CorePsychBlog: Tips on Medication Management: Finding The Top and Bottom of Th... - The Diigo Meta page

• 08 Apr 08
  

  Jim McClintock

  corepsychblog ssri ADD zoloft vyvanse wellbutrin psychology therapeutic window

  • Why are we having so many Black Box  Warnings for the use of psychiatric medications?

     

    Simple answer: Many do not aim for, do not measure, and indeed don't seek  that mercurial Therapeutic  Window.
  • • Simply feels like you are toxic, it's just too much. You shouldn't feel  stoned or drugged.
  • • Confusion, disorientation, cognitive stress, anxiety, self expression  diminishes.
  • With some stimulants you can feel moody and depressed all day - and relieved in  the evening as they have a shorter 1/2 life with an expected duration of less  than 12-14 hrs. If you feel better when they are gone from your system, - this  is a big hint.
  • • If you feel these kind of symptoms for the first couple of days after  starting a new med, usually no problem. If symptoms continue, urgency  is called for and an adjustment is very likely necessary, - see your doc.

  • The Therapeutic  Window represents the body's ability to metabolize the medication  effectively. Several easy rules apply here:

     
     
    1. If the medication is just right in dosage and duration you will  feel that you are simply floating through that effective opening - no problem,  and no, or very few, "side effects."  
    2. If the medication is too much, too high a dosage, you will have  signs of toxicity, and will hit the top of the window - bump your head on the  top of that window.  
    3. If the medication is too little, too low in dosage, it doesn't appear to be  working at all, you can't get into the window, and your chin keeps hitting the  sill at the bottom.
  • • New genetic studies show that many do not  metabolize drugs at the same rates. Studies show that less than 50%  of the population metabolizes medications at an average rate.
  • • Pharmacogenetic  studies [regarding, in this case, 2D6 metabolic pathways] show that 5-7% of  the population are very fast metabolizers and require more than expected doses  to turn the therapeutic tide.
  • • Metabolism is not completely dependent on body size, and the old  adage that body size, larger weight or height, suggests a need for more  medications, is outdated.
  • • Also outdated is the cookie cutter dosage suggested by some based upon age.  Each dose for each person must be reviewed at every medication check - Each  individual's Therapeutic Window will tell  the tale. Drug dosing, sometimes suggested on preliminary reports, can be  misleading. Simply go low and slowly with everyone at the outset. Often psych  medications are under and overdosed through the process of not establishing  specific improvement criteria.  
    • With stimulant medications used for ADD: the top of the window can look like  the bottom of the window, creating an apparent need for more medications in the  real context of too much. Said another way, too much medication can diminish  focus and attention.  
    • Noted repeatedly at CorePsychBlog: Drug  interactions clearly effect the therapeutic window.  
    • As we have been regularly reporting here at CorePsychBlog: Metabolic issues,  such a gluten  sensitivity, bowel and liver  problems also challenge the expected rate of metabolism.  
    • And see more here at  Genelex on pharmacogenetics for antidepressants and antipsychotics.

  • What I am about to tell you is from my own experience, and is documented  somewhat indirectly in the drug interaction book on my website bookstore [Cozza  and Armstrong], but has not found it's way to the literature yet.
    I say  "indirectly" because Vyvanse is not in there, only AMP as a class is  documented.
  • side effects increased, particularly sedation and brain fog, with little added  benefit

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