Intuniv, As With Any ADHD Medications: Watch the Burn Rate
Intuniv Posts:
This post is the fifth, with four others, documenting Intuniv Overview, Dosing Details, Drug Interactions and Addiction Indications. Please review all of these posts and the many comments [over 150] on the Overview post to see what readers are saying about Intuniv, this interesting new ADHD non-stimulant medication.
Burn Rate:
If you have been reading CorePsych Blog you will note that I have been writing about my new book, – and the good news, it’s finished, and in edit at this moment – I do hope to get it out by March ‘10. The Patient’s Guide for ADHD Medications: What To Do When Nothing Is Working details an entire chapter on Burn Rate, as everyone who takes ADHD meds should absolutely master the burn rate principle.
This Specific Q & A:
- Is an example of the many Intuniv questions, challenges and positive remarks in these several posts:
Question About 8 yo Boy, Picky Eater and Metabolic Challenges:
“I have just stumbled across you and this site in my research into Intuniv. My son just recently turned 8 and was diagnosed with ADHD this past spring. As I continually read about ADHD kids Luke seems wise beyond his years, is very bright when it comes to building things, or math, and picks things up quickly when he is receiving instruction one on one or in a very small group,- but he struggles in school generally. Long story short, we started with a Central Auditory Processing Disorder diagnosis when he was six. His primary issue seemed to be language, both receptive and expressive. An exam with an audiologist confirmed a fairly significant CAPD at the time. As he progressed in school it was obvious that ADHD was also a large part of his problems as impulsivity, restlessness, inability to attend, and defiance increased as he got older. We saw a neurologist who, after an EEG, prescribed Focalin XR. This worked like MAGIC, at first.
We started with 5mg and after about a month moved up to 10mg. He was able to focus, concentrate and made great strides in school. His language issues even seemed to improve. Now it seems the Focalin is either failing him or is the wrong drug. His ability to focus has tanked, he has become very impulsive (throwing things, slamming things on his desk) and is increasingly defiant (refuses to do work, follow directions). While other times he seems spaced out, and at home sometimes too compliant, and sometimes melancholy for no reason. With age it seems his receptive language abilities are about right, and at developmental level, but his expressive abilities are still below, which of course is leading to some frustration on his part especially when he is supposed to expressing himself through writing. We were seen by the NP in the neurologist’s office today and she suggested Intuniv. From what I’m reading it sounds like it may work for Luke but she has suggested we stay on the Focalin while we start the Intuniv? Do you agree? (She mentioned d/c’ing the Focalin eventually)
Second, in one of the posts above you mentioned something about “immune dysfunction, bowel challenges and is-he-a-picky-eater”. While Luke is rarely sick, I don’t think he has a solid BM in his life (not watery, but always very, very soft) and he would live on Mac and cheese, peanut butter and jelly and chips if I’d let him. He NEVER willingly tries anything new and is indeed very picky about what he eats. As all of this is very new to me can you shed some light on what this may have to do with anything and what to do about it – or point me to the best place to read about it? We have tried adjusting his diet, etc. in the past but because he is so picky it is very difficult to do.
An Additional Metabolic Point - Headaches
One additional thing that the NP this a.m. more or less ignored – prior to starting meds Luke would wake up in the middle of the night crying and saying his head hurt. He’d be up 30 min. or more, would eventually throw up and then go back to sleep. In the morning you’d never know anything happened. This would happen about once a month from the time he was about 6. I only recall it happening once during the day at school. Once we started Focalin those incidents ceased completely. We had our first return of that 2 nights ago. Any idea what that’s all about? Initially the neurologist said it was “interesting”but had little else to say about it.”
My Answer, Abbreviated To Stay With Metabolism and Burn Rate:
My reaction to this question and many others seen on the many comments on Intuniv and Vyvanse: We must always look at the metabolic hints, the possible changes in metabolic rate before starting the meds. They are subtle but include the following:
- History of bowel issues, too soft, too hard, constipation, diarrhea, monolithic stools, too slow in transit time,
- Developmental delay issues: CAPD, speech issues, Asperger’s, Autism,
- History of Fetal Alcohol exposure
- Headaches, stomach aches, tired all of the time, dark circles under the eyes, pale skin
- Picky Eater
- Not eating breakfast, waking with stomach issues and no appetite
- History of failure with many meds – including stimulants or non-stimulants [Intuniv, Strattera]
- Narrow Therapeutic Window
- History of food allergies even back to early childhood, e.g. “lactose intolerance”
- History of rashes, allergies, asthma, upper respiratory infections, ear infections
If we don’t look at these issues [and more] we cannot predict what the outcome with the medications will be – and every one of these issues can significantly change the underlying metabolic patterns, the amount of neurotransmitters in the body, and the cofactors that burn the neurotransmitters effectively.
Medication management now requires a full awareness of the entire pattern including nutrition [which feeds the amino acid building blocks for neurotransmitters and cofactors], – without more careful questioning at the outset we will have predictable problems – as the burn rate will vary dramatically with all of these variables. Burn rate will effect Duration of Effectiveness [DOE] – dosage patterns and speed of titration at the onset of meds.
Then, if Burn Rate varies, we must always take the next step to measure the immune dysregulations, the neurotransmitters, and the downstream endocrine issues so often found with these upstream irregularities.
Phone Consult Availability
Check out these remarks regarding how to start these reviews with a phone consult: See this post on Intuniv: Comment by Gina Pera on January 29, ‘10 2:30 PM
Related articles by Zemanta
- Holistic Reviews At CorePsych (corepsychblog.com)
- INTUNIV demonstrated symptom reduction on oppositional subscale Conners’ ADHD rating scale (scienceblog.com)
- A non-controlled substance drug for ADHD: Intuniv (guanfacine) ER (medicineandtechnology.com)
—>Tweet this post below! For ADHD Medications: Download complimentary white paper Precise Solutions now, – and get ready for the complete version of ‘The Patient’s Guide’ details to follow. Get Neurotransmitter Details Here
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Hello Dr. Parker
I am very nervous about starting my son, 11-yr old on Intuniv. He was diagnosed with ADHD 5 yrs ago. He has underlying anxiety and PDD/AS traits-not officially diagnosed, I’ve had this brought to my attention. He’s a wonderful boy, but his nervousness and social anxiety is hurting him at school and we’ve delt with some pretty severe bullying in the past.
Concerta has been our one and only med for the entire time. We’ve been at 36mg for the majority of the time, with success overall in attention and focus, but the comments from school continue to be related to his anxiety and social struggles. He see’s the social worker, who is just wonderful. I’ve noted a decrease in his attention in the past 4-6 months-his weight is right around 70 lbs and he is 4ft-ish in height.
I did go to a child psychiatrist recently, and she was more concerned with the AS side-she did not meet him, but our overall discussion/description pointed to this-which I”ve heard before. She would like to meet him and consider starting him on a high dose of Prozac-which she tells me is the treatment of choice for AS and keep him on the Concerta 36mg. I went to my Ped about this and told him I’m not comfortable with this and this is when Intuniv came into play.
Can you give me insight into the Prozac/Concerta combo and the Intuniv/Concerta combo-apparently, we would continue the Concerta with both, until he adjusted. Prozac flat out scares me.
Thank you for allowing parents this place for questions-I’m sure you understand our apprehension and great care in medicating our kids.
V
Veronica,
As you will see from even a casual reading of these posts I am clearly not a fan of Prozac, – and the idea that it is the antidepressant treatment of choice of AS is your psychiatrists personal view, is not in the literature, and if it is, someone was not paying attention to the multiple drug interaction details. I do disagree with that opinion for the many reasons stated here at CorePsych Blog.
One quick observation and a brief story: Concerta blocks 2D6, so a person can become toxic on the interaction there, in that MPH will cause the Prozac to build up with possible disastrous results – including even suicidal regressions. [Prozac is a 2D6 substrate, and is lipophilically stored in the brain, and actually interferes with its own metabolism, as it blocks 2D6!] Many years ago co-wrote an article for Primary Psychiatry with my son, a medical student at the time, on these matters, but they didn’t get the fact that I was a doc!
See the comment on 1-1-09 post on interactions for this story: Girl from Scotland quite psychotic in behavior, toxic on Prozac and Concerta – with SPECT images to confirm significant toxicity as well. Not recommended, especially with AS.
Intuniv has no interaction with Concerta, and a recent affirmative study is out regarding that combination, – but I can’t dig it up on the Internet at this moment.
cp
Dr. Parker,
If you do come across that no-interaction study confirming concerta and Intuniv I would appreciate a copy of the link to this study. My daughter just began Intuniv to supplement the 27mg/daily dose of Concerta for ADHD diagnosis. Thanks very much!
Mike G
mjbeanie@comcast.net
Intuniv has no interaction with Concerta, and a recent affirmative study is out regarding that combination, – but I can’t dig it up on the Internet at this moment.
cp
Mike,
Sorry, don’t have the time this AM to chase that down, but would refer you to this book if you want the details.
cp
Dr. Parker,
My son is 14 and was dx at age 7 with ADHD Inattentive type. He has very slow processing speed (visual) as well. He seems much like a very intelligent Sluggish Cognitive Tempo type, but he has a superior auditory working memory. He first tried ritalin at 7 and increasingly became more depressed and flat affect over several weeks. We tried again in 7th grade with Concerta and Adderall XR but he complained after a couple of months of “feeling like he has got to move.” Was on Straterra for a year without side effects but not helping with attention and executive issues. He is now on Intuniv 3 mg and loves that he is not daydreaming for the first time in his life, but he is way too sleepy in class. He has tried caffeinated drinks and energy drinks and taking the medicine at night. Nothing has helped with the extreme sleepiness. He has tried focalin regular release, and says that even at 2.5 mg he feels racy. If he takes 5 mg of focalin, his responses become delayed with extremely flat affect (almost staring into space–scary.) He has had EEGs that noted some abnormal frontal lobe spikes, but the report stated it was nothing. Could the stimulants be causing him to have subclinical seizure activity? Are some more prone to cause this than others?
Mandy,
Some general remarks, not trying to diagnose from a distance, just pointing out several likely challenges:
1. Of course it is most reasonable to suspect any comorbid neurological disorder because he is reacting so ‘biologically,’ not psychologically. A consult with a neurologist would be useful.
2. I would expect that review, however, to prove negative, and if it does, the next step involves assessment for his very narrow Therapeutic Window. More specifics on the Narrow Therapeutic Window at this CorePsych Blog Post.
3. My very distant guess is that he has an underlying metabolic problem. I would expect a history of bowel problems from childhood, gas, touchy stomach, picky eater, constipation or diarrhea – and barring any of those would look for dark circles, exhaustion, pale skin and general lassitude – any of these can forewarn of underlying immune system issues in the gut. Extreme sleepiness could be a side effect of the Intuniv, but could very well be amplified background noise from a pre-existing condition.
4. Immune system issues slow down metabolic turn over, and narrow that window – so that a tiny bit is too little and a tiny bit more is just too much.
5. Seizure activity is possible, but very remote. More likely in the range of some of these items I am sending out here, – but this note should not obviate a complete workup for any suspected neurological impairment.
cp
Well, right on!! He has terrible immune system problems, and had his first ear infection within days of birth! Takes 4 different allergy desensitization injections. He also has difficulties with constipation. Luckily, he is a good eater though. Thanks so much. I will look more into the Narrow Therapeutic Window blog.
Mandy,
Great to hear we are getting your guy closer to dead reckoning – on the mark. Drop an offline note if we can get the testing out for you.
cp
Hi,
My name is Heather Jones and I am the assistant editor of Epsychologist.org. I am contacting you today in hopes of developing a relationship with your website; we have seen your site and think your content is great. Epsychologist.org offer a free informational resource to both the general and professional public on several issues.
I hope you show some interest in building relationship, please contact me at heather.epsychologist.org@gmail.com.
Heather,
Did drop you a note off line, look forward to seeing your team’s perspective.
cp
Just let me know when the book is ready to go, and I’ll help spread the word.
Checked out that page- which links would you suggest? I see many……
Thanx,
Terry
Terry,
Best to start from the top with the synapse, then go to the basic info “Start with this introductory webinar” and then the Cass presentation under Metametrix. What I find so interesting, having done many of these, is using the neurotransmitter testing with the meds already in place – significant improvements accrue with that new real evidence… pd for by most insurance!
And thanks so much for the book offer – will be setting up affiliates if you find it useful.
cp
Thanks, Chuck.
Couldn’t get thru the long webinar, but did watch the Cass presentation. And of course, have read a lot of your material over the past year or so.
Question: if I were to have my daughter tested and the recommendations were to make changes in diet, how does one do that successfully with young people like her, who are incredibly fussy eaters? She won’t even drink water. No joke.
Would love to be an affiliate when you’re up and running.
Terry
Terry,
Therein, as the Bard said, lies the rub. There are several good books out there on the slow conversion of picky eaters, finding the taste they like but replacing it with parallel healthy things. With the Neuroscience interventions they have several targeted amino acid products that are delivered in a liposomal delivery systems to obviate irritation of the stomach, and bypass the bowel. A few well placed sprays can change the attitude and correct underlying neurotransmitter imbalances… sounds like snake oil, but I can tell you it actually works. The liposomal product [e.g. EndoTrex] makes delivery right from the buccal mucosa thru the blood brain barrier… and home to the holographic brain.
Not to worry if you review the holographic YouTube link… just the point that if perceptions are neurochemical, we can tip- toe-in with some safe, natural interventions. It’s all good.
cp
Hi Dr. Parker,
Our 8 year old son has been on 2 mg of Intuniv for 4 weeks for ADD. We have no behavioral issues. His teacher has noticed some improvement in attention and social choices. We started him on it in the mornings and he seemed to have insomnia so he’s taking it at bed time. He’s been wetting the bed for a week now, and it’s really impacting his self-esteem. Can you suggest a dosing regime to help us work through the insomnia and the bed wetting?
He’s on other meds – 15 mg Prevacid twice a day, 10 mg Focalin, Flovent, Albuterol as needed, and frequent antibiotics. He has almost constant sinus infections and multiple learning disabilities. I’ve read about neurotransmitter testing and read many of the links off your page. I’m struggling with what our next steps should be and if neurotransmitters could be impacting his health and his learning issues. Any insight you can offer over the internet?
Thanks
Kari
Kari,
I seriously doubt that the bed wetting lives only downstream from the Intuniv. Rather, I do expect he has an immune condition that is significantly contributing [guessing from the Flovent, Albuterol, and Prevacid with respiratory and GERD likely] If you look at these Prevacid side effects [quite numerous] – you will see insomnia there. My strong recommendation is that you consider the shift from treating symptoms to digging into the food sensitivity issues likely behind the many other symptoms here.
Bed wetting, tic disorder and a variety of symptoms often attributed to the ADHD meds [stimulant or otherwise] are often associated with comorbid immune dysregulations, and/or side effects of a combo of meds, as in his case treating the tips of immunity spawned icebergs.
I seriously doubt that the Intuniv is the problem, therefore am unable to throw out a guess that will likely prove inadequate for the underlying issues… that, by the way, are very easily corrected once measured.
cp
Thanks, Dr. Parker.
Our son has a hiatal hernia and has been on Prevacid for 7+ years. Intuniv was the most recent medication added and lists bed wetting as a side effect, which is why we wondered if the newly developed bed wetting could be attributed to that new medication or the new combination of meds.
We’ve wondered about an immune problem given frequent illnesses, and found Dr. Kellerman’s webinar quite interesting. We may be in touch for a consultation.
Thanks again,
Kari
Kari,
I look at side effects as having multiple causes – yes the med may be involved, but I always think more deeply and seek evidence beyond symptoms alone. For example: just saw a very interesting guy yesterday with severe IBS most of his adult life. He is under stress, out of the Navy, and completely refractory to any psych meds in spite of chronic depression and ADHD. He has significant sexual problems with every SSRI.
I am sure we will find out that the adrenal fatigue, and hormone balance will show much lower titers of testosterone, and the SSRIs are only pushing him off the diving board that he finds himself chronically perched upon. Yes the SSRI is causal, but the background noise on the hormone dysregulation is the underlying culprit, and the IBS is the actual problem, the SSRI is the only problem easily visible.
I look forward to a possible chat.
cp
Chuck,
Can’t wait for your book to finally land! Congrats on finishing it.
“Kiddo” is up to 3mg Intuniv. No positive (or negative) results seen yet. Will keep you posted.
Terry
http://www.MomsWithADD.com
Author, Survival Tips for Women with AD/HD
Terry,
Thanks on the book, – now have to get it converted [pdf] and out there! On your ‘kiddo’ – complexity often means more than a silver bullet fix. Multiple intervention strategies become necessary to address the many subterranean issues. I know I’m preaching to the choir here, – just trying to add a constructive reframe!
cp
Chuck, are you self-publishing? I can hook you up with Specialty Press (Dr. Harvey Parker), if you’re interested.
Re: my kiddo- oh, I know. It’s not all about meds. But this has been a work in progress for 22 yrs. Looking now to consult with a brain injury specialist re: behaviors. Current therpist is wonderful but not when it comes to parenting tips. But she sure can untangle her inner world and help her to make sense of the outer world, too. A real complex situation, this kid!
Terry,
Yes, will self-pub the book as an eBook – available off the CorePsych site, with the expectation of a hard launch later once the readers catch on that it does have merit. Will chase down Dr Parker over at Specialty – tnx.
Do take a look at the excellent webinars on this page – just loaded a few more that will give you more options down the road with your girl.
cp