Bipolar

Watch For: Top of the Therapeutic Window

This comment on Vyvanse is worth your time, and so commonly seen in the office. Vyvanse in the PM is so forgiving that it’s hard to measure exactly when it finishes. Measure the DOE anyway – always start with a detail grid – and download the pdf on the PS below.

Dear Dr. Parker.

Your articles and videos have helped so much in navigating the crazy pathway to treating ADD. I serve as my 52 year old brother’s ADD coach. He was just diagnosed two years ago, after a lifetime of failed jobs, frustration, alcohol abuse and all the other common experiences of others in his situation.

He was diagnosed with depression years ago and has been on Wellbutrin and Lexapro for years and continues to take both. He is also one of the nicest people in the world.

After reading about and realizing that he has classic symptoms of ADD, we found a psychiatrist with expertise who tried him on several stimulants, finally settling on Vyvanse. This made such a tremendous difference in his executive functioning, success at work and self esteem! The doctor started him on 30 mg and quickly switched to 70. At the time, the other doses were not yet available. He has been on 70 mg for a year and a half. The only negatives were that every once in a while, he would go through episodes of agitated, short-tempered, hyperfocused behavior – especially at work. These were very out of character for my mild-mannered brother and very short-lived. He would call me, incensed at how others at work weren’t doing their job, his boss was treating him like a peon, etc. His language and tone were very volatile and his perspective seemed irrational. Without exception, within 24 hours, he would be calm and rational and question why he had reacted with such ire.

These episodes happened sporadically, but increased this past February to the point that he was in jeopardy of losing his job. His boss, who is aware of my brother’s diagnosis and treatment (which includes behavior therapy) made it clear that he might have to let him go. At that point, it didn’t occur to his psychiatrist or me that this could be a toxic effect of the Vyvanse being above the top of the therapeutic window. The doctor suggested it was “shades” of bipolar [mood disorder is the too frequent conclusion] that are sometimes seen with ADD. He prescribed Abilify, 10 mg daily. The agitation ceased shortly after, but within 6 weeks, my brother became so sedated that he was sleeping 15 hours a day and half-asleep the other hours. When we realized this was a side effect of the Abilify, the doctor took him off. The withdrawal was awful and included tremors, anxiety and sleep disruption.

It has now been 3 1/2 weeks since we stopped the Abilify, and my brother continues to report “anxiety” which appears to be gaining in severity, as well as continued sleep disruption and some difficulty processing thoughts. Today, he described the feelings as “going 100 miles and hour”, “jumping out of my skin”, and “about to explode”. When he lays down to rest, he can’t stop his thoughts.

After reading many of your articles and watching your videos, I am beginning to believe that too much Vyvanse was the culprit all along. He was agitated; treated with a sedative (antipsychotic) that masked the agitation; and now that the sedative is gone, the agitation is returning because the Vyvanse remains the same. He does not seem outwardly angry just continually nervous and restless. The symptoms are not evident when he first wakes up and ease toward late afternoon and evening – which corresponds with when the Vyvanse is active in his system. [This is the frequent presentation at the top.]

Could you please give your opinion? I would like to ask the doctor to lower the Vyvanse dose to see if it would relieve the agitation. If you agree this is a wise course, how low would you start and how would you titrate upward? I have read people’s blogs that claim lowering from 70 to 60 relieved symptoms. Should the doctor start at 30 again, or maybe 50?

Any advice you can give would be a blessing. It has been a long course, with a lot of twists and turns. My brother, like so many others has shown tremendous courage and perseverance, and was just beginning to experience some success and peace, but the events of the past few months are eroding his confidence and he is feeling helpless, as am I.

Thank you so much,

Anne

_____________

REPLY NOTES:

This is such a classic situation, and so well written/reported in this comment that it deserves a full posting. To cut to the chase here – I often go down to 1/2 of the dose in a situation like this [knowing only these few variables, and not knowing about other key issues such as breakfast and transit time]. I’m on the conservative side, but don’t think you have to go all the way back to 30mg. My recommendation, because he is having so much trouble: just stop the med for a day or two and expect rebound. Then start back at about 40, and watch the DOE, – specific Duration Of Effectiveness timing will set the titration perfectly [most of the time!].

He may very well wind up at 60 mg, as only 10 mg can make a big difference, – but why not dial it in slowly and correctly, rather than leap over the necessary measurement/titration process to find the exact sweet spot?

My take with this limited info: it’s not the Vyvanse, you’re right, it’s the dose. Need to go more slowly in the first place. Easier on Monday morning looking at the game tapes!

Hope this helps-

cp

PS
Sorry for the silence, – writing and speaking have been busy. I just finished an extensive white paper/small ebook for the vADHD – Virtual ADHD Conference coming up in October – It’s loaded there now for those attending the meetings – ebook Title: Predictable Solutions for the 10 Most Common Challenges with ADHD Medications.

And: This pdf Handout for my presentation at vADHD - Download this handout for your review

Hope you can make it!

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Tagged as: ADHD Medications, Antipsychotic, Aripiprazole, Bipolar, Lisdexamfetamine, Mental health, Mood, stimulant dosage, Stimulants, Vyvanse

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