We have heard it since we were kids, but do we really need to take our vitamins? 

· Homocysteine levels by 17%

· C-reactive Protein Levels by 32%

ADDERALL XR (amphetamine-dextroamphetamine)

ADDERALL XR is a mixed salt amphetamine approved by the FDA for treatment of Attention Deficit Hyperactivity Disorder. Mixed salt amphetamines have been studied and used clinically to treat ADHD since the 1930’s.

Amphetamines, as a class of stimulants, increase activity of the brain’s natural stimulants, Dopamine and Norepinephrine. Dopamine regulates interest, motivation, energy, concentration, pleasure seeking and movement. Norepinephrine regulates alertness, focus, energy, and vigilance. Adderall’s effects on Norepinephrine are about equal to its Dopamine effect.

ADDERALL XR comes in 5, 10, 15, 30, 25, and 30 mg slow release capsules. The cost is the same for all 6 sizes. Total duration of effect for the XR form is 7-12 hours. Half of the dose is absorbed immediately, and takes effect in about 30 minutes. Half is absorbed in 4 hours.

ADDERALL tablets (scored) come in 5, 7.5, 10, 12.5, 15, 20, and 30 mg sizes. Duration of action for the tablets is 3 ½ - 6 hours. Tablets are more likely to have rebound side effects, and doses are more likely to be missed or delayed.

Unlike most prescriptions, ADDERALL cannot be called into the pharmacy. By state regulations all stimulants require written prescriptions, which MUST BE FILLED WITHIN SEVEN DAYS. This means a prescription written on Monday must be filled by Sunday.

HOW TO TAKE ADDERALL XR

GUIDELINES

DOSING

• STARTING DOSE is 10mg in am for adults, 5mg in am for children.
• Increase dose by 10mg every 1-4 days until symptoms are under control.
• Dosing needs to be individualized for optimal benefit but is in the 20-90 mg range for most people. Maximum total daily dose is usually 2/3’s body weight in pounds. (Do not go above prescribed dose without doctor’s approval.)
• Higher doses last longer and can be effective up to 10-12 hours.
• If nervousness or over-stimulation occurs, always REDUCE the dose.

SWITCHING FROM ADDERALL TABLETS TO CAPSULES (XR)

If switching from ADDERALL tablets to capsules (XR), total the daily dose of tablets in mg and take half as often. For example, if currently taking 30mg tablets twice daily, switch to 60mg XR in am (two 30mg XR capsules). If taking 15mg 4x per day, take 30mg XR twice per day.

MANAGING SIDE EFFECTS

Most side effects are mild and occur mainly in the first two weeks of starting medication. In studies, very few people stop medication due to side effects. If side effects are experienced to a bothersome degree, decrease the dose.

May aggravate tics.

Side effects that peak around 6 hours from dose are most likely due to the medication. Dose needs to be reduced.

Irritability and tiredness/fatigue that occurs more than 6 hours after last dose are more likely due to medication wearing off (rebound effect). Dosing may need to be adjusted by adding an extra dose or by increasing the dose.

Many side effects are well controlled by Tenex (Guanfacine).

APPETITE SUPPRESSION

Eat a good breakfast 15-30 minutes after the morning dose. A nighttime snack such as ice cream is also recommended. Appetite usually improves over time, but if not, other methods of management can be used. Weight loss is common especially in people who are overweight. This is usually not due to appetite decrease but to a decreased tendency to eat due to boredom or stress.

Tenex may help taken a.m., evening, or both.

Remeron (Mirtazapine) helps sleep and appetite. Start very low (7.5 mg or lower). Remeron can cause morning drowsiness, especially when first starting.

SLEEP DISTURBANCE

First, shift dose to earlier in the day. If earlier does not work, take dose LATER in day. This may be caused by a “rebound” of ADD symptoms. Sometimes, medications that provide normal sleep are needed.

NOTE: Blood pressure should be monitored especially if any of the following is used on a regular basis with Adderall. Tenex is the first treatment option since it directly counteracts the effects of Adderall and these medications on blood pressure.

• Caffeine-large amounts
• Appetite suppressants
• Thyroid
• Some asthma meds
• Wellbutrin XL
• Effexor XR
• Tricyclics
• Cymbalta

For full information, see package insert or prescribing information.

Tenex (Guanfacine) is usually taken once or twice daily.  It can be taken 3-4 times/day but it has a 16 hour half life so frequent dosing is not necessary.  If taken regularly total blood levels will gradually increase over the first three days and then will level off.

Tenex comes in 1 and 2 mg tablets that are easily broken in half.  If taken primarily for help with sleep or if an individual is very sensitive to side effects it can be taken in the evening.  For irritability, muscle spasms, anxiety, increased blood pressure or any symptoms associated with high levels of norepinephrine it is usually taken in the am or am and evening.

As with most medications, start with a low dose – ½ of 1mg and gradually increase as needed until the right dose is found.  Extra doses can be taken for acute symptoms like agitation associated with increased or unusual stress.

Side-effects are usually mild and transient – especially sluggishness or dizziness.  If any side effects are bothersome decrease the dose and take at bedtime only.

Daytrana (methylphenidate)

Daytrana is an adhesive patch formulation of methylphenidate (such as Concerta, Ritalin, Focalin). It is the first patch to be approved by the FDA for treatment of ADHD. Although the formal indication is for use in children 6-12 years of age it can be used in all age groups.

The approved wear time is for up to 9 hours, providing 12 hours of effective control of symptoms. Wearing time for the patch can be individualized so that it is removed 3 hours before you want it to wear off. This allows for up to 15 hours of effectiveness, i.e., 12 hours wearing time. Many patients leave the patch on for 24 hours. The effect wears off in 15 hours and sometimes sleep is better when leaving it on.

HOW TO APPLY THE PATCH

The studies for approval were done by applying the patch to the side of the upper leg, just below the waistline of the underwear. It probably works just as well on the abdomen (in women) or on the side of the arm.

It is essential that it is applied properly.  Half the backing is removed and that side of patch applied to the body. The skin must be clean, dry, and have no hair. Then the other half is removed and pressure is applied by the palm of the hand for 30 seconds.

The combination of heat and pressure will keep the patch firmly attached. Most people begin to notice an effect in one hour, but for some it takes 1 ½ to 2 hours. To speed up the rate of onset it may help to keep firm pressure on the patch for a full minute.

DOSING

The patch is 10, 15, 20, & 30mg in strength. This refers to the amount of medication released during a 9 hour wearing time. If left on longer than 9 hours additional medication is released.  After 4-5 weeks of regular wear, absorption improves and up to twice as much medication is released.

This may result in better efficacy or may cause side-effects. In the event of side-effects the dose just needs to be reduced. Total dose should not exceed the maximum published dosing limits of 2mg per kg of body weight.

This translates to:

100kg = 220 pounds

50kg = 110 pounds

1 kg = 2.2 pounds

The medication is equally distributed throughout the patch. Although it’s not part of the formal FDA approval some patients report that cutting the patch in half and wearing on separate days works well.

Patients may wear 2 patches at one time when requiring a higher dose. It is recommended they both be put on the same side. The patch should be alternated between the left side and the right side. If any redness remains don’t put the patch on the red area but move it down or further back on the hip.

Each patch has 2 ¾ the total medication on the label.  This means that:

10mg has 27.5mg

15mg has 41.3mg

20mg has 55mg

30mg has 82.5mg

A unique feature of Daytrana is that after 4-5 weeks of regular use the absorption of medication improves and close to twice as much medication is released into the system.

If switching from Concerta 36mg, Daytrana 30mg was found to be equivalent.  After 4-5 weeks the dose of Daytrana may need to be reduced. 72mg of Concerta (2 x 36mg) may require 2 patches of 20-30mg initially but after 4-5 weeks one patch will be sufficient.

The patch sizes are:

1 ½ x 3 ½ inches(30mg)

1 ½ x 2 ½ inches(20mg)

1 3/8 x 1 7/8 inches(15mg)

1 3/8 x 1 3/8 inches(10mg)

SIDE-EFFECTS

Side-effects are the same as for all methylphenidate products except for possible skin irritation. In a large clinical trial only 7% discontinued due to side-effects and about ½ of those were due to skin irritation.

Other side-effects include:

• Decreased appetite
• Sleeplessness
• Sadness/crying
• Muscle twitches
• Weight loss
• Nausea

Most of the significant side-effects like muscle twitches, insomnia, irritability, and possibly even decreased appetite and stomach ache can be improved by reducing the dose. But if side-effects persist at the effective dose then Tenex (Guanfacine) ½ to 2mg once or twice daily can be very effective plus it also improves distractibility.

Most patients do not have any skin reaction or have mild redness that goes away quickly once the patch is removed. A small percent of people will have more marked redness that may persist for a few hours and a very few may develop a more significant localized skin allergic rash.

GENERAL INFORMATION

Remember that after 5 weeks the amount of medication released is almost double the dose on the label if worn for 9 hours and even higher if worn longer.

Because the patch provides up to 15 hours of effective symptom control and can be flexibly dosed to wear off within 3 hours when removed, it should be considered the first line form of methylphenidate in clinical practice. No other stimulant on the market provides more than 12 hours with single dosing and in ADHD it is hard to remember to take second and third doses of medication.

Note: If there are concerns about the possibility of growth delay – especially in children in the bottom quartile, Tenex can be given at bedtime. Clonidine is even stronger but is frequently too sedating. Tenex is also effective for the occasional person that has increased blood pressure from stimulants.

LAMICTAL (lamotrigine)

LAMICTAL (lamotrigine) is formally classified as an anticonvulsant drug.  However, it has been used for many years for migraines and pain.  It is also effective for treating bipolar depression.

WARNING: STOP THE MEDICATION IMMEDIATELY IF A RASH APPEARS.

Lamictal comes in scored tablets of 25, 100, 150, and 200mg. It is most cost effective to buy the larger sizes and cut them in half.

The dose may need to be increased to a total of 250-400mg.

SIDE EFFECTS

If significant side effects occur (e.g. dizziness on 25mg), the dose may be reduced even further. 

To decrease side effects (especially risk of rash) take each dose for 2 weeks.

WELLBUTRIN SR and XL (Bupropion)

Wellbutrin SR comes in two strengths: 100mg blue tablets and 150mg purple tablets. Wellbutrin XL comes in 150mg and 300mg tablets.

Wellbutrin enhances the brain’s natural stimulants, dopamine and norepinephrine. These help increase mental energy and motivation/interest. Wellbutrin also helps to control addictions, increase sexual functioning (especially libido and orgasm), and aids in weight reduction.  Wellbutrin works just as effectively as the Serotonin Reuptake Inhibitors (SSRI’S) for anxiety symptoms associated with depression. 

HOW TO TAKE FOR DEPRESSION

WELLBUTRIN XL

Do not break tablets.

WELLBUTRIN SR

OTHER TREATMENTS

SMOKING

300mg of Wellbutrin SR is usually the most effective dose to help quit or decrease smoking. It’s is even more effective when combined with nicotine replacement. (Nicotrol inhaler is best-tolerated form) 

A smoker does not have to be motivated to decrease or discontinue smoking. They just need to try the drug along with the smoking. Most people find that after taking the medication they no longer crave nicotine, and the need to smoke decreases.

SEXUAL DYSFUNCTION

Wellbutrin is effective for treatment of low sexual interest. It can also help primary orgasmic dysfunction or secondary orgasmic problems caused by other medications, especially SSRI’s. Treatment success is usually 40-50% for orgasmic dysfunction on an “as needed” basis.

WEIGHT REDUCTION

Wellbutrin has recently been found in studies to improve weight loss in obese patients. It is also an effective treatment for sluggishness and weight gain secondary to medications.

ADD and BOREDOM

Often respond well to Wellbutrin.

ANTIDEPRESSANT AUGMENTATION

Wellbutrin works well as a complementary drug with other antidepressants to achieve a more effective response in some patients.

SIDE EFFECTS

Side effects are usually mild and controllable with a dose adjustment or by adding a second medication to control side effects until they subside.

Most common side effects are:

• Insomnia
• Dry Mouth
• Nervousness
• Irritability

For full information, see package insert or prescribing information.

EFFEXOR XR (Venlafaxine)

EFFEXOR XR (Venlafaxine) is a slow release capsule and comes in 37.5, 75, and 150mg sizes.  It is a broad spectrum medication, which means it works by blocking reuptake of Serotonin (at 37.5 to 75mg) and norepinephrine (at 150mg+). Serotonin and norephinephrine are the two primary stress neuromodulators. Because Effexor XR works on both these neuromodulators, it is effective in treating anxiety and depression. When Effexor XR is taken, the brain levels of Serotonin and Norepinephrine are lowered if too high (as in anxiety), or raised if too low (as in depression).

Effexor XR has no significant drug/drug interactions and does not require dose decreases for the elderly.

HOW TO TAKE FOR ANXIETY/DEPRESSION

PARTIAL DOSING

During transition, (if less than 37.5 or between 37.5 and 75mg is needed), capsules may be opened and used as a sprinkle form on any soft food. Sprinkled granules remain slow release unless bitten into.

PANIC PATIENTS NOTE: 

This step is especially important in panic disorder where initial doses as small as 9mg may be needed. It is essential to minimize side effects with panic patients because of extreme sensitivity to side effects. The dose can usually be gradually increased.

DO NOT abruptly stop the medication.  This can cause rebound symptoms such as muscle aches and nausea. When tapering the dose decrease by 37.5mg every 3 days. 

WHAT IS THE BEST DOSE TO TAKE FOR ME?

Take enough, not too much!  How much is that?  I don’t know.  Each person has to find the dose for him/her that achieves the goal of remission (completely back to normal functioning).

• If you have some side effects but they are mild – remain on dose schedule
• If side effects are bothering you - shift the dose time, split the dose or decrease the dose for 3-4 days, then try to go back up
• If you have taken it for 1-2 weeks and not seeing significant benefit - increase the dose

SIDE EFFECTS

HOW DO I SWITCH FROM ANOTHER ANTIDEPRESSANT TO EFFEXOR XR?

Note: The most important rule of changeover is make only ONE change at a time. In other words don’t change the Effexor XR dose and SSRI dose both on the same day.

SONATA (Zaleplon)

One of my slogans is “The right medication at the right dose.”   When starting someone on a medication, I tell them I’m not looking for them to say, “Doctor I think it is helping some.”

What I’m looking for is “This medication is great! It has made my life better and it’s not causing any significant side effects.”

Essential to finding the right medication is knowing HOW TO TAKE your meds.  You need to take enough, but not too much! How much is that?  I don’t know.  Each person has to find the dose for him/her that achieves the goal of remission.  Remission = completely back to normal functioning.  Before you decide a certain medication "doesn’t work" or "makes me sick," make sure you’re taking the right dose at the right time and in the right way.

I will regularly add "How to take …" to this category.  Use the comment section below to tell us medications you would like a "How to take…" for.