ADD/ADHD: Medication – Start Meds At Bottom of the Therapeutic Window

by Dr Charles Parker on October 27, 2008 · 6 comments

ADD/ADHD Medication Axiom: Start Low and Go Slow – for any Stimulant Med

A couple of quick hint for starting ADD/ADHD meds: Find the Bottom of the Window ADD/ADHD: Medication Start Meds At Bottom of the Therapeutic Window

  • Underdose the Start: I always recommend carefully, slowly starting the ADD/ADHD medication at the outset – lower than the expected endpoint.
    Most of the new drugs have different rates of metabolism, and it is
    quite easy to overdose the patient. This happened with Adderall in the
    beginning, it happened with Adderall XR, and it happens with Concerta
    and Vyvanse even today. So start much lower than expected, and move
    slowly up – about every 2 weeks when close to precision.
  • Start with The Duration of Effectiveness [DOE] in mind.
  • Vyvanse is Especially Tricky: I see many second opinions wherein the docs started with the Harvard study in mind for the 6-12 yr olds. I always carefully ask about the metabolic rates, sensitivity to medications, bowel issues in an effort to predict slow metabolic challenges – that would cause toxicity at the outset.
  • Low Start Requires Bottom Awareness:
    The axiom for stimulant meds: start low, and go slow, watching for the
    effect to show. Address the ADD Symptoms: When it is working the focus is better, the impulsivity
    is down, the worries are diminished and the patient can get going with
    projects – overcoming avoidance and procrastination.

The Bottom looks easy, – but if you don't see it, it can become quite complicated.

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Tagged as: ADD, ADD Medications, Adderall, ADHD, ADHD Medications, Ritalin, Stimulant medications, Therapeutic Window, Vyvanse

  • http://www.corepsychblog.com Dr Charles Parker

    Terry,
    Odd where the boundaries are…
    1. sometimes on the way up = Amphetamines are not the best and are addictive
    2. at the top = the dose is inappropriate based on not knowing the metabolic parameters
    3. at breakfast = causes stomach problems but want to not eat breakfast,
    4. etc.

    Hang in there, the answer will come if you knock on a few doors,
    Chuck

  • http://www.addconsults.com Terry Matlen

    Dr. P.-
    Very true. Unfortunately, the first pdoc was much more laid back and approachable, but very conservative, though she’s always been willing to risk antipsychotics for other issues. But not a jump to 90 mg Vyvance? She never wants to be the first on the block to go off label, etc.

    Terry

  • http://www.corepsychblog.com Dr Charles Parker

    Roger,
    Many variables in those amounts depending on strength of tea, volume of glass etc, – The short answer is yes, probably on the top side of what is best for you – an overdose of tea.

    Other, more natural energy supports can derive from better evaluation of the underlying nutritional and metabolic challenges such as cortisol levels through the day [measured with sputum], and other excellent energy supports for any flagging mitochondria such as L-carnitine and CoQ10 in higher doses. We love the CMP and have a pdf sample here on this site if you Google that topic.

    See here:
    http://en.wikipedia.org/wiki/Carnitine and
    http://en.wikipedia.org/wiki/CoQ10

    NB: I’m going a bit against my own philosophy here as I strongly support finding out the underlying cause before throwing supplements or meds at the “possibilities” – but just these two will serve as an easy example of alternative considerations.

    Further, http://www.perque.com has some excellent literature on the bioavailability of supplement such as these and spends considerable time to ensure you aren’t taking sand.

    Hope this helps a bit-
    Chuck

  • http://www.corepsychblog.com Dr Charles Parker

    Terry,
    Tough to switch, but it is the nature of the times with the advancing science. I completely understand, but find that those who do venture forward tend to be a bit more picky, careful, about what they are doing out there, myself included, than others who don’t wish to think so deeply.

    Of course this is a good thing… moving ahead, and being careful. Love those windows!

    Best wishes for your girl,
    Chuck

  • http://www.publishedandprofitable.com Roger

    Your comment about stimulants and interaction with meds brings up a question about caffeine.

    I’m somewhat addicted to iced tea. (Hopefully, as it is less toxic than artificially sweetened and often caffeine-laden sodas.)

    Can large amounts of iced tea–5 to 7 large glasses at breakfast and lunch (combined) create an unwanted interaction with medications? Is this a “toxic” amount of iced tea to be consuming every day?

  • http://www.addconsults.com Terry Matlen, ACSW

    It makes sense. However, in our case, my daughter’s pdoc would not go higher than 70mg of Vyvanse. My daughter is a fast metabolilzer and has been on stims for 15 years. She switched from Adderall XR 40mg to Vyvanse. 70mg Vyanse was like a placebo. Finally, we had to switch to another doc who put her on 90mg and it’s been great.

    The other doc was simply uncomfortable going up to 90mg. Yet, she’s been following my daughter all these years. I hated switching…

    Terry

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