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01 Sep 08
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08 Apr 08
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[Full disclosure: I do speak for Shire, the company that makes Vyvanse, and have for years made a considerable effort to teach medical colleagues around the country how to use stimulant meds more effectively. I have presented for Adderall since its launch, Adderall XR, Focalin XR, and Daytrana as well as Vyvanse.]
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- It is a prodrug with a slow and forgiving delivery process: No heavy AM hit, no big drop in the PM
- It is a prodrug with a slow and forgiving delivery process: No heavy AM hit, no big drop in the PM
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Both studies and clinical experience show that it is more efficacious [post hoc review] than Adderall XR, and Adderall previously held highest efficacy ratings on comparison studies.
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longer duration of effectiveness, with no need for a PM "kicker" dose to complete homework or home chores.
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Always start at the lower dose: 30mg which roughly equals Adderall XR 10mg.
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With a medication sensitive child/adult you may want to divide the dose in 1/2 to get started: Take the capsule, pour contents into 2 oz of water in mixing cup, drink 1 oz
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All psych meds are better tolerated and more effective with a protein breakfast
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Always remember the ADD 3R's, discussed in my first post, in reference to medical treatment for ADD: Right Diagnosis, Right Medication/Intervention, Right Dosage
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MPH products like Focalin block 2D6, and I strongly recommend against using drugs that clearly interact - as Vyvanse is an AMP that runs thru the 2D6 pipeline [Google 2D6 on this blog and you will see much about this issue].
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Likely the dose is not correct if it isn't working in the AM - at the correct dose it works in .5 hr... and again we aren't looking for "feeling," but for cognitive change.
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You can't get it right with whatever was in the hookah on board - highly unlikely the fall was due to Vyvanse alone, highly likely secondary to meds + hookah, or hookah alone.
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If you are in the US you are most often talking *weed/marijuana* with "hookah" use, - and weed, as other addictive substances, should be avoided if you want the true fix.
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Bottom line: breakfast of protein first, then any psych med after.
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Second point: dosage may change that reaction and the post on water titration may help.
Third point: Some people cannot take AMP meds.
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Neuropsych testing and SPECT tells us much.
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noticed a decrease in appatite since starting Vyvanse (prev on Focaline XR). It also makes me nauseated when I do try to eat sometimes.
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I just read an article on CyberPsych that scientists aren't even sure what these drugs they are prescribing for ADD do or how they work. What gives?
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I started getting a severe backache and noticed it was only when i took the Vyvanse
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I strongly recommend John Ratey's book: User's Guide to the Brain
http://astore.amazon.com/cpbks-20/detail/0375701079/103-7756357-1889446
- his work is cutting edge and he also would be a great resource for your further investigations.
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If the therapeutic window seems just too narrow and either up or down dosing is insufficient - you very likely have a metabolic problem, or simply the wrong medication for that symptom complex - from a defective 2D6 metabolic pathway [to be measured by genetic testing with either Genelex [used by the Mayo Clinic and available through our office] or Detoxigenomics [also available with our office from Genova] ...or other metabolic testing indicated by our questionnaires and a personal interview.
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She must be medicated in order to fall asleep, yet though everything we try sedates her, her body/mind fights it and she ends up staying up way too late. She walks around with eyes half shut and looks intoxicated, yet she can't stop her body from moving. That means repeated runs (she does not walk and she's 19 yo) up and down the stairs, grabbing food, items, cat, etc.
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know John Ratey, who suggested intense exercise, but she is unable to follow formal routine exercise. I do have her skating and bowling once a week via special ed groups but know that's not enough. This is a young lady who can't read her body; who never tires; can't tell hunger from full, etc. Extrememly hyper/impulsive due to her brain injury as a tot.
The only time she is able to sit is when she perseverates on the compute
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Look for the therapeutic window, the top means it's too much, the bottom, where you appear to be on this brief missive, is nada...it isn't working. We look for the middle. You can't get out the window by going thru it, or bumping against the window sill.
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I completely agree with your psych about her start dose, and his observation with you that she is a fast burner at a previous Adderall dose of 80mg. You do already know she is fine with the AMP molecule, so she is not [as they say in research], a *virgin [innocent from previous stimulant, -and, in this case, not innocent from AMP stimulant] patient.*
So, with that foundation, 50mg Vyvanse would be expected to have a positive effect on prefrontal cortical brain function [to coin a phrase!]. At the previous DOE [duration of effectiveness] on the IR Adderall @ 3.5 hr, she was slightly under-dosed. I have come to expect a solid 5-6 hr on the DOE with the IR.
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Constipation in our entire adolescent/adult society is rampant.
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I would look for metabolic and nutritional components vigorously - and even though she is smart and motivated, I am an anti-carb hound. Carbs mess up the bowel, diminish effective metabolism, mess with the estrogen system [listen to my podcast on PCOS and the other on estrogen dominance] and then can create sleep problems, appetite and breakfast problems.
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Bottom line: My experience at the Vyvanse top with high dose: the person is likely a fast burner, and adding 30 will probably be no problem. Agitation may occur for 2-3 days but should settle and she should be consistently better.
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For her, the Vyvanse is effective for about 8.5 hours and she notices a drop-off in concentration/orientation if she lets it go much longer. What are practitioners doing to handle the "after it's done its job for the day" problem? Many people I work with need some stimulant on board in order to get to sleep, and my daughter is one of them. So many sleepless childhood nights -- she averaged 4-6 hours all during her middle childhood -- and we finally figured out what made the difference.
She has been taking two equal doses of Vyvanse (50 mgs.) and this sees her through past go-to-sleep time. Covering a 16-hour day would be important for lots of people.
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Here are the correlations from the *forced dose* research:
10XR=30 Vyvanse
20XR=50 Vyvanse
30XR=70 Vyvanse
But anyone working with Shire [the pharma company] including Frank Lopez MD one of the lead investigators, would tell you, just don't think on those terms. Research is research, practice is practice. These are very vague guidelines only. Every med is different, even if it is the same AMP molecule at the *core...* -notice how I slipped in that word? -
Stimulants need some attention! AMP is metabolized differently than MPH and that can make a difference in response.
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My own titration strategy for Vyvanse is simple: Don't look for the "feel," look for the cognitive improvement, the decrease in impulsivity, and leave it alone. If you go for the "feel," you often go over.
As I have said in all of these Vyvanse posts:
Titration strategy is simple - go slower than you think, and don't follow the exact dose equivalence stated in the literature.
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