Adderall

Cookie cutter medicine in psych treatment is on its way out folks – from SPECT reports to simply adjusting the dosage of medications in the office, the public knows, as do many of the informed docs, that one size, one label, one basal ganglia platitude, one description of one mood, does not fit all. – And one dosing strategy doesn’t cut it.

Functional complexity is the reason we are missing the treatment boat so often.

Each person deserves a customized approach that will individualize their care. So much of psych medicine now is throwing medication at a superficial diagnosis, or even a cookie cutter SPECT report without understanding the patient.

This brief question and comment on a recent post deserves more attention due to the prevalence of the questions regarding customizing the upper dosage of Vyvanse [video here at CorePsych]- and the science behind why finding the best dose may not be that easy with some.

Question from Daisy:

The first week on Vyvanse, everything was so clear and seemed so right, it’s hard to explain, but my brain was with me all the time. I wasn’t off daydreaming. I had never felt that good, but then it went away after a week. So, we raised the dose, but that never seemed to work again. I’m on 70 mg, I was on 30 mg that first week, so I assumed when it stopped working it was because I needed to work my way up to the appropriate dose. So, we worked up, I think there was only one or two steps in between, up to 70mg where, I am now. My dr stopped, because he says this is the highest dose, and my symptoms are just as bad as they are off the medication.

This is my 4th medicine change, I was on this first, when we got up to 70 mg, with no noticeable improvement, he took me off of this and tried, that barrel shaped one, that can’t be crushed, I can’t remember the name off-hand. That didn’t make me feel any better, then we tried Adderal XR and again no change. At this point he said those were my only options and to give up at this point, so I asked to go back on Vyvanse, and I tell him it works OK, so he doesn’t take me off of it and leave me with nothing, as he was going to do before and I thought I could play with the dosing on my own, to see if I can get it to work again. I want that week back, that week of feeling clear headed and coherent. Of knowing what was going on around me and understanding people when they talk to me.

The Problem of Ultrarapid Metabolism - My Answer

Without a few more details this sounds at first like you were right: a good example of too much too fast – too rapid a titration, not leaving about 1-2 weeks near the top dose before increasing to the next, and, as you point out, no appropriate slow steps in between. With adults I rarely go faster than 10 mg increase every 1-2 weeks, watching carefully for that expected 2 hr increase in DOE in the PM with that carefully adjusted dose – and I fully admit I am very conservative. The only problem with that process in my office is the patient’s becoming impatient, as I rarely create a drug excess with that protocol.

Many docs feel the same way yours does, as they stay only with the package insert. He is simply following the ‘insert rules’ as Vyvanse is a controlled product, and just as I have almost no experience writing for antibiotics – and simply won’t write for them – he is simply doing a good job following guidelines.

My possible contribution to this conundrum is a mix of common sense and experience over the time that Vyvanse has been out – with a dose of clear science about the CYP 450 genetic polymorphisms of 2D6 [see the many posts here].

1. Common sense: Adults already often go over 30 mg Adderall XR [roughly = 70 mg Vyvanse] regularly – and can be titrated based upon watching carefully for the DOE as outlined in this post. If your medical person goes very slowly they will not have a problem, and I don’t recommend that you ‘play with the dose’ – even tho your doc may not be working with you at this moment – do stay tuned with your medical team with your actions, or you very likely will loose [justifiably so] their medical support.

2. Experience: I do go up past 70 mg in dose at times, and have heard whilst in CA last week that some have not only gone up to 400mg, but have recommended simply ‘going to the top’ without careful titration, a practice I completely dismiss as dangerous. I always steer completely away from an answer to the question of ‘just what is your top dose?’ because that discussion drives practitioners away from the essential practice of careful titration into cookie cutter medicine – a point with which I am completely philosophically at odds… don’t get me started!

3. The genetics: about 1.5% of folks are 2D6 [the AMP pathway] ultra rapid metabolizers [UMs] as reported in many books such as Drug Interactions in Clinical Practice leaving practitioners with a challenging few that just can’t correct their ADHD on average doses, as they burn up the effectiveness just too fast. These individuals are often unhappy and disappointed, often with long unsuccessful trials of meds. For these folks only someone completely comfortable with those higher [notice I didn't say 'highest'] doses of medications [using the predictable, careful titration strategies outlined in multiple posts here at CorePsychBlog and at http://www.squidoo.com/vyvanse is recommended.

Best bet: talk these issues over with your doc, and see if he is comfortable with a little increase - if not perhaps they can suggest someone more experienced in your community to walk carefully down that path with you. Do shoot for the 12 hr duraton [DOE] as noted frequently in these blog posts. [Video on Vyvanse and DOE}

Interesting and common problem - just talked to some of the docs in CA last week about this very issue - thanks for sharing it with our readers.

cp

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Tagged as: Adderall, ADHD Medications, Attention-deficit hyperactivity disorder, duration of effectiveness, Health, Lisdexamfetamine, Medicine, Mental health, Pharmaceutical drug, Single photon emission computed tomography, SPECT & Brain Imaging, Stimulant medications, Vyvanse

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