Intuniv For ADHD Is Guanfacine, But Better and Easier
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 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.
Intuniv Audio Reports At CinchCast:
My last Cinch Recording, 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.
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 
] 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.
cp
This post does bear retweeting! Please send it out to your crowd.
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Make sure you take a look at these pages!
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“Rules” Affiliate Link
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Dr. Parker,
I had a question. I have had some issues with overfocusing at times and dealing with stress overload when I have multiple things to do and then doing and executing one job at a time. This predicament has had quite a negative effect on me and caused me to stop , then start a task and this ends up carrying over into life and seemingly I have issues doing many things at once with accuracy. At work I am speaking of working as a broker and doing several things, by email, instant message and phone calls all at once. It has lead me to alot of frustration and even physical symptoms of anxiety at times. Well, I have tried ssri’s in augment to my stimulants but it quite frankly turns me into a zombie at work and makes things work. I mean two weeks go by and I end up being less frustrated with amplified adhd symptoms and no motivation… I have tried tenex at night at low dose and feel alot better, a few headaches when starting but I think this must be the right path for me. As with tenex , based on my experience I feel that the stress overload is basically me to be more and more distracted at work with incoming channels of stimuli and the addition of an ssri would in theory make sense but actually worsens my syptoms, thus making tenex the likely choice by lowering frustration without lowering cognition while decreasing distracting stimuli while at work. Would you agree with that?
Jeff,
Tenex would be a good choice if, in fact, it was helpful! If you were in my office I would ask you many pointed questions about Cognitive Anxiety, which seems to be abundant in your presentation. See the very last 1-2 min of this video to show you why the SSRI is creating that problem!
My quick take, since you asked, – why struggle with Tenex at night with its short half life, no effect during the day, and some significant ADHD symptoms.
If you were in my office and I had the time to go over your situation more carefully to confirm the findings I very likely would suggest a good stimulant med like Vyvanse as a first choice with its 12 1/2 life. No need to struggle when you can get correction so easily with a careful titration of a more effective stimulant med.
cp
Hi Dr. Parker,
My 9 year old son is doing well on 5mg of Abilify and 2mg of Intuniv. The Intuniv seems to help with his follow through and his ability to participate in activities. His diagnosis is ADHD and SPD. He has some Asperger’s traits but not enough for a diagnosis. He does not do well on stimulants…way over focused and more inflexible. Zoloft alone made him hypomanic. His Doctor does not feel we can diagnosis Bipolar disorder at this point.I tried to take him off Abilify last spring hoping maybe Intuniv would be enough. He started showing some hypomanic behaviors about a week after we stopped the Abilify so we started it again. He was better in a matter of days.
I have 2 questions. Do you think his prior medication responses indicates Bipolar disorder? Also he has gained allot of weight quickly both times we have put him on Abilify. It is very difficult to keep his weight from going out of control. We work very hard to keep him active. Try to avoid sugar and processed food. It sometimes feels like a losing battle. Any thoughts?
Sandy,
Many think that meds reveal underlying bipolar – but I don’t. Bipolar is a diagnosis of appearances only, and from that perspective, yes, he may *appear* bipolar. I don’t think that anyone should be writing meds without thinking metabolically and of the multiple biomedical reasons a child can regress. I can guess on this one: his serotonin is likely too high, he is likely suffering with an immune condition, likely has significantly modified bowel transit time, and I can be certain that without knowing the biologic his treatment will remain a roll of the dice based upon appearances.
My new book ADHD Medication Rules documents these issues in some detail.
cp
Hello Dr. Parker,
My 61/2 yr old son is on Intuniv( 2mg for 2 months). Originally he was taking the med in the morning, but this made him terribly sleepy. We switched to the pm and he has been doing beautifully. I thought to change it back to the am dosing time because it was built up in his system and wanted to see if the great results got greater. Well…he was off the wall today! Extremely hyper, impulsive (placed himself in over 5 dangerous situations), some aggression, irritability and so on. I was taken back. Of course we will go back to the pm dosing starting tomorrow night (he had it this am and I didn’t want to give it to him again 12 hrs. later). My question is WHY? Why did this happen? Just to be clear…he had his dose of 2mg at night (Tuesday), nothing on Wednesday night and gave him the following dose Thursday morning. I know it is a 24 hour duration and I didn’t want to overmedicate.
Also, I have heard that this medication begins to wear off after time. Why does this happen? And in your experience, what is the duration of expectancy long term? I feel like it’s too good to be true sometimes and I’m waiting for it not to work. I don’t want to be negative, but I saw this happen with Focalin XR with him. He was on 10mg and was great for 2 weeks, then bumped it up to 15mg and he was withdrawn. Then Focalin XR 10mg with Intuniv 2mg and he became OCD and terribly anxious, withdrawn and depressed. So we are just on Intuniv now. I just wish there was something that worked that we and HE can depend on.
And one more question.
It is my understanding that Intuniv helps with the adhd child’s working memory. Is this true? On stimulants, my son was focused, but appeared robotic. He was almost too focused. It also was in the system and then gone..so what skills and strategies are they really learning for the long term? I feel as though the Intuniv does not help with focusing as much. However, over time, I am noticing he is able to recall short term memory skills which he was unable to do in the past. Does Intuniv help build the working memory, given that it is a 24 hour med and there is no lapse of effectiveness?
Thank you for your time,
Melissa
Melissa,
Yes, it does look to the researchers that Intuniv does assist/address working memory. Sounds like the PM dose is the best based upon your experience in his specific response.
Regarding changes in effectiveness over time: All psych meds can and do change in effectiveness over time, as neurotransmitter availability changes with growth, nutrition, stress, hormones etc. It appears that Intuniv is not one of those meds that has a high rate of deterioration over time, but that it is comparatively stable to some of the stimulant meds, requiring less frequent adjustments once dialed in correctly.
cp
Hi Dr. Parker-
Many questions…is your book available in hard copy, or only as an ebook? Also, what are your thoughts on Celexa for OCD/anxiety? I’ve written you before, my son has ADD, OCD, Tourettes which is mild right now, and Trich (has pulled eye lashes out so many times it appears they may not ever grow back). He’s been on Luvox for OCD, but compulsions don’t appear any milder, and Luvox is quite expensive under my plan, compared to Prozac & Zoloft. Doc is willing to try what I suggest. I’d like him off anti-depressants (since they aren’t helping w/OCD), but when we tried last summer he was still emotional after 3 weeks, so doc said it may be him as oppposed to withdrawl. SO, how long does it typically take to wean off of SSRI’s (it was Zoloft then)? Off of Luvox specifically? More than a few weeks? He’s had suicidal thoughts, so as much as I want him off (it’s been 3 years), we have to be cautious.
Also, doc suggested we try Vyvanse for ADD, as he seems to get tolerances to…so far…Adderall, Focalin, and now Concerta. I know everyone reacts differently, but what is a preferred combo for OCD/ADD…SSRI/stimulant, from your POV?
Thank you,
Mk
MK,
Only an eBook now, will be a hardback after we develop a readership on this level. Hope you enjoy!
RE: your guy – every single one of the characteristics you describe is representative of
1. Disarray in the neurotransmitters, likely unbalanced with some too much and others too little.
2. Immune system dysregulation is highly likely – with a likely Histamine elevation on the NT testing.
3. A consequence of the immune dysregulation is a bowel problem, either constipation or diarrhea or both, picky eater etc. The GI problems can occur in either the North or the South!
Speediest intervention: measure and correct the imbalances whilst mixing the appropriate meds as indicated by history and NT findings. Likely will need a dietary plan/change as well when you get that info.
cp
Dr. Parker,
My 11 year old daughter was being treated for ADHD with 2.5mg Abilify and 15mg Focalin XR. Due to side effects and emotional outburst we stopped the Abilify four weeks ago. She did fine at first, but became more and more frustrated on just the Focalin XR (DOE was about 6 hours). We tried increasing the Focalin to 20mg which substantially increased the frustration and irritability. Decreasing her dose decreased the DOE and she was still frustrated/irritable. She has always had trouble on stimulants alone. Her Doctor suggested we try Intuniv without a stimulant at first to see her response. We are on day 3 at 1mg am dose and she is extremely tired. She sleeps most of the day becoming more alert 9 to 10 hours after the am dose. Should we try pm dosing, add a stimulant, or both? Years ago she tried low doses of Adderall XR. DOE was within expected range but she would pick at herself.
Thank you for your help.
Chandra
Chandra,
When tired like this we often find the attention has fallen off and continue with a stim, and if the Adderall XR working in the past, that might be best. My personal choice for augmented/combined therapy is Vyvanse and Intuniv, and, as I have always indicted here, if the basics don’t work well, just make sure you get into that next level of inquiry, don’t let it drop, and try the neurotransmitter testing.
cp
Dr. Parker,
Thank you for your prompt response. Your website has become an invaluable source as I try to educate myself regarding ADHD medications. I just downloaded your new book and look forward to reading it. Intuniv is not helping the way we had hoped. The somnolence during the day did not improve and we saw an increase in her irritability. We stopped after only 5 days. I know this is too short but she was feeling worse not better. We have gone back to low dose tenex -.25 mg in the evening. She becomes a happy, pleasant child in about 30 minutes. Why can she tolerate very low doses of Tenex but not Intuniv? Would this indicate a problem with her metabolic rate? (As a side note, I have not yet tried Vyvance because I wanted to chart the effects of one medication at a time.) We see her doctor this week and I am going to ask for neurotransmitter testing. I think he will be open to this, if not, I will find someone who is. What other testing do you recommend?
Chandra,
Thanks for taking a look at Rules – it is pretty darn comprehensive – and therein I think you will see that your girl very likely has a metabolic problem. The rate of burn is just too slow, and no genetic changes in the system that metabolizes Intuniv. The dose of .25mg is so very low it is below the side effect level. Interestingly, if you stay with the Tenex for awhile you may find that a very low dose of Intuniv [1/2 of a 1mg] might work after a few weeks on Tenex.
Testing, no question about it – I have had so many good responses with NeuroScience neurotransmitter testing – but if that Histamine is up you will have to chase down possible immune system challenges with an IgG review of food allergens. NS has several different test options including one for ~49$ [22 basic foods] you can check out their website and more info here on this CorePsych Blog page.
Thanks again!
cp
Doctor,
Thank you for your interesting and informative website. My 7-y-o son has been diagnosed with ADHD and ODD. He is incredibly bright, but unable to control his emotions or temper. We tried stimulants starting at age 6(Concerta and Adderall), which left him zombie-like, crying and with tics; Strattera for a few months with very limited effectiveness, Strattera and Celexa, which seemed to help with anger and frustration at least for a month or so but then stopped working; and most recently was on Intuniv and Celexa. He started the Intuniv at 1 mg for the first week and then stayed on 2 mg for a few more weeks. At the start of those weeks, he responded so well that his teacher and parental assessments were coming back to no longer put him in the ADHD/ODD diagnostic category. However, after a few weeks, he became increasinly tempermental and frustrated. He was taken off the Intuniv and left just on Celexa for a week. He became not only more irritable, but absolutely manic. He then went med-free for about a week and while he was no longer manic, he was incredibly angry and frustrated. We have put him back on Intuniv (just finished 1 week at 1 mg and are now in our first week of 2mg). As with our previous experience, hyperactivity is greatly reduced, but still having big problems with anger/frustration/irritability/violence. Is there another medication that can be combined with Intuniv to help with the anger/frustration issues (I know definitely not Paxil, Prozac and Luvox from your post above)?
Nancy,
Zoloft might be a good choice to discuss with your doc – is clean on 3A4 and 2D6.
Likely the Celexa dose was a bit too much, sounds like you were on the right path. Zombie on the previous meds only indicates a dose that was not adjusted carefully enough… he sounds very med sensitive, needing very small doses rather than the average for his age/size.
cp
Dr. Parker, I have an 11 yo son who originally was diagnosed with PANDAS when he was 3. We already know of the immune issues as he and his neurotypical 7 yo sister both inherited my celiac disease. I am currently using Vivaglobin SGIg for my PID. Things were pretty well with Cameron for the last 2 years but this year we have had more aggression, ODD and just horribly mornings and emotional explosions than we can really handle. He takes 18 mg Concerta in the am and at noon, .05mg Clonidine 3x a day, and his Risperdone was increased to .25 3x a day but it’s just not working. He has been diagnosed as having TS (related to the basal ganglia damage from the PANADAS and it acts up when his strep titers are too high), ADHD, and PDD-NOS. Two months ago he was asked to exit his school at the end of this year because they can’t provide the appropriate environment for him any longer. As we live in Japan (US and French citizens) we are forced to deal with the bulk of our medical situations during summer holidays to the Dallas area. My neighbor was recommended Intuniv for her daughter who has many of the same aggression issues stemming from her ADHD and PDD. I would like a bit more knowledge when I go in to speak with the doctors who are great at giving behavioral advice but poor at listening to “the parent”. We do have a doctor who does our follow up here in Japan, but she goes on the recommendations of the US doctors and unfortunately the Japanese system is a bit ancient in these areas. I would welcome any advice, because it’s looking like I”m going to have to home school and it scares me to be honest.
Robin,
You do have your hands full, but don’t despair, much more can be done nowadays with more info. I do like Intuniv for these kinds of complicated issues with the impulsivity and ODD dysregulation, but I would encourage you to drive deeper for more information rather than simply treat the symptoms. Over here more understand and use it, and the fact that it hits different receptors brings excellent promise for a trial.
You [yours is already in evidence], and likely Cameron. both could profit from further testing such as the IgG testing mentioned elsewhere and here under Metametrix to find possible offending antigens and remove them. If you want to do the testing in Japan and have LabCorp available there the test # is 680230 for IgG [96 foods].
Downstream from immune issues very often is leaky gut, and perpetual increases in immunity related issues if the gut isn’t directly healed. With the immunity is almost always found nutritional problems secondary to the malabsorption with the gut deterioration. Many of these folks have symptoms of changes in transit time that foretell the need for further action.
Take a look at the many other references here at CorePsych Neuroscience on this complicated subject.
cp
My daughter is 6 and we have tried about all the stimulants there are, some worked for awhile, then we upped the dose, they made her angry or anxious, nail biting, skin picking etc… She has adhd and odd and she has been very argumentive, interuptive and angry. She is currently on metadate cd 40mg, does not work at all, lots of problems at school, thinking about trying intuniv, what do you think,? IF she does try it, should she contine taking a stimulant along with it, or quit those and just be on the intuniv, thanks so much
Traci,
Every time I hear this series of stimulant trials with no or little response I am quite certain the person in question has:
1. Measurable neurotransmitter imbalances, likely a mixed breed of too many excitatory neurotransmitters, and too few inhibitory, with a diminished level of dopamine. Measurement is the absolute next step. Many other combos could be at play, but this pattern is one we see multiple times everyday in our office.
2. Highly likely that she has an immune dysregulation with IgG imbalances and specific reactions to food. Could be other toxins, but foods need to be assessed first as they are so easy thru many nationally available labs… see other comments here on which LabCorp test. The food thing is big, and many specific books tell you what to do once the offending antigen is discovered.
Yes, Intuniv is certainly worth a try, and often works in these challenging presentations – absolutely. Especially because it hits that different neurotransmitters system: glutamate. Only problem: PEA, DA, and NE all effect concentration and focus on the excitatory side – so the solution is not a simple one trick pony.
Your next best bet:
1. My strong feeling on the new standard of care – Always: Measure neurotransmitters before moving down the line for the big atypical antipsychotics with their multiple metabolic challenges and long term side effects.
2. We measure in every other aspect of medicine when we are unsure, why not psych? Basic…
cp
Hi Dr. Parker, You seem to have an incredible handle on all of the ADHD medications and a wonderful way to explain the pros and cons to parents. My son is 9.5 yrs old amd weighs about 64lbs and has ADHD and some aspects of Aspergers as well as recurrent worries. He has tried every stimulant on the market except Vyvanse. He had a lot of anger when on adderall and since it is in the same family as Vyvanse, our dev. ped. has been reluctant to try it. He has been on Strattera 40 mg for 2.5 years. He seems to do better with the Ritalin family of meds and has been on Ritalin LA (not long lasting enough), Daytrana (bad skin infection) and is currently on Concerta 18mg in addition to Strattera 40 mg (pm). He also takes 3 mg of melatonin to help him get to sleep at night. We are not at optimal now as he is extremely disorganized and unfocused though his body is relatively calm. We tried to increase to Concerta 27mg and he got very weepy and angry so we dropped back down to 18mg. So we have been using the non-stimulant Strattera as the main medication with a low dose stimulant as a boost to improve focus. Since we are not at optimal and a new non-stimulant is available, I have considered weaning him off of Strattera and trying Intuniv. Which is better for kids who tend to have anxiety? It is not completely terrible right now, but I feel if my child is going to be medicated, we might as well have the intended results. Thank you for your consideration of our situation.
Michelle,
Thanks for your kind remarks.
1. Intuniv would be a good choice as the main thrust of your concerns at first appears to be the ADHD symptoms.
2. Vyvanse often works well when Adderall doesn’t – same molecule, different delivery makes a considerable difference and with his sensitivity you might try the water titration process at very low doses.
3. Strattera is almost purely NE in effect. Meds aren’t specific for superficial symptoms such as anxiety, but are only specific for different neurotransmitter indications measurable thru, for example, NeuroScience.
4. I would seriously look at enteric allergens, see the IgG testing pdf on the Neuroscience page here.
Totally agree with shooting for predictability!
cp
Dr. Parker,
My son is 6 yrs old. He has TSC (tuberous sclerosis complex). He is on Trileptal twice a day for seizures (he has been seizure free for 2.5 to 3 years). We strongly suspect that he may have ADHD (OC type) and I came upon Intuniv, however, I see that it is not as effective if taking a class III med. Any suggestions?
Kelly,
Intuniv and/or stimulants are both indicated. The Intuniv might be the best bet to try first, as it is a non-stimulant.
cp
Hi
My son is 9.10 years old. He has been on Abilify for 6 months, 1mg daily (we started with 2mg, but it was too sedating) and it has worked well for him. He is diagnosed with a mood disorder, GAD, ADHD, emotional dysregulation, tic disorder and has LDs (and is a super sensitive sweetheart!). Anyway, his GI doc found that he has elevated liver enzymes and thinks it’s from the Abilify so we (with his neurologist) decided to take him off. I have a prescription for Intuniv here. It is day 3 without Abilify and he is having a really rough time. He is crying a whole lot, angry, aggressive, unfocused, says he ‘misses’ the Abilify and hates how he feels. My question is, do I start the Intuniv now, or wait till the Abilify is out of his system? If i start the Intuniv now, how will I know if he is having a bad reaction to the Intuniv or if it is a withdrawal from Abilify? Will the Intuniv help with the withdrawal side effects of the Abilify? Thanks.
Elizabeth,
Abilify has no withdrawal, and does not increase liver enzymes. Liver enzymes are likely elevated by immune dysfunction that could be tested by LabCorp #680230 IgG 96 Food Sensitivities – been there, seen that one, worth a look-see. No reason to wait for Intuniv, no interaction, no problem, and less cost to the system than Abilify. Both can be used together, but need to chase down those liver numbers and look at bowel function.
cp
Dr. Parker,
Your blog continues to be so helpful! Based on your anecdotal experience with Intuniv, have you seen any benefit in going above 4mg with an adolescent who is tolerating it well but seeing little benefit? Stims and Strattera have not been well-tolerated so our md is considering going higher on the Intuniv, but believes that those studies are just being done now.
Any insight?
Thanks, JB
JB,
With Intuniv and the ADHD meds I look for every option before going to the non-approved levels. To answer your question specifically: I don’t go over 4 mg. For your situation, unless you are completely against stimulant meds, that would be the next move in my office. As you likely know my favorite is Vyvanse, and often a very low dose like 20 mg will turn the day. Remember to work with your doc to dial it in correctly and the two often significantly compliment each other.
cp
Hi there! After a couple years of battling with being told my son has attention & impulsive issues in school and a late diagnosis of Dyslexia, we just recently started him on Intuniv 1 mg daily. Over the past few years I have changed his diet, limiting junk food to nil if possible and trying to avoid dyes as much as possible, feeding him the most natural foods I can that he likes with an occassional splurge. There were some small changes in behavior but not consistent. He has been on Intuniv for approx 2 1/2 weeks. We started it in the evening because I thought that is what the doctor had said. The teacher, tutor and myself noticed a small change in his focus and reading, more smoothly and at a better pace. I noticed here at home that I didn’t have to repeat myself so much when asking him to do something. Since his checkup last week we started giving it in the a.m and he seems to be more distracted again when getting ready for school and more hyper. What dosage seems to be the most effective for a 9 year old and when is the best time to administer it? The doc said we could increase the dose, I was wondering if 1 mg in the a.m and p.m would work? Curious on your thoughts, you seem to be more experienced with this med. His pediatrician is new at administering this for ADD. Thanks & look forward to your response.
Bobbie,
Agree with your ped, clearly can go up as discussed here in the dosing details. We never prescribe for ‘9 yo’ but always individuate dosage for the specific needs of each patient based upon their metabolic rate and individual response to the medication.
At this moment going up seems most reasonable as the DOE is not covering to the following AM – a sign that often indicates insufficiency.
cp
6yr. old daughter diagnosed with ADHD. Intunive 1 mg. prescribed once a day at night. She has just started med but has slept a lot especially on the second day. Will this improve as her body adjusts or should I call the doctor?
Ginger,
Do review this post on Intuniv Dosing, it gives all the details for dosing and timing, and yes, that is a common side effect, and yes, 6 yo is always more likely to need more time to make adjustments. Don’t think yo need to call unless it persists more than a week, or if it simply is impossible to deal with.
cp
Hello Dr. Parker,
First…I think your website is wonderful and so very informative! Thank you for sharing some of your knowledge with us!! My daughter is 15, diagnosed in July 2009 with ADHD Inattentive Type. She was basically misdiagnosed in the 2nd grade and struggled until right before entering 9th before receiving a diagnosis. Stimulants work very well for her…. Vyvanse was a wonderful medication but she developed grade 4 acne from it. After discontinuing the med her skin cleared up quickly, the dermatologist was shocked at how quickly it cleared up after stopping the med. Before Vyvanse she never had issues with acne, just a pimple here and there. Her doc switched her to Concerta 27 mg, she became very irritable and emotional so it was lowered to 18mg and again she did very well on it. But she developed the same acne- I use the term acne but it was more like open sores and the “acne” sores caused a lot of pain for her from both of the meds and she only got it on her forehead. Her child psych changed her to Strattera 25 mg but later dropped to 18 mg and it was a nightmare for her on both dosages. Severe mood swings, dizzy, very sleepy- she would fall asleep on the way home from school and want to sleep until it was bedtime and then she would go to bed, she was depressed and highly agitated, irritable while awake and much of the time couldn’t control her feelings. It was a horrible experience for her and scary for me. She has always been a child with stable/balanced moods so this was very out of character. She was removed from the Strattera and we took a medication break for a couple months after the Strattera experience. The child pscyh told us basically her last medication option to try would be Intuniv. She started Intuniv 1 mg and she had the headaches, dizziness and sleepiness at first BUT she has been tolerating it very well but again the acne started coming back on her forehead (this is the only area that gets affected each time). I am just at a loss right now. The doc is at a loss as well. I have her taking magnesium, calcium and zinc supplements along with DHA. Could the ADHD medication be causing something to happen in her body that is producing the skin problem each time? I would appreciate any recommendations or guidance you might be able to give!!! We are not sure where to turn at this point. Thank you so very much! Kristi S.
Kristi,
First look at her periods: Every time I see acne in a girl her age I jump on all the estrogen dominance questions. If she has estrogen dominance she may have some testosterone accumulation – all of these can be measured.
And, in addition, when anyone has all of these clear metabolic problems with the stimulant meds I always look for more biomedical issues such as immune dysregulation with a subsequent bulletproof liver.
cp
Hi Dr. Parker,
Thank you so much for the reply! Her periods are 21 days apart every month. She is a tall and thin girl. I asked her about her bowel movements. She “claims” to have 1 BM per day. It is just very puzzling that the acne/sores appear once the medication is in her system and when the meds are out of her system it clears up completely. During the 2 months of being medication free she did not have any acne issues at all. It does seem her body isn’t removing toxins. I will definitely check into the biomedical issues you discussed. We are pretty much desperate for answers right now. I had thought about a candida cleanse for her in the past. Do you think this would be wise? Also any tests that you would recommend? BTW- she has had a mild case of eczema since she was very young. Thank you again for your time! It is greatly appreciated.
Kristi S.
Kristi,
Her doc could eval for candida, and there are several good labs to do a stool assessment. Find someone near you who does work with Metametrix Labs, they have a very comprehensive stool assessment eval. The eczema does indicate she has something going on with her immune system, and also a look at Omega 3 Fatty Acids, see another comment just sent on this post about a boy with similar problems.
cp
Hi Dr. Parker, my son has been taking 4/mg of intuniv at night and 30mg of vyvanese in the morning. He has been taking these doses since January. He started breaking out in a rash over the last week which seems to get really bad when he goes into the sunlight. Can either medication be causing this ? Thanks, Ricky.
Ricky,
Sunlight rash is not a common complaint of either med, and I haven’t reviewed the full package insert on those details. They are available on the web, please take a look and report back what you find – only time for a brief reply.
cp
Hi Dr. Parker, thanks for your response. From what I can tell, a rash is a less common side effect of guanfacine the main ingredient in intuniv, but never the less it is a side effect. It looks like it starts more from when my son sweats than the sun itself. His doctor is discontinuing his intuniv, but I would like her to increase his vyvanese from 30mgs to 40 mgs but my son doesn’t want to take it at all because he feels it is causing his acne and it hurts his appetite. Do you have any suggestions ? Thanks for your help. Ricky.
Ricky,
Thanks for the update on the rash, we just don’t see it yet, tho it might be an issue. Regarding the dosage of Vyvanse: main issues for everyone – a protein breakfast. If he has a good protein breakfast, takes the Vyvanse after, and completely gets off anything like pop tarts, sugar or any trash carbs, he will likely do much better on the acne side. Do take a look at the breakfast link, take him to the store with you and figure out which one he could do.
If he is constipated, or toxic in any way, get him on Omega 3 Fatty Acids ['Fish oil'] in the range to 2-3000 mg/day and I think you did say he was on zinc [20mg chelated/day], an excellent multivit would also help – and fiber to go every day.
cp
Thank you for your insight Dr. Parker. One last question: The Vyvanese takes my son’s appetitie away which is why it is hard to get him to take it. Do you have any thoughts about what we can do about that ? Thanks again, Ricky.
Ricky,
Protein breakfast is the first line, but if he has an immune dysregulation with some gastric irritability anyway that item will become first on the to-do list.
Thank you! Hope it works,
cp
Hi Dr. Parker, My wife met with my son’s math teacher this past Friday and he commented how much more alert Mike was in class. This was after we took him off the intuniv (4mg, we were giving it to him at night). The problem now is he doesn’t want to take the vyvanese anymore because he hates the way it makes him feel. He takes fish oil every night made by Nordic naturals, a multi-vitamin, and 250mg of magnesium. I told him if he doesn’t want to take any medication he would have to eat more protien. Do you have anyother suggestions in terms of natural substances for ADHD such as ginko bulba or anything else ? His ADHD is more the inattentive type. Thanks again for your help. Regards, Ricky.
Hi Dr. Parker, you mention in your last response about getting my son’s neurotransmitters tested. We live in Northern, NJ. Where would we find a lab or doctor that does that in our area ? Thanks, Ricky.
What about the combination of Intuniv with Strattera
Marc,
Strattera is a 2D6 substrate, just as Adderall and Vyvanse, making it contraindicated with Prozac and Paxil, but doesn’t effect the 3A4 pathway or Intuniv metabolism a-tall.
cp
Thanks again for taking the time to answer my questions.
You seem to have a good knowledge of medications. Have you heard Mesocarb/Sidnocarb? It is a medication that has been available in Russia since the 70s and is used for a wide variety of things including treating ADHD. While doing research on the different medications available I came across it. It seems to work the opposite of amphetamines, and it selectively increases dopamine without increasing norepinephrine. My understanding, based on extensive research is that dopamine re-uptake also happens on norepinephrine transporters, which is why amphetamines increase dopamine levels, and not because amphetamines blocks the dopamine transporter. Its also much less neurotoxic than stimulants. There are numerous clinical trials and studies done on it but much of the literature is old or in Russian.
It seems like a much better option than stimulants but it not available in the United States. I’m not sure why this is but I suspect it may have to do with patenting. Since the drug company’s didn’t discover it themselves maybe it is impossible for them patent it and make money off it. Do you have any thoughts?
Brian,
You got me on that one. I spend so much time writing and seeing folks in the office I really don’t keep sufficiently up with the ‘perhaps’ meds. Interesting point though, and will welcome your further insights on this one as time passes,
Thanks,
cp
Hi Dr. Parker,
I’m a 20yr guy who was diagnosed with ADHD (primarily inattentive) just over two months ago. I’m in college for psychology and when learning some basic facts about the disorder in an abnormal psych class I began to suspect I may have ADD. I delayed doing more research or going to get checked for two years. Finally, I took action and went to get checked at my college health center. The process there is you talk with a doctor, then psychologist, and finally a psychiatrist to prescribe you medication.
The psychiatrist put me on Concerta for the first month and setup a follow up in one month with the original doctor I had seen. I won’t list all the side effects but they were really bad. On the follow up, the doctor decided to switch me to 10mg IR Adderall twice a day. The medication seemed to work for the first week but gradually lost its effectiveness over the next few days. I upped my dosage to 20mg in the morning and 10mg mid day and the medication began working again. The side effects were much milder compared with Concerta, but still high, Dry mouth, insomnia, loss of appetite, jittery, ect.
I started doing heaps of research on different medications. I discovered many patients get better results with Dexedrine because of the purer d-amphetamine. At my next doctors visit I suggested this and he said he won’t prescribe it because it is more abusable. He also said he didn’t believe Adderall could develop a tolerance and put me on 10mg twice a day again, and suggested I talk to the psychiatrist again. I agreed, the psychiatrist also said he doesn’t prescribe Dexedrine but suggested I try Vyvanse. I explained how I was concerned with insomnia because the IR Adderall seemed to create insomnia even when the last dose is taken at 12pm. But he still thought Vyvanse was the best option and placed me on 20mg Vyvanse once a day. Since there is no generic like there is for Dexedrine, the cost was $40 for one month compared with the $5 for generic Adderall.
I tried the 20mg for a few days, but it wan’t effective so I started taking 40mg a day. This dose worked well and the Vyvanse nearly eliminated all the side effects that Adderall had with the exception of the insomnia. I have only been getting around 5-7 hours of sleep a night compared with the 8-9 hours I used to get.
I have found a few studies that show stimulants do not provide any long term benefits and their toxicity also concerns me. I don’t think Strattera would help me because most of the negative side effects I have seem to come from the norepinephrine stimulation. I am thinking about suggesting Tenex at my next follow up, with the psychiatrist again, in about three weeks. Do you think this would be a good idea?
Thanks for your help, Brian
Brian,
You are very close to what many would consider an excellent resolution of challenges.
1. Agree, Strattera has limited benefit and is not worth the time unless you fail everything else.
2. You are responsive to AMP, and they work much better than MPH [Ritalin products], with few side effects
3. Your sleep could likely be corrected with some Melatonin over the counter 3-6 mg, talk to your doc.
4. Disagree with the doc that Dex is better.
5. Your DOE with Vyvanse sounds like it is nearly right on.
6. Tenex may be necessary, but the Vyvanse will do a much better job with fewer side effects if tolerable, – but Tenex is quite inferior to Intuniv and not really effective with all the dosing strategies and diminished half life.
7. You may simply need to go to the Vyvanse 30mg dosage for the specific DOE to meet with your approval and resolve sleep issues. No med will make it completely resolve, but you are very close.
8. In psychology you will come to know that your personal and professional future will likely evolve with the understanding of neuroscience/neurotransmitter imbalances anyway – and down the road testing may be in order to correct your entire sleep and ADHD picture.
In the end the best choice, IMHO, is the Vyvanse, and it is quite likely that your doc will agree – and he/she will have to sign off on any changes.
cp
Thanks for your advice, I was already considering taking Melatonin to help fall asleep so I will try that.
As I’m sure you know, Vyvanse is essentially the same medication as Dexedrine. It is dextroamphetamine with an amino acid added to prolong its effects for 10-12 hours and make it only active orally. Dexedrine Spansules on the other hand last for 6-8 hours but are available in generic, so the cost would be $5/month vs. the $40/month for Vyvanse. These two reasons are why I thought Dexedrine would be a better option.
The half-life of Tenex and Intuniv are similar though, taken directly from the Intuniv prescribing sheet, when taken once daily the half-life Intuniv is 18 ± 4 and 16 ± 3 for Tenex. I would much rather take generic Tenex twice a day (if that is even necessary given there similar half-life) than pay for the cost of Intuniv which is sure to be much higher.
Brian,
No harm in any of your choices, for sure. – Just answered you according to my preferences and so that you would have a clearer idea of what we actually see in the office with these meds. If cost is the issue, the other problems are diminished, and the only issues that do loom are efficacy and and compliance. The Vyvanse lasts 14 hr, that will be a big deal if you take it longer, and tenex will be less likely work than Intuniv, [in the office it's different, shorter, than the package insert] but it may do the job – people are indeed different in their responses.
Best wishes, thanks for asking the questions, and I do wish you well on your several journeys-
cp
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