with sleep most of the time. Just go up on AM dose under direction of your doc, and watch the DOE as outlined here. If the reaction continues atypical suggest the other ELISA Workup to hit other metabolic variable. The article here will be of interest and you can Google LRA/ELISA for more info. Biologic problems need more eval, then things can be more easily corrected. We also do specific nutritional testing to see what needs to be added to the metabolic mix. I love the evidence, makes things more predictable. thnx. cp

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Dr Charles Parker

Murphy - Best to take a look at this link to build a foundation for your concerns - There are two types of anxiety, one affective, one cognitive, and the cognitive may be directly associated with a subset of ADD... so that one you will have to take back to your medical team. And, BTW, they may be interested in reading the post at this link! cp

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murphy

I am on concerta, for anxiety.... I have been reading in books and on the internet, that it is really for ADD, but what I really have is anxiety not ADD... should I be on concerta?

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Dr Charles Parker

Theresa, Very complicated case, and if he was a patient in my office some other thoughts do come to mind: 1. What are his patterns with breakfast, food intake, bowel habits, allergies and immune dysfunction symptoms? These are questions not for you to answer here, but these are but a few of the questions I would be asking. In a word, more is going on than simple ADD/ADHD. You may wish to read the paper by Jaffe under Useful References [CorePsych Toolkit to the upper left on this page]: immune dysfunction for background... I don't recall that the paper mentions tic disorder specifically, but you can see better where I am going with this answer. Bottom line: more comprehensive evidence is available, and necessary to unearth the next steps in this complicated presentation. 2. Tenex often helps with tic disorder, but I see tic disorder as a tip of a neurological/metabolic conundrum that needs more than simple psych meds, and that underlying problem may in fact be related to the ADD and associated symptoms as well. Psych meds help, but won't fix the underlying problem. 3. You are on the right track, ped neurologist should be the next step. 4. And one other effective intervention that does not exclude working with meds, and with metabolic, - our trusted tic intervention process: neurofeedback. We have had many good results with this combo of interventions. Google Neurofeedback and find providers near you. 5. My best advice, leave no stone unturned, keep looking, there are available answers for this presentation. Best of luck, Do keep us posted on what the neurologist says- cp

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Theresa

Dr. Parker- My son has tried a plethora of meds. The adderall w/had negative rebound effects but no tics (I did not try giving a 2nd dose later in the day,however, which may have helped at the time). Later, we tried Concerta (18 mg)--severe whistling tics started a week later. His doctor took him off immediately and the tics cleared in another week. Did the Straterra thing and after a month night terrors occured at 10p 5-6 nights/wk. So then he went back to Metadate CD (10mg) which made me nervous due to tics...a month later tics started and this time the doctor said it may just be underlying tics and stay on it for a few months...we continued for 2 mos. and the tics morphed and became more frequent--we switched to 30 mg Vyvanse w/only a 5 day break in between the Metadate and Vyvanse. The Vyvanse was great for everything except the tics continued, Risperdal prescribed (.25 mg). Only helped tics by 25% and they just morphed in breating tics. After school was out for summer took him off Vyvanse, while remaining on Risperdal a few days later--the tics looking more like tourettes (though he has never been a vocal or facial tic kid) and said he wanted to kick his legs. Took him off Risperdal and the leg kicking ceased. However, it's now 7 days later and tics are somewhat better but does odd cough sound and still yells out his words now and then and adhd symptoms seem worse than previous summers. Why didn't he get any tics the 9 months on Adderall a few years ago but did w/Vyvanse? Why does he seem more immature than 4 mos. ago when he wasn't on anything? Any help would be appreciated. He has an appt. w/ped. neurologist in a few months but wanted your input.

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Denise Claude

Hi Theresa, My name is Denise and my son has experienced the same issues with the tics on Vyvanse, i was wondering if you have talked to any representation to see what your options were about this unfamiliar severe side affect. I would appreciate it if you would get back to me asap. Thank you!

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Dr Charles Parker

Denise, Amphetamine products and methylphenidate products can both show tic side effects. Often these side effects can be modified by using Intuniv with the Vyvanse, but quite often require their own set of separate intervention strategies - including going off the stimulants, and obtaining clear neurotransmitter biomarker results. That neurotransmitter information has proved useful in many children with tic disorder. Most commonly seen as you would suppose, an increase in excitatory neurotransmitters and significant immune dysfunction - casein is an antigen often associated, as is gluten. If you don't look you can't see. cp

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Dr Charles Parker

Jerry, Inappropriate to give you advice without seeing you... Take a look at this post and you will likely find some of your situation there. http://www.corepsychblog.com/2008/01/tips-on-medicat.html I would go back to your doctor, go lower and slower and titrate more carefully looking for cognitive not affective improvement. All of these symptoms sound like those in my office of too much medication, out the top of the window. I will leave that to your doc and you. I will bet you aren't sleeping well, have lost your appetite, and have more swings than you have had before, even depression. If so, it is too much, suggest you consider with your doc: as noted, start over, and go more slowly- cp

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Jerry

Hi- Hoping someone can give me there advice. I was diagnosed with adult ADHD a month ago, I'm 34 yrs old. Started on Vyvanse about 3 weeks ago. First week was great. Able to focus, prioritize tasks and get a lot of work done. But then after 1st week I started to crash so doctor increased my dosage and I’m up to 1.5 pills of the highest dose. Crashing, feeling lathargic and worst part is I feel like I’m in a total and complete daze most of my entire day which is how I felt when I was 1st diagnosed. Getting nothing done at work, not motivated and in a daze. Anyone else feel like they are in a complete daze on it? Could I be suffering from something else besides ADHD? Suggestions would be great. Thanks.

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Dr Charles Parker

Addman, From the looks of things you are slightly overweight, and have a problem with both AMP stimulants based upon a phenomenon call "tachyphylaxis." [see a post on this interesting phenomenon coming soon] With the metabolic issue that appears to hum in the background and the rapid tolerance to both stimulants, I would strongly suggest you ask your doc to look for other comorbid conditions. Chronic bowel problems could be one expected comorbity, for example. Don't answer us here, but do ask yourself: "How many times a day do I go #2?" The rapid tolerance to both drugs, especially the Vyvanse, which, from my experience has less tachyphylaxis, strongly suggests other medical problems and the need for deeper investigation. As you know from these posts, ADD itself can present as just the tip of the iceberg, and can present as downstream swill from sleep disorder, brain injury, metabolic disorders [hypothyroid, adrenal fatigue, etc], and chronic malnutrition downstream from gluten sensitivity to name just a few. So, best to dig deeper, Chuck

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theaddman

I am a 57 year-old male (6-1 and 248 lbs). I have taken Adderall 30mg, 4Xper day for the last 5 years. The dose cyle or pattern goes like this: The first week, it works great. The second week, it starts to peter out around 3pm. The third week, i start adding doses to make it through the day til at least 8pm. (my normal workday). On the fourth week I usually run out of my RX for the month. I crash for a few days, stumble around in a fog for the next couple days, and then it is time to get my monthly RX refilled. And it starts all over again. I asked to be switched to Vyvanse last month, and was started at 70mg 1X per day. It worked very well, and lasted most of my day. I was very excited about it, but then I noticed I was getting some very uncomfortable chest pain, and related indigestion. I also noticed headaches were becoming a daily event. I am in my third week of Vyvanse and am not sure if the new drug is for me or not. The jury is still out. Just FYI...

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Dr Charles Parker

Eugene H, As you know, it is impossible to say definitively exactly what the problem is from this distance, and yes, this is one for your doc. In the mean time two considerations that may or may not be accurate, and are not recommendations, just thoughts: First if you feel too sedated and somewhat toxic, most often the dose is simply too much. I have now one very sensitive adult on 1/4 of the 30mg [see the water titration post]. He is covered at that dose all day, and has several proven comorbid metabolic issues that are also in the process of resolution. Most often a new person with Vyvanse looks for a "feeling" that it works, and in that effort can actually misinform the doc who also is carefully looking for outcome measurement tools. The second point: Review again the cognitive outcome objective, the clear brain idea, and see if that may be the problem. When you are dosed correctly you should feel better not worse. Yes, don't take action on this post, - not appropriate, but do get back with your doc and perhaps reconsider the dosing strategy. Thanks, Chuck

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Eugene H.

Dr. Parker, I began treatment with Vyvance a month and a half ago, and have worked my way from 30 to 50mg. After an initial two week period where I felt amazing and unstoppable, my mood and energy seemed to slowly drain away in a smooth progression from high to low. When the dosage was raised I felt the initial pleasant effects once again, but only for three days and at a milder level. I have been feeling depressed and I am not sure if it is a side effect of the Vyvance or if it is due to other things going on in my life. I am not usually prone to feel this way for long periods of time, but it does not seem to go away like normal sad spells. Along with that, it often feels like the Vyvance is almost sedating me. I wake up in the morning and feel energized, but about an hour after I take my medicine I am tired and withdrawn. By the end of the day (8pm) I feel I can sit still with relatively few thoughts for an hour if need be, a true rarity for me. This feeling of detachment is not just for unimportant actions; I am not bothering to communicate much with friends and I don't feel worried about the assignments and work I have been charged with completing. Could these be side effects of the Vyvance? I am not sure whether to see my doctor about this as soon as possible, or whether I should wait the two weeks until my next visit. Any of your input would be appreciated.

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Dr Charles Parker

Richard, Some very general comments on the larger picture regarding these minimal facts in this comment: The symptoms you describe could, of course, be related to bipolar. My own findings in the patients I have seen, as described in detail in my posts, is that your description is also quite typical of going out the top of the window, and is more likely dose related [too much at the outset] - unless you have a mood disorder history. Suggest you go back and follow up with your doc and review the details more carefully on the next visit. Hope this helps, Chuck

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Richard

Dr. Parker: Thanks for the excellent information. I was recently diagnosed with ADD and prescribed Vyvanse. My psychiatrist initially gave me the 70 mg. doseage then was surprised by the side effects I received (euphoria, talkativeness, excess of energy). Although I did get the positive benefits as well (ability to concentrate, exceptionally productive, no more chasing my tail type distracted behavior, etc). He believes the negative side effects show that I do not have ADD and believes me to be bi-polar (despite no obvious signs other than occasional anxiety attacks). He states that an overprescription should have made me overly calm or have some other effect than what it did. Long story short: it seems his advice contradicts everything I have read and heard about this drug. Any thoughts on what I should tell him? Thanks!

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