Intuniv For ADHD: Dosing Details

by Dr Charles Parker on November 28, 2009 · 245 comments

Intuniv For ADHD Is Guanfacine, But Better and Easier

4139448544 d97445222b m2 Intuniv For ADHD: Dosing Details

Fresh Day For ADHD

ADHD treatment evolves: This will be a short note to quickly address the growing comments here at CorePsych Blog on the previous Intuniv post.  There I discussed reports on the differences between Tenex and Intuniv, now that I have seen the action in my office. Tenex, generic name guanfacine, has been used for years with specific good effect to manage and treat the angry and irritable individuals with ADHD – the Oppositional and Defiant.

Remember: Intuniv is not a stimulant – refills on prescriptions will not be so problematic. This medication for ADHD is not a Ritalin ADHD concern!

Intuniv and ADHD Audio Reports At CinchCast:
My last Cinch Recording [11-20-10], already Tweeted out, tells you in about 2 min the details on Intuniv dosing strategy, and I will also outline them here. Listen to my comments on the other CinchCast recordings on Russell Barkley and Amy Arnsten from Yale. Another more recent recording is embedded below.

The Differences Between Tenex, Intuniv, and Clonidine

1. Tenex has a shorter half-life, and often requires at least twice a day dosing.
2. Intuniv is once a day, and, interestingly often remains effective for irritability in the next AM – coming up to my favorite subject DOE [Duration of Effectiveness]: in this case – 24 hr!
3. Tenex has peaks and valleys of effectiveness with dosing strategies that require significant adjustments to dial in correctly.
4. Intuniv is easier to dose: See the protocol below.
5. Clonidine is an alpha 2A agonist, encouraging the closure of the post synaptic calcium channel, but also stimulates other alpha 2 receptors [B&C], thereby creating more problems with hypotension [low BP] and encouraging sleep.
6. Interestingly, Intuniv has a significant soporific turn, but in the 12 -14 hr range often helping with sleep, without further medications in the PM and no dose necessary at noon.
7. Clonidine is not approved by the FDA for treatment for ADHD.

Dosing Strategies: Uncomplicated
1. There will be few problems with dosing as Intuniv comes closer to absolute simplicity than many of the other ADHD meds.
2. Titration: First week 1mg in the AM, second week 2mg, third 3mg and fourth week 4mg as indicated by response – highest recommended dose = 4 mg/day.
3. Bottom of the Therapeutic Window – it isn’t working – this will be self evident!
4. Top of the Therapeutic Window is determined by side effects on the forced dose study completed for FDA safety/efficacy approval – simply being soporific [sleepy] or fatigued – the two main adverse effects when the dose was pushed up [too] quickly for the study.
5. Look for an effect lasting 24 hr regarding the Sides of the Therapeutic Window. AM cranky/anger often disappears.
6. Most people were successful with the dose at 3-4mg/day, so be patient, don’t rush the increase, watch for side effects, and if it’s too much back down to the previous dose.
7. Most did well at 3mg, the dosage is often weight related, but not always [more weight-higher dose] details later.
8. A significant number are doing well at 1 and 2mg.
9. If you are coming over from Tenex, drop the dose down, start at the 1mg and work your way up.
10. Not recommended with Clonidine for bed, for obvious reasons – using more of the same type of medication.

Other FAQ and Observations

1. It can be used with Vyvanse and Methylphenidate products, more posts coming soon on this matter.
2. It has an excellent effect on simple Inattentive ADD, just for attention and is approved by the FDA for ADHD.
3. First line indications for this medication: ODD, anger, frustration, irritation, in spite of doing well on other ADHD meds.
4. For those medical teams out there looking to treat angry kids with atypical antipsychotics for “childhood bipolar” this looks like [purely anecdotal] it will be good for some of those kids who look bipolar, but are actually more ADHD with ODD.
5. Confusing presentations can still be explained by more comprehensive neurotransmitter evaluations reported elsewhere here at CorePsych Blog. Using neurotransmitter precursors to support neurotransmitter imbalances simultaneously with Intuniv show no challenges, and have worked exceedingly well with some of the most refractory kids seen in our office.
6. Incidence of hypotension in the forced dose titration trials was 6% with Intuniv, and 4% with placebo.
7. No deaths reported from guanfacine since it was launched in 1986.
8. More on the specifics of glutamate relevance as a new focus for ADHD neurotransmitters coming soon.
9. This medication is not like Strattera at all [except that it is not a Schedule II]. Strattera only effects norepinephrine reuptake at the synapse, Intuniv actually modifies/facilitates glutamate neurotransmission. Glutamate is the most prevalent neurotransmitter in the brain, with ~ 1/3 of the brain receptors = glutamate. ADHD can be corrected by enhancing flagging glutamate networks through the post synaptic activity of stimulating that alpha 2A receptor post-synaptically. More on all this, and some important drug-drug interactions soon.

My Prediction
Bipolar Redefined: This one is anecdotal, but relevant for future watchfulness: With all of the ‘bipolar’ misdiagnosis so prevalent out on the streets [identifying almost any angry mood as a primary mood disorder] – when the underlying oppositional and anger problems so often arise from the oppositional subset of ADHD, Intuniv will change treatment protocols and outcomes.

Said another way, the use of atypical antipsychotics so frequently in children and adolescents will no longer become the first off label choice – if the diagnosis is actually ADHD and treatable with Intuniv. My take: Intuniv should/will become first line for this subset. We are already seeing, both in our office and in comments from many physicians, a trend in this direction. Time will tell. Intuniv wins hands down on the safety issue, and appears, at this early juncture, to help rather remarkably with those angry moods.

Drug Interactions
1. From the package insert: Intuniv is a CYP450 3A4 substrate. It will be induced [reduced in effectiveness] by Trileptal, Provigil and Tegretol. It could accumulate, and take the patient out the Top of the Therapeutic Window with Prozac, Paxil, and Luvox all of which significantly block 3A4.
2. Suggestion here: don’t use Intuniv with these latter 3 medications at all. Prozac and Paxil, as you know from my many comments on these meds regarding the 2D6 CYP450 pathway, regularly create unpredictable outcomes with stimulants – and over here on the 3A4 [I think I'm on an LA freeway icon wink Intuniv For ADHD: Dosing Details ] they are still dirty drugs. This drug interaction duo should be on your ADHD medication radar, and off your list for patient care. If you are on the Trileptal group of inducers, expect a significant accumulation when you discontinue any of these as your dose may have been higher as a result of this induction process.

Food Allergies

Milk addiction, casein, gluten and other food sensitivities preclude effective dosing strategies based upon the Roving Therapeutic Window discussed elsewhere.

More Details – Listen to These Intuniv Audio Notes from March 15, ’11[4.33m]:

 

ADHD Medication Rules

For many more details see my book: ADHD Medication Rules – it outlines specifically why stimulant meds so often miss the mark.

Intuniv remains an interesting new ADHD treatment option…
cp

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Intuniv For ADHD: Dosing Details

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Tagged as: ADD and ADHD, ADHD, ADHD Medications, adhd meds, adhd predominantly inattentive, ADHD treatment, antihypertensive agents, Atomoxetine, Attention-deficit hyperactivity disorder, Atypical antipsychotic, brain, Celiac Disease, Child and Adolescent, cinchcast, Clonidine, CYP 450 3A4, dopamine, dosed, Dosing, Dr Charles Parker, FDA, Food and Drug Administration, glutamate, Guanfacine, Intuniv, intuniv for adults, Medication, Medicine, Mental health, methylphenidate, milk addiction, neurotransmitter precursors, nootropics, Norepinephrine, Psychiatry, Psychology, requires, Russell Barkley, Stimulant, Stimulants, strategies, strategy, Tenex, tenex adhd, therapeutic, Therapeutic Window, window, yale

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  • Anonymous

    Dr. Parker,
    My son is 9 years of age.  He has ADHD and was started on Intuniv 8 months ago, and he is now on 4mg.  During the last 3-4 months he has been less focused, too talkative in school, and much more active.  Intuniv is still working, if he misses a dose, I can tell right away by his behaviour.  What medication will you recommend to add along with Intuniv.  I have no medical insurance and will prefer something in the generic type.  please let me know, Thank you

    • http://www.corepsychblog.com drcharlesparker

      Braft,
      First make sure you are at the best dose of Intuniv, if you have room to increase do so, if at 4mg, then the next best thing without insurance is simple adderall IR but he will have to go to the school nurse at noon, no biggie. If he is too sensitive for that look into the generic ritalin time releases.
      cp

    • http://www.corepsychblog.com drcharlesparker

      I just caught your other note, and edited your first comment to include that he is on 4mg, so the next steps are as described.
      cp

  • http://www.corepsychblog.com drcharlesparker

    KES,
    Look forward to seeing you – the answers will be in the data… most often the tests that have already been run don’t cover the chronic subterranean factors that we test for. Talk soon!
    cp

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  • Gerald

    Dr. Parker,

    My 9 year old son was diagnosed with Tics about two years ago and ADD this year by his pediatrician. His tics became extremely bad this past summer and after doing much reading on-line I asked that we try Intuniv since there is some indication that it might help with tics. We worked our way up to 3 mg but weaned him back off since it did not help his tics at all and 3 mg seemed to make him “sedated”. It did seem to really help with ADD and mood swings!

    About a month ago…his temper, irritability and rages were really starting to effect our family. So I asked our Doc if we could try Intuniv again, but this time we were looking to treat his ADD not the tics. We are up to 2mg and that’s were we’ve stopped since we know 3 mg made him too sedated. We have seen some improvement in his mood but now we are having sleep issues at night. He wakes up every night around 10:30/11 pm and has trouble falling asleep again and when he does he is constantly flopping around in bed and does not seem to fall into a “deep” sleep?

    The first time we tried Intuniv we gave it to him at night after dinner, but he was very sleepy during the day. This time we are giving it in the morning and he does not seem as sleepy during the day but now his teacher is reporting that he gets a little sleepy at school? I really think this might be because he does not get enough “quality” sleep at night?

    Do you have any suggestions as far as night/morning dosing or what might help with sleep at night? And do you know of any Docs in the Dallas area that might be able to help us sort this out? Or maybe we should schedule a phone consult with you?

    I would appreciate any suggestions!
     
    Thanks,

    Gerald

    • http://www.corepsychblog.com drcharlesparker

      Gerald,
      Quite honestly tics are some of the most difficult situations to resolve, are quite often seen with ADHD, both on the front end before stimulant meds, and after stimulant meds as well. For many years the original tenex seemed to help with tics somewhat, and in our practice we have regularly had some salutary effect not only with tenex, but with Intuniv, and quite frequently with Neurofeedback.

      Further, as you well know, stimulants can significantly effect/encourage tic disorder. Interestingly you and your doc need to know we have seen tic encouraged/aggravated by Intuniv at times, – so Intuniv isn’t simply a panacea, tho it is my favorite med if insurance will let me use it.

      What I do recommend, now having had many levels of experience with neurotransmitter testing [see this video in spite of it's poor production and slides -> http://www.corepsychblog.com/2011/10/adhd-treatment-video/, is that glutamate excess does not respond well to Intuniv, and in fact all tics are encouraged by two main issues: immune dysregulation not corrected [e.g. casein, gluten, eggs], and, often associated but sometimes independent, toxic issues secondary to heavy metals lead, bismuth, mercury, etc. The toxic treatment requires specific chelation and is less common, but needs consideration/attention if other, easier data proves refractory with subsequent treatment.

      Final note, quite simply: after all of this, I do feel a consult would be helpful because we could quickly drive down to the root cause instead of chasing symptoms. We have had significant good results with IgG and neurotransmitter testing, subsequent changes in diet, and neurotransmitter precursors mixed with meds as indicated in the context.

      Not promising anything, as medicine always has a significant unpredictable element, but more data frequently brings better results, and we can do all this by phone, unless you would like me to write for meds. Increasingly we are finding docs working with us locally, just depends on your local medical crew, how data driven they are, or how much in denial of basic science.
      cp

      • Gerald

        Dr. Parker,

        Thanks for your response! My wife and I are very eager to start working towards a solution, not only for our son but to bring a little peace to the household. How do we go about contacting you for a consult?

        Gerald

        • http://www.corepsychblog.com drcharlesparker

          Gerald,
          Sorry to be so late, now having to cover the comments on the weekends as have been working on CoreBrain and posts that are burning to get out on time. Easy ans, wer to your question: connect with Sarah at http://www.corepsychblog.com/244-2/ our CorePsych Services page, and she will get you filled in on the details, bottom line we will push to get you in asap.
          cp

  • http://www.corepsychblog.com drcharlesparker

    Karl,
    My quick take: when you talk to your doc drop back, not up. Let Intuniv sit a bit longer before going up and take a more conservative dosage adjustment strategy as your guy sounds a bit like a “slow burner” [Type that into SEARCH for more info]
    cp

  • http://www.corepsychblog.com drcharlesparker

    Karl,
    My quick take: when you talk to your doc drop back, not up. Let Intuniv sit a bit longer before going up and take a more conservative dosage adjustment strategy as your guy sounds a bit like a “slow burner” [Type that into SEARCH for more info]
    cp

  • http://www.corepsychblog.com drcharlesparker

    Laura,
    Sorry completely inappropriate for me to suggest specific changes on the Internet – especially with folks I haven’t seen… the troops would soon be at my door and leave with my license in their hands. Won’t go there on the Intuniv.

    On the other hand your guy has very typical findings of metabolic imbalance and it would be completely reasonable for you to consult with me long distance on the measurement of those imbalances. Type in “IgG” in my SEARCH here, read my digital *Rules* book [only 10$] and begin to look more carefully at things immune. Just doing an elimination diet doesn’t fix the problem if you miss a single detail. You need all 4 wheels for the car to move down the road!
    cp

  • http://www.corepsychblog.com drcharlesparker

    Heather,
    I can tell you much more on a long distance consult… we do them all the time. Do read my book – for 10$ it’s filled with information you should absolutely have for next steps. If you don’t call I can tell you with considerable certainty more if you SEARCH here for “moving therapeutic window” and “narrow therapeutic window” – with this Disqus I haven’t figured out how to put the links in …. so you will have to check them out. He will be found in those comments.
    cp

    • Heather

      Dr Parker, thanks for the response, I ordered your book and have been reading the pdf form.  A bit over my head with some of it, but I’ll keep reading.  I called today and ordered a new patient packet to fill out for a phone consultation. 

      In the meantime, can you help me understand the dosing for intuniv?  My son was taking tenex 1mg am and 1mg around 5:30pm, but now is taking 2 mg at 8am for 2 weeks now.  School reports even more improvement than with Tenex, but we are having problems at home.  At first he was falling asleep around 6pm, then understandably had trouble sleeping at night.  But now he has trouble sleeping even if he doesn’t nap.  The last 4 nights we have noticed that the intuniv appears to “wear off” around 7 or 8pm.  He becomes hyper and impulsive similar to what we saw before if he got his tenex later in the afternoon.   He does not fall asleep until at least midnight – 1am no matter what.  Is it possible that the intuniv is wearing off after 11 hours? 

      BTW – oddly enough, mornings have been great.

      • http://www.corepsychblog.com drcharlesparker

        Heather,
        Look forward to talking. Several possibilities for discussion with your doc.
        1. If doing better needs some melatonin at bed, or Clonidine depending on response to Melatonin.
        2. Some folks have a better response with Intuniv just at night, check with your doc on this one.
        3. You might need to go down in dose and trim with a stimulant like adderall or Vyvanse. This combo proves useful in that it covers the side effects of both meds thru low dosing of both.

        Look forward to talking,
        cp

  • Karl G.

    Dr. Parker,

    My 6 year old, 40 lb. son is on Intuniv.  He is ADHD and moderately autistic.  We just refilled his 3mg prescription of Intuniv and he’s really wired.  He was finally at normal kid energy on the last prescription.  Do you think that he needs 4mg?  I often wonder if the amount of medicine slightly varies from pill to pill or batch to batch.  The last batch was wonderful!  He was enjoyable and of course, did have his moments but it was like we got our son “back” from this condition.  He did seem a little more soporific but not terribly.  He’d take a nap and would be fine after he woke up.

    I or my wife will call our pediatrician tomorrow (today is Sunday) but I wonder if 4mg would be the right dosage for him.

    Thank you,

    Karl G.

  • Laura Pollard

    Dr. Parker,
    I am new to your blog and want to thank you for the great information! My son is 5 1/2 yo who was given an official diagnosis of ADHD with sensory integration disorder and fine motor delay by Kennedy Krieger Institute in May. Prior to the official diagnosis we tried Concertante for a few weeks and had the angry psychotic a/e’s. So then we tried Focalin for a few days but it made him a zombie. We took a break fro and decided to focus on diet we tried the cassein washout….no change. We have been dye free and HFCS free since March, along with organic meat, milk and produce. Still, no big changes in hyperactivity. So, when Intuniv received it’s official indication we consulted with our pediatrician and began therapy at 1mg in May. It took the edge off his impulsive behaviors but the awful drowsiness and nighttime sleeplessness has never gone away. We tried 2nd but the daytime sleepiness was worse. We dosed it in the a.m, up until this past weekend we changed to the p.m. He just started kindergarten and has a wonderful teacher who says that he isn’t focusing, agitated and still extremely sleepy all day long.

    We are seeing our first psychiatrist on Thursday afternoon so I am hopeful that we can start on a new soltution. In the meantime, is it o.k. To cold turkey the 1mg of Intuniv?

  • Heather

    Dr. Parker,
    Thanks for all the info, I’ve been reading through all these posts.  Where can I find someone who will try some of these things in Minnesota?  My 10yo son has Tourette’s, ocd, generalized anxiety, and Adhd – though bordline on the attention, he is definately hyperactive and impulsive.  We started chlonidine 2.5 years ago to help with tics and were amazed when his teacher reported less impulsivity in class.  Unfortunately it made him so sleepy that we couldn’t increase the dosage as necessary, so it eventually became less effective for that, but still helped with tics.  Last year our son asked his doc if there was something else he could take to help with school as he was always “being bad”.  We started him on Strattera and seemed to help at first, then he became paranoid when we increased, cried all the time and said he was scared.  We reduced it back down and continued 1 month at the lowest dose, the crying stopped, but defiant incidences at school increased 400%!  Off it he went.  He also had started having an issue when he became worried about something and suddenly couldn’t talk.  This started before Straterra, continued while on it and got so bad after it, that he was spending 1 hour in the pm and am unable to talk because he was worried about school.  Dr told us it was anxiety problem called selective mutism, with atypical presentation, as it was happening in anticipation of something.  He started taking Celexa, and the episodes completely disappeared. 
    Still was having trouble in school, so we tried Concerta, again seemed to help at first, cranky in the evening, and AM was near impossible, as he was so hyper.  Then one day he forgot to take it, school called and I had to pick him up, they said he was literally climbing the walls, running around and hiding.  He jumped out of the car when we got home and starting running down the street.  Off it he went. 
    Dr started him on Tenex, he currently takes 1 mg AM 1 mg 5:30pm.  Two months now and much better results.  We are trying Intuniv tomorrow, but I’m worried about switching.
    My son has been tested for allergies and food sensitivity, I don’t know if it is the kind you are talking about, but they took blood and sent it away, it was called “delayed sensitivity” I think.  He was not found to be sensitive to anything they tested.  But he does have allergies.  What is this histamine level thing you keep talking about?  Could his allergies be a reason these medications haven’t been working?
    We planned on starting the Intuniv in the AM, is this the best time?

    Thanks for your help.
    Heather

  • sazzy

    Dr.Parker, First…thank you so much for this blog!  It is beyond helpful and informative.  Quick question regarding how soon is too soon to assess that Intuniv might not be the right drug.  My 9 year old just started Intuniv 5 days ago for ADHD-Combined Inattentive/Hyperactive.  He was on Daytrana for 2 years successfully till anxiety and tics made us stop. He gained 7 pounds and 1 1/2″ in height in the 3 months off Daytrana and we are thrilled.  We have been on Intuniv for 5 days with dosing at 1/2 milligram (days 1-2) and 1 milligram (days 3-4).  We have already seen an increase in hyperactivity, tics, and he has tingling under his fingernails.  He’s had no sleep issues, tiredness, or dizziness.  I just want to get your take on my assumption that maybe his glutamate levels were already normal/high and this just isn’t the right drug for him.  OR…do I wait it out to see the drug reach it’s full potential and how long do I give it to make a correct assessment?  Any input would be greatly appreciated.

    • http://www.corepsychblog.com drcharlesparker

      Sazzy,
      Sorry to be so late, been writing a great deal getting Rules ready for an Amazon launch, see the post today.

      Yes, your guy is highly likely already out the top on glutamate. The tics etc indicate too much excitatory activity. You very likely got that one right! Sometimes, don’t know why yet, Tenex might work when Intuniv doesn’t if the tics are quite easily stimulated. The tingling is often associated with a variety of issues not the least of which is relative toxicity.

      He very likely would be a candidate for neurotoxic review, hair sample, to get that data and assess comorbid challenges from that perspective.
      cp

  • http://www.corepsychblog.com drcharlesparker

    g,
    If no BP problems tenex would be a good choice, the half life is only about 6-8 hr, so you might need to take it AM and Noon, starting with your NP approval of course at .5 2x/day.

    Ensure is a protein drink with significant protein, try that for breakfast. Get more serious about absolutely staying off of milk and wheat, and if that doesn’t do it try off eggs – the Trifecta in allergens.

    Hang in there,
    cp

  • http://www.corepsychblog.com drcharlesparker

    Kev,
    Those two are completely kosher together, excellent choice, just commented elsewhere on the blog on a similar question. With Downs or *any* developmental delay issues I always find, yes always find, improvement, no cure asserted, with neurotransmitter testing to balance those biomedical challenges. See the Testing Options page, your psych would probably like that info, tho likely would be suspicious as we all are of things we don’t know.
    cp
    cp

  • http://www.facebook.com/Rivkasmom Grace Acosta

    Dear Dr. Parker,

    Please forgive me dumping my life story here but I have nowhere else to turn.  I’m on SSDI with Medicare, and I’m sure you know that they don’t cover anything unless you’re hit by a
    bus.  My primary care is a nurse practitioner at a low income clinic,
    and she has no idea about meds.  I get to see a psychiatrist once a year
    for med reviews, and that’s it.  I can’t afford to do any fancy
    testing, although I’m sure I probably need it.  I have a fairly
    complicated medical profile, hopefully you can make some sense out of
    it.

    My current diagnosis is Bipolar Depression (slow cycling), Generalized
    Anxiety Disorder, ADD, Chronic Fatigue Syndrome, Fibromyalgia, Delayed
    Sleep Phase Disorder and Migraines.  I’m 46 years old, height/weight
    proportionate – but I have to work on it.

    In the morning I take Zoloft 100mg, 250mg Depakote and 30mg Buspar.
    At night I take Zoloft 100mg, 250mg Depakote, and 1.5mg Lunesta

    Right now, my ADD is completely untreated, and my disorganization is
    making my anxiety really bad, which then triggers migraines.  I am
    highly distractable, irritable, and prone to wanting to kill people
    /jk.  Trying to stay on track all day is exhausting, and then I go into
    CFS mode.  I’m pretty sure I have no adrenals left at all.  I’m a train
    wreck! 

    Another big problem for me, is that I have NO appetite, ever.  I have to
    force myself to eat when my blood sugar gets low.  Just the idea of
    eating in the morning is enough to make me feel nauseated.  I have
    always hated breakfast, even as a child.  It usually takes me several
    hours to work myself up to wanting to eat anything at all.  I eat as little dairy and wheat as possible, and try to focus on lean protein, fresh fruits and veggies.  I don’t eat
    packaged junk foods at all, and I try to get some moderate exercise like
    walking the dogs or gardening.

    I can’t take stimulants because I have a transient heart murmur,
    anxiety, and mania. I really want to try Intuniv, but I don’t have $500 a month to
    spare.  Tenex is only $5.00 a month at the big chain drugstores.  I am
    very compliant with my meds, to taking one every so many hours is not a
    problem with me. 

    So my questions are, do you see any contraindications with my current
    meds?  Considering my sleep cycle disorder, do you think that I should
    take the Tenex in the morning or evening?  How can I get past my intense
    dislike of eating when I first get up?  Is there something I might be
    overlooking that I should research? (Preferably that isn’t expensive.)
    Thank you so much for your time and concern!
    g

  • http://pulse.yahoo.com/_FYUCWUTNJ7UMS6TEGBZE4NZSQA Kevin

    My 11 yr old daughter (75 lbs) has been diagnosed with the following:  Down’s Syndrome, ADHD, and Sensory Processing Disorder.  My wife and I accept her disabilities, our main concern has been to find some med combination to make her disposition happy or at least pleasant.  She is very irritable, often growling rather than speaking.  Currently, we are trying 3 mg or Intuniv and 15 mg of Celexa.  Do you see any interactions between the two?  Also, do you have any suggestions, our Child Psychiatrist is very open to suggestions.

  • http://www.corepsychblog.com drcharlesparker

    As you know it would be inappropriate to formally suggest your next steps, but I can tell you from a number of discussions with colleagues and clients that night dosing is not at all contraindicated, and, as you point out, it’s likely that the initial response will improve over time.
    cp

  • Wormiemb72004

    My daughter is 6 1/2, weighs 44lbs. She has been Dx w/ ADHD and ODD. She has tried many stimulants and i didnt like the anger and irritabilty she had when she was taking those. She used to take clonidine QHS to help her sleep, they have just started her on Intuniv and the first days she took it, she slept all day and was very lethargic, with this being said, I want to give it a try but will it still be useful if we give it to her at night instead of in the am? Thank You

  • http://www.corepsychblog.com drcharlesparker

    Carolined,
    Only piece you need covered better is the PM drop, and a small amt of stimulant on the immediate release side of things should cover family time! Good to hear from you-
    cp

  • Tinkermom

    My son is diagnosed PDD-NOS, which hyperactive characteristics.  His doctor does not give him a true ADHD diagnosis, but he has been taking ADHD meds successfully since Kindergarten (he is not in 4th grade) and they have helped him immensely.  He is currently on Concerta 36mg.  He started 2 1/2 years ago on 18 mg and we quickly raised him to 36.  He has been very successful on this medication.  However in January his para was complaining that his focus had completely fallen off and his behavior was a problem.  After discussion with his doctor we raised him to 54 mg.  It was awful.  The poor kid was a zombie, so we dropped him back down.  He had lost his whole personality on the higher dose.  He went back to being the happy kid he was, but there were changes so as it turns out we do need to make a switch.  Concerta used to inhibit his appetite and now he eats like a horse…that’s just one example.  And he definitely cannot focus the way he used to.  Sometimes we even wonder if he is overfocused because he will concentrate on one thing and it completely stops him from doing anything else.  For instance, he’ll write his name and get stuck on the second letter. 
    We have a med check tonight and his doctor told us to research Intuniv.  I’ve read some very good things about it, and I love that it is not a stimulant or controlled substance.  I’ve also read, though not on your blog, that some children wake up in the middle of the night frightened and out of sorts and cannot go back to sleep.
    Our doctor wants to try to introduce Intuniv in addition to the Concerta.  I’m not sure whether he wants to keep the 36 mg dose of Concerta or lower that when the Intuniv is introduced.  I’ve read a few items saying that the balance of the stimulant and non-stimulant has been successful.
    What are your thoughts?

    • http://www.corepsychblog.com drcharlesparker

      Tinkermom,
      The balance can be successful with Intuniv and Concerta, and poses no problem from a drug interaction point of view. When I have problems like this I consider two things:

      1. Concerta is very difficult to titrate and find the right dose because of the way it’s made – the doses don’t help with small adjustments. That’s another reason I prefer Vyvanse.
      2. I always consider the possibility of metabolic challenges when the med sweet spot is narrow, or appears to narrow as in this case. Breakfast, sleep, bowel frequency, nutrition and even immune dysregulations can all contribute to significant problems with med precision.
      cp

  • http://www.corepsychblog.com drcharlesparker

    Michele,
    I stay away from Prozac with any of the drugs for ADHD for the following reasons:
    http://www.corepsychblog.com/2009/12/intuniv-for-adhd-avoid-drug-interactions/

    Everyone is different on Intuniv, some do better at bed some in the AM… likely the Prozac is backing it up, giving your team a cloudy picture based upon the interaction with the Prozac blocking 3A4… and making it almost impossible to regulate. If he was on stimulants with the Prozac that is the specific reason they didn’t work – reactions based on 2D6 interactions – this from a post almost 3 years ago: http://www.corepsychblog.com/2008/12/add-adhd-medications-amphetamines-2d6-drug-interaction-update/

    I completely agree with your view of the “playing with it” concept – nuff said.
    cp

  • Squirmy08

    How exactly does Intuniv work? I know most ADHD drugs increase nor-epinephrine levels in the brain but this one decreases nor-epinephrine levels. What exactly is the physiology behind the drug?

    • http://www.corepsychblog.com drcharlesparker

      Take a look at the several blogs I have earlier than this one on Intuniv – specifically the one on tenex and alpha 2 agonism – the specific action on glutamate neurotransmission is documented and linked there. Thanks,
      cp

  • Darrius Jenkins

    can intuniv be used for adults adhd?

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

      Darrius,
      Not approved for adults by the FDA as yet, but many are using it with the caution about the blood pressure as the main concern for side effects and proper screening.
      cp

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