Intuniv For ADHD: Dosing Details

Roxy,
Tiredness is different than BP, and tiredness doesn’t mean that he has an associated BP problem. Side effects should slow in 7 days, or you might skip a dose and give it that night. Some have had better response to night dosing.
cp

Sue,
Since he is only on 2mg, you first check with your doc about this, as he is the responsible party. Either way will work, and agree with keeping the Zoloft in the AM. Likely more able to maintain function and not skip a day if takes it that night, rather than waiting an entire day, as any ‘Top of the Window’ side effects would occur whilst sleeping.
cp

Susan,
Would have to talk more about the details to render clear opinion – but hey, sounds like it’s working. I never use MPH with AMP as MPH also blocks 2D6 – however a small dose of Adderall IR in the PM, even 2.5 mg [1/2 of 5] can be helpful, if not too close to 6PM – as will cause insomnia if too late.
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J,
Copy on the protein!

Amantadine can be helpful in some of these complex presentations… but, hate to sound repetitive, she needs a workup for neurotransmitters and immune dysfunction, no doubt. I would just get-it-done. Evidence beats speculation no matter how well trained we are. You can set up a time with Deborah, we can do it long distance, and I can tell you some specifics of what-to-do from that testing, for sure. Both NT imbalanced, and Immune system is rusty from these brief comments. If you have a doubt, read this book by Dr Laponis.

No interaction with Strattera and Intuniv. Haven’t used them in combo myself, as I use Strattera so infrequently, because I get the job done without it.
cp

Patricia,
You are making the point exceedingly well about comorbid metabolic issues. Often, as you can see here and in the other Intuniv posts, the real challenge is for those with metabolic issues. I am certain that your guy has some of those issues, in spite of your excellent supervision and planning with the meds. Bottom line: he needs the testing to identify the underlying cause of the challenged slowing.

His situation does present with too many questions to jump in with a specific rec – but having said that, I would seriously consider just working within the framework of his Therapeutic Window, and actually lowering the dose to see what his response is now that he is reacting this way. Not my first choice, but something to consider with your doc prior to obtaining the more precise information.
cp

Roxy,
Absolutely continue with the vits, organic foods, – and you didn’t include exercise [see the review of Spark by Ratey on this CorePsych Blog post]. As you correctly hinted, the treatment for ADHD covers more than one dimension, and these amino acids and vits don’t interfere with meds. Only cautionary note is 5HTP with serotonergic meds as they might encourage a serotonin syndrome – but with a measured, low serotonin, that concern becomes less significant.

One of the regular observations we witness at CorePsych is the significant need for mixing a variety of supplements with traditional meds – as traditional meds often have limited value in the context of significant metabolic and nutritional issues.
cp

Stephanie,
Last, first: A ‘melatonin regimen’ should not make him tired. If it is the dosage is too high, or there are other mitigating factors – such as metabolic issues noted in this post on Intuniv.

Strattera response usually occurs in those with other metabolic compromises. Barring the possibility that he is one of the 5-7% with inability to metabolize AMP due to CYP 2D6 polymorphic [genetic] changes – because Strattera also passes through 2D6. Said another way, I’m certain that he can metabolize AMP because he has metabolized Strattera at relatively high doses for > than 2 years. Conclusion: The AMP was likely too high or too low when first adjusted, either too quickly topped out or not sufficiently dosed, and Vyvanse would definitely be indicated for the stimulant side of matters.

Regarding the Intuniv: There is no drug interaction with Intuniv and Strattera, – Strattera runs through the 2D6 pipe, and Intuniv, as outlined in this post, runs through 3A4 – so no interaction of competitive inhibition.

So many of these questions overlook the most important part of the equation: Is he eating a protein breakfast? Is he a picky eater? What are is bowel function patterns -times/day #2? What is his diet – too many carbs? More information on sleep. Does he exercise? etc. All of these require more thought for the proper connections and conclusions that available here.

Hope this helps a bit with your team out there. If you remain stuck schedule an hour with me and we can cover the details.
cp

Ingrid,
No drug interactions with Risperdal and Intuniv, so that part is covered. I do think the doc is on the right track, have gone up to 4 mg on Intuniv, but don’t think any of these meds should be given in some kind of protocol, as you can see from these many remarks. All need specific targeted titration strategies.

On sensitive kids with a history of medication unpredictability, I would have been slower on the increase from 50 to 70mg, as every time I scoot up too quickly, problems arise. I only increase with the specific criteria for Vyvanse DOE as seen in this video, and when they are close to perfect I always go more slowly. Yes, I would have gone to 60, but not having been there and not knowing the specifics I can only tell you my patterns, not recommend specifics for your girl.

The CD on Brain and Immunity, on the 4th or 5ht disc by Dr Laponis has a great deal of info on Immunity and the intrauterine experience. It is highly likely that she has some other biologic imbalance, not as visible as ADHD symptoms, and would absolutely do further testing to find out what is going on with Neurotransmitters, Endocrine function and IgG [immunity] testing for other sensitivities including foods. It is quite unlikely that a simple, even very careful titration strategy with Intuniv will completely turn the tide – based upon her complexity and history.
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Jenn,
Complicated case, not an easy shot with such a paucity of information – but briefly to the point: I do agree with your doc in that Intuniv appears to have a much better side effect profile than tenex. The slow release provides a markedly diminished roller coaster effect on the blood concentration values thru the day. Regarding the aneurism comment – not at all on my radar, never heard of that concern, and it hasn’t come up in any of the meetings with my research colleagues.

On a deeper note, my ears burn on the metabolic issues: heart rate elevation and whatever else may be contributing. Is he a picky eater, does he eat a protein breakfast. Without neurotransmitters you can be shooting blanks whatever your team does with the meds. And check out the Brain and Immunity reading list at the neurotransmitter link for more possible information.
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Danny,
Whatever you do girl, just keep writing. Your note here is excellent, well written, and clearly shows you have much promise with your communication skills.

I am going to guess a few points, because I see them all the time:
1. I will bet you have significant problems with not eating a protein breakfast.
2. I also bet that you have significantly increased transit time on your bowel activities, probably one every other day or every 3rd day.
3. In addition I also guess that your menstrual periods are challenging, but you are toughing them out, and everyone has said, just hang in there girl, this is what it’s like being a woman. Listen to this estrogen dominance podcast if I am right.
4. You might also be a picky eater on top of all of this.

Now because your are 16, and this is the Internet, I am not asking for specifics on the reply. Bottom line if I am correct on any of these your immune system is likely the problem, and the neurotransmitters are unbalanced downstream, so the fix will be deeper investigation of your metabolic issues before you will be able to get it all together.

Again, keep up the good work!
cp

Jean-Marie,
Complicated and off label situation, not one to deal with over the internet as kids this age are particularly challenging to balance in the first place. My best recommendation is to get on the real testing for neurotransmitter imbalances as soon as possible. See the NeuroScience Testing available here, and look at the webinars on this link, and consider Brain Immunity as discussed on this same page by Dr. Laponis

Reasons:
1. Age
2. Refractory to meds, often associated with immune dysfunction
3. PDD often associated with immune dysfunction
4. Severe ADHD, often associated with immune dysfunction
5. Stomach aches are essential to F/u, – immune dysfunction until proven otherwise
6. Nightmares can indicate several issues with unbalanced neurotransmitters and are often associated with immune dysfunction.

To guess at any one of these with this complexity would likely prove ineffective. Having said all of that, yes some docs are using Intuniv with this type of child at this age and have been having some success. The best strategy: take a look at the evidence first to discover the underlying issues.

Take a look at this post on Celiac and chase down the links there to consider next steps.
cp

Perel,
Definitely would consider adding Intuniv with your medical team. Far more information needed to take a shot at which one goes first. Mixing the Daytrana and Concerta is one way to help with after school duration… does that system work for the evenings as well?
cp

Wendy,
Sorry to be repeating a bit, but in complex situations the real complexity lies in watching the side effect profile for each medication in question. “Too much” will show as a side effect, oversedation, decreased ability to manage feelings, anger – and too many more symptoms to list here. That’s why it would be very important to keep your eye on the Therapeutic Window with each medication, with your doc, and do share your concerns with him/her. If you think the meds are too much, you must have a reason.
cp

Karin,
Intuniv does hit a different neurotransmitter system [specifically glutamate], and very well may be creating a positive response that increases the side effects of all the other sedative bipolar drugs. I have seen this using neurotransmitter precursors when the correct imbalance is identified, and the other neurotransmitter modifiers [that missed that specific pathway] have been cranked up to cover it by default.

A good example of this phenomenon: I have seen literally hundreds of folks given Prozac for ADHD – and many claim that it works!! The original comorbid depression was identified correctly, the cognitive anxiety, however, was misidentified as part of the depression, rather than seeing it as a manifestation of the comorbid ADHD, . To cover the cognitive anxiety Prozac was increased, with the result: they become ‘Prozac Stupid’ – and simply can’t think. They think they are better, and indeed they are with that ‘unmanageable cognitive abundance,’ – but their ‘operational ADHD’ is flaming, and they can’t concentrate on anything, even ordinary conversation. Duh! What were we talking about?

The Prozac appears to effect the initial problem, but does so in a secondary rather than primary way, by cranking the serotonin to such a level that the brain becomes relatively toxic. The symptoms appear to resolve, but the underlying ADHD problem continues to proliferate in an different way.

Another less obvious possible interaction, not commonly appreciated, is the possible drug interaction between Intuniv [a 3A4 substrate] and other meds traveling up through CYP 450 3A4 by competitive inhibition, specifically Klonipin. You may, and this is quite speculative – but worthy of consideration, be toxic with Klonipin secondary to that possible interaction.

Honestly, your question has many more variables, including the original reading of the SPECT, and the formulation of treatment from the SPECT images and your history in the first place. Having seen many second opinion “Ring of Fire” conclusions, I am concerned that far too many have gone off with that new, evocative diagnostic label, only to find that the subsequent intervention strategy proves limited in the long run, because the underlying neurophysiology is assumed from the hyperperfusion and hypermetabolism, rather than understood completely on a cellular-metabolic level. That discussion is considerably deeper than this response, but if you have had SPECT scans with a Ring of Fire ‘diagnosis’ you will surely understand what I mean.

The problem of missing the underlying neurophysiologic complexity can still exist even with good SPECT evidence. SPECT, in spite of it’s obvious contribution to the search for real functional evidence, rather than just labeling folks by external appearances, is still a ‘macro look’ at brain physiology, and almost completely overlooks all of the underlying causes such as basic immune dysfunctions like gluten sensitivity, for example.

Hope this helps,
cp

Wendy,
Yes, no problem, no drug interactions with Concerta, only caution is dosing strategy for best ‘Window’ placement.
cp

Sue,
Your doc will always treat each side effect differently – and in the contest of this limited info I would suggest just dropping the Zoloft to 1/2 of 25 mg with your docs approval… sounds like he hit the ‘disinhibition’ side effect seen so often with SSRI, even on low dose. See what your medical team things of that idea, and do keep us posted.
cp

C-
‘Wow’ is right… this is far more than syncope, – your guy needs a medical workup ASAP, brain MRI work up will be helpful, but he needs a complete medical workup from top to bottom – many thoughts come to mind from ‘toxic’ and heavy metals, to immune system dysregulation with something as simple as gluten, and nutritional evaluation is important as well. Take a look at the Metametrix portion of this Neuroscience page, and consider a consult with a provider who can read the *Triad Profile* outlined there. First the acute workup – for the most serious obvious challenges, then on to the cellular and molecular measurements – My take: your guy has a biologic condition, with a psych presentation.

The clinical keys here are cold sweat, pale, lethargy, BM whilst sleeping, tremors, jerks, spasms, eye rolling, – this is most likely not an Intuniv reaction – if that is a question for you. If concerned about Intuniv simply wind it down and off to eval response to going off it – if your doc approves.

Please keep us posted. Hope this helps a bit.
cp

Susan,
I am completely with you regarding your consternation with your guy’s diagnosis, and find interesting the most recent NPR reports about changing the diagnostic coding in psychiatry to cover these kinds of complex presentations. In a word, the new coding does absolutely nothing to address brain function, and adds on more superficial observations and speculations than the previous set in DSM 4r. The new angles are somewhat less political, but do very little to improve office practice.

Most perplexing to parents is the fact that we diagnose problems in psych by external appearances, and appear to have no real science, no facts, to turn to to point the way for improved care. This unhappy circumstance is changing, – too slowly, – but is changing. We do have more evidence available and brain and body function, IMHO, should absolutely be measured in any person with complex presentations. The outside labels just don’t work as predictably as biologic measures, period.

So on the biologic diagnostic side, he could be gluten sensitive, casein sensitive, high glutamate or PEA, mold neurotoxic, candida infested …etc, the list is much larger and the complexity requires more in-depth analysis.

Bottom line on the multiple variables: Complex presentation do require more meds, more supplements in the short run, and better evidence. As to your basic question regarding Intuniv with your guy, it is very hard to predict – as kids like this can go significantly either way – Big improvement, or surprising regression.

Why? Because the specific neurotransmitter imbalances are not on the table, and without that solid info we are completely in speculation. Do discuss with your doc, it certainly is reasonable to try, and there are no contraindications with the current med mix.
cp

Janis,
Interesting question, appreciate it! Tristan may simply have a comorbid depression that was hiding behind the ADHD behavioral presentation. As the Intuniv pulls off the covers, the depression becomes more obvious. At this moment I see no indication from any reading that the action of Intuniv downregulates 5HT, serotonin. Take a look at the many answers on this CorePsych Blog post on Intuniv if haven’t been over there [now 155 comments].

Simple solution: try low dose antidepressant if your doc thinks that is reasonable.

More predictable outcome solution: Neurotransmitter testing.
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Susan,
Used to have an office in Reston whilst working with Amen for four years, but now only at Va Beach. Hard call on the meds, sounds like he is a guy that clearly needs a more complete look at all the variables. Often Intuniv simply turns them around, even with a bit more time than at first expected… but sounds like going back up may not be the solution. Without asking the specific questions and without knowing many other details it’s hard to take a shot.

I do look forward to meeting you in Va Beach, even tho we are in 6″ snow right now, will likely be quite gone on Monday!
cp

Gail,
Each of us had our own practice preferences, and from a psych perspective I always wait on BC pills for anyone as they are, IMHO, not the way to start life as a young woman – bad precedent [this point is emphatically supported by all of the writers on this page at CorePsych Books]. Yes, they [BCs] might help, that is not the issue, and, yes, they may be indicated from the surface of matters, but for those having any problems with starting menses a simple sputum test to assess hormones can significantly help out – evidence matters on that end, for sure. I worked with a great girl in my DC office who started showing hair at 8 yo, had significant gluten sensitivity, and when tested was estrogen dominant pre-puberty! She did very well with carefully administered bioidentical hormones, needed gut healing, off of wheat, and all of that was years ago before NT testing. Short answer NT testing does help, your doc will likely not know about it, and yes I can tell you more with specific evidence by reviewing your materials. One final point with your daughter: so many have simple ADHD and need a stimulant to turn them rapidly around – but I need more info to discuss that point specifically. She would benefit from NeuroEndocrine testing for both NT and Hormones [the latter with sputum].

Your son is almost a poster child for those children that seem to benefit most from Intuniv. Every one of these psych meds is completely different and, tho they may have similar actions, often behave differently based on a variety of metabolic variables. I discuss all of this in my new book in detail: Patient’s Guide for ADHD Meds. Strattera is the least effective ADHD med out there, agreed upon by all of the many researchers and speakers, and a failure of Strattera mean next to nothing for a good prognosis. Your son’s sleeping problems suggest more comorbidity that deserves further evaluation with NT testing.
cp

Mary,
First: the folic acid thing…. it’s a Deplin thing, not a folic acid thing, please see the Deplin link on the other comment with the Stahl article.

Regarding dosing: Not recommended by the pharma company, but seen here at CorePsych Blog and in my office: some do better with night dosage with oversedation matters. BD is a tip of the iceberg diagnosis, not wrong, just incomplete because it only deals with moods on the surface, not what the underlying issues are. Multiple comments here deal with the issues, and you might wish to attend the Holistic Health Virtual Conf… the entire conference will give you ideas of ways to approach the significant background noise, and the underlying issues there. Whiny could mean many things including serotonin challenges, side effects, sleep issues, too complicated to rush off a response here.

The recurring theme in these posts: more evidence will help answer more questions.
cp

Susan,
Good plan, intuitively correct and I’m sure your doc will agree. Follow this link for the Deplin info, and yes, far better than folic acid for the reasons noted. See this S Stahl link for even more detail with the tetrahydrobiopterin (BH4). Deplin has been a remarkable med for those non responsive to meds – a pre-pre synaptic intervention.
cp

Patricia,
As you will see from this CorePsych Blog post, it could be that he suffers from comorbid depression in the first place, aggravated by stimulant meds, less likely to be aggravated by Intuniv. My experience is simple here: Stay with the program on the Intuniv, but watch for the side effects and slow down as needed. He may need the higher dose, even at 52#, only a trial will tell.

Another thought if he were in my office: Sounds like he is out the Therapeutic Window in the PM and crashing, often see with Focalin, not seen with Vyvanse in the PM. My next augmentation strategy would likely be Vyvanse, sounds like you haven’t tried it, and it could fix the focus whilst the Intuniv corrects the agitation and assists with the focus.

You’re right – you are actually chasing different neurotransmitter systems, and ADHD is not so simple as many suggest – treatment often involves more than a simple dopamine intervention.
cp

Michelle,
Combo works, but I think you do need to dig deeper and will do well to review the comments over at this other post on Intuniv. You definitely need more clear evidence.
cp

Jamie,
Some have noted a decrease in tiredness with night dosing, the jury is still out on that process, and it certainly isn’t a first line recommendation – tho no harm in trying.

With the several tidbits of info you have added here, I would take the next step to figure out the background noise, as I have regularly recommended on several other comments here. Could have a simple problem with only neurotransmitters, but I suspect it is more as he has tics and need for Growth Hormone – when I see those two signs I would look at food sensitivity testing, immune dysregulation, picky eating as a possibility, and of course neurotransmitter review. He will show an increase on excitatory neurotransmitters, – just don’t know which one, and each needs a different approach.
cp

Susan,
Thanks for your kind remarks.

The Intuniv DOE runs about 24 hr, so if compliance is an issue, no harm giving it in the PM. I’ll bet he will improve, and AM compliance with the absolutely essential Protein Breakfast will become easier. Remember Intuniv also works on neurotransmitters, and neurotransmitters are built from protein. Some of these kids can use Deplin a drug [actually a pharma nutraceutical used for refractory depression, but which actually works to build neurotransmitters out of the protein in the diet.
cp

Pat,
I am with you on the hesitancy. Bipolar for me, thinking from an informed biologic/neurotransmitter perspective, begs for a more complete work up to actually see the real neurotransmitter options. The question for your team: What is the clinical objective for the Intuniv?

If the objective is ADHD treatment, and you absolutely want to stay away from stimulants, you might be pushed to give it a very conservative dosing try. My take: stimulants do work well if bipolar if the bipolar is managed first.

Having said that: Intuniv and tenex are the same parent compound, and it quite possible that you would have a problem with Intuniv as well – the significant advantage of Intuniv is the time release quality which clearly shows evidence of less of a peak and valley effect.
cp

Dr Hunt,
I have to confess that as soon as I saw the narrow therapeutic window phenomenon I guessed either bowel or diet… and then there it was: “hates food!” Your guy is a quintessential picky eater, and honestly I could make suggestions from my experience all day with meds, but the first, absolutely first thing you have to do is read this post on Breakfast Protein, and sign up for my book in the upper right hand corner here, as I just finished the discussion there on the narrow window, immune dysfunction, and breakfast. It will be out in about 2-4 weeks, just have to get it in pdf and set up right for readers [footnotes need attention - will add links to every footnote for usefulness].

But back to your bottom line: He is hyper not just with Concerta on the Top of the Window, but his window is so narrow, due to metabolic challenges, that just a small drop down takes him out the Bottom. His main problem is that his excitatory neurotransmitters are just blasting away, likely glutamate and PEA, and without correcting that balance you can mess with meds for the next many years.

I just rebuilt this page on Neuroscience testing we do here, and, though I don’t know your PhD interest, bet you would find some interest in those papers on Neurotransmitter testing. Getting it precise is the way of the future… and I added some interesting work there this weekend on other sites, including great work done by Metametrix – just down from the Neuroscience materials on that same page. They are a bit harder to understand with the biochemistry on the front end, but deeper into the nutritional side of matters.

I have no prob going up with Intuniv [see additional comments regarding adjustments here] as he does not appear to be hitting his Top with that med from your explanation, but will leave that to your team.

BTW, with proper testing, and intervention, I am sure you will be able to significantly diminish the visits and worries about all the titration woes, and will likely be able to significantly reduce ADHD meds.
cp

Gretchen,
As noted elsewhere on Drug Interactions With Intuniv [second paragraph of My Reply] – Trileptal is not contraindicated – it will just diminish the effectiveness of Intuniv for the reasons noted. If you were in my office I would be very interested in doing a full Neurotransmitter panel, would ask very carefully about picky eater issues and bowel function as with the metabolic problems with the fast burning array she likely has clear, correctable underlying immune dysregulation issues.

BTW: Focalin can block the metabolism of 2D6 the Vyvanse pathway, and I make it a rule in my office not to use MPH together with AMP for that reason… it can artificially increase the Vyvanse levels, blow the patient out the top of the Therapeutic window [see the EzineArticle link there for more].

Do keep us posted!
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Lisa,
Naturally it’s not appropriate for me to offer specific medical advise for someone over the Internet – but I can tell you what I am seeing in the office and as you can see from these comments, and comments on the other posts about Intuniv [this post in July has ~ 78 comments] this problem is not uncommon.

My experience in the office has been to simply evaluate the seriousness of the side effect, and if it is incapacitating I drop back down. If not, we stay with it and it slowly resolves over 2-3 week, but I don’t go up. Actually in the studies the researches noted a specific improvement in sleep with the AM dose, again over time. The rule appears, on this one to be patient, back off when necessary, and put some time into the equation.
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Kay,
Your guy has multiple metabolic and developmental issues:
1. Asperger traits
2. Tics
3. Aversion to food
4. Thyroid problems
5. Muscle spasms
6. ‘Developing’ scoliosis
7. Mental developmental delays
All of these require more investigation, not from the purely ‘psych’ side with more meds, but from the metabolic side with complete evaluation of cellular and molecular physiology. Your guy has a set of chronic medical problems not available through regular Lab Corps reviews. That review should include multiple immune, metabolic and neurotransmitter precursor reviews – my recommendation for a start: Triad Profile over at Metametrix..

His ADHD is likely only the tip of an iceberg… connected to much more going on below the surface.

And, yes, Depakote is a mild inhibitor of 3A4, and could contribute to the issues with Intuniv. Depakote is notorious for complicating matters with any kind of liver challenge – it could be contributing – but the other medical evaluation is much more to the point of the other underlying issues.
cp

Kay,
Yes, thanks for posting, – all of these new drugs do require some field testing to fully understand the treatment expectations.

Your guy sounds like he is having a pretty typical start, perhaps a bit too much sedation. If you are concerned at all, just take it more slowly with your doc on the titration up to the next click. Sleepiness does get better over time. With this one it simply is not like the stimulants with big results right out of the box. Shire is very interested in not building false expectations, but rather suggesting deliberation and patience with Intuniv – it really is a different med and we will all take some time getting used to the specific parameters.

Bottom line, if in doubt, slow down, breath deeply, and hang in there. Many take 3-4 weeks to get it right. As you can see from some of these comments others take even longer.
cp

Ricky,
Glad CorePsych is helping you review matters. In specific planning I always defer to your doc there. The researchers who did the studies did agree that slow is best and that if 3mg is not sufficient, you should go to 4mg. The weight relationships are guidelines, not written in granite, and are simply there to help find the correct dose more easily. Those weight relationships appeared ‘post hoc’ – after the studies where completed, and are suggested as a grid to titrate, based on the fact that most fell into those response ranges.

But please remember, titration is always, always, customized for each person. Customization during the titration will provide the most accurate results with the fewest side effects. Stick with watching and moving slowly with your doc there, and set specific objective criteria that your son can respond to as well.
cp

Susan,
No absolute need to go back at this moment – but since he has been with it only 2 days, it would be quite reasonable to go back to the sample pack and start as recommended. The reason: slow starts bring fewer Adverse Events, pure and simple. Now you may, as some likely will, get away with pushing the dose, but why bother? Every mistake I have made in my life with meds has been made in the context of trying too hard, too much enthusiasm, the zeal to heal.

I don’t consider ‘no effect’ a mistake, but, rather, in the case of Intuniv, a proper expectation at the outset – as all the researchers with whom I have spoken, every paper I have reviewed, says go low and slow on this one. Most do best with a two to three week titration strategy as you accurately outlined.
Be well,
cp