Obtaining ADHD Medication When Traveling Overseas

Suppose you would like to travel overseas, either for work or for pleasure, but you have to take your ADHD medication with you.  Is that even possible?  This article deals with what you can bring with you, what you have to leave behind, and what you can get a prescription for abroad.

Tourism
Most countries will allow a limited supply of medications from a foreign country provided that the medication you are bringing is (1) limited in quantity (limits may be country, drug, or length of stay  specific) (2) for yourself and not someone else , and (3) on your person.  You have to be very careful about this.  If you bring the wrong meds, or the wrong quantities, or break some other rule, you could be imprisoned for drug smuggling, which can have severe penalties.  I recommend checking with the embassy of the country concerned to be sure before you bring your medication outside of the country.

Additionally, TSA has its own rules about traveling domestically with medication which you should also be aware of. These rules change depending on existing threats and so its best to check the TSA website for up to date information.  Individual states also have rules you need to comply with.

Long term stays
It can be very tricky to get ADHD medication if you do something like stay overseas for more than 3 months for work, for example. The best possible scenario is that you see a doctor overseas and get your prescription there.  However, not all medications available in the United States are available overseas.  Although many countries may have Ritalin, most do not have the wide range of different dosages or delivery systems (such as Concerta) that are available in the United States.  Also the criteria for diagnosis may be different, so that there is no guarantee you will meet diagnostic criteria overseas.

If you have a child who requires ADHD medication for school, it is possible that the school overseas may be more accomodating than your school in the US (the opposite is also true), so that your child will not need medication.  Typically this would be with younger children who mostly have trouble sitting still, and who do not need medication on the weekend.  Most older children who need medication will find the expectations for sitting still will probably be the same.

What you should NOT do is have your medication shipped from the United States.  This would be considered drug smuggling and could get you in a heap of legal trouble.

You must consider the possibility of needing to return to the US to see your doctor and obtain your prescription, carrying only a limited amount of medication back with you every so often.  This could become an issue for your employer, your budget, and/or your doctor, so before committing to a lengthy overseas stay, be sure to know all the relevant regulations.

Supplements

Not all medications and supplements retain their designations as prescription medications and/or supplements overseas.  All stimulants are likely to be regulated as prescription only if they are allowed at all in most countries.  However, supplements like CBD or fish oil which are regulated as over the counter supplements may require a physician's prescription or even be illegal to possess in other countries.  Do your research carefully before travel.

Book Review: 1000 Best Tips for ADHD

1000 Best Tips for ADHD, by Susan Ashley, PhD, a psychologist specializing in behavioral disorders in children, is a practical book that has helpful tips for improving various aspects of life for parents of kids with ADHD.

The book has an introduction on how to use the book, followed by a list of tips categorized by the issue at hand.  The introduction is crucial to using the book, otherwise, the book is a reference style manual meant to help parents with specific common problems faced by children with ADHD.  The book avoids being trite and it acknowledges the hard work that sometimes comes with implementing behavioral strategies, so in a sense, while this is a book of tips, it is not a book of hacks.  Some of the suggestions given are easier to implement than others, and some of them will not work for a given child's situation.

The book has many strengths.  It is very practical and is not a long treatise on a certain approach or philosophy.  The main philosophy in this book seems to be, "Do what works."  Many parents with ADHD willl appreciate that fact that this book is reference style, so you don't have to read the whole book to understand or get to the part that you want, which is a fix for your child's problems.   The book offers a wide variety of tips in a wide variety of areas such as medication, behavioral issues, school, diet, and social issues.

There are several downsides to this book.   I was looking for a book about managing behavioral issues specific to older children and teens with ADHD, things like hygiene, organizational skills, and driving.   Those issues are not specifically addressed in this book.   I  would love to see the author write a similar book about teens with ADHD.  Another omission was that the book only talked about children having difficulty in brick and mortar school situations and did not address how to alter home schooling to help a child with ADHD.  It does refer the reader to a website and there are some tips on homework and specific subjects which could be helpful, however. 

Overall, though, the book offers many useful behavioral strategies you can try to help your child with ADHD.  While it is not the only book you will ever need, and not really a "complete reference for parenting a child with ADHD" as it is advertised to be, it certainly is a solid starter book for parents new to dealing with ADHD in a younger child.

Jornay PM for ADHD

Although Jornay PM (Ironshore Pharmaceuticals) (methylphenidate) is marketed as the first bedtime medication for ADHD, it is in fact, not quite all that.  Guanfacine (Intuniv,    ) and clonidine are often given at bedtime and treat symptoms during the day as well.  Jornay isn't even the first stimulant that can be given at bedtime.  Mydayis is actually the first and has been on the market for several months.  However, Jornay PM is the first stimulant that can be given to children at bedtime (unfortunately Mydayis caused a high rate of insomnia and appetite suppression in children and so is unlikely to ever be available for kids).  And anyone who knows what it's like to struggle with ADHD in the morning can tell you, the potential to have a medication work first thing in the morning could be a game changer.

Disadvantages

Cost.  Like any new medication  Jornay PM is likely to be expensive while it is under patent.  It is yet to be seen what type of assistance, if any, Ironshore Pharmaceuticals, will offer to patients.  Also, during the first year after approval, insurance companies are unlikely to cover any new medication unless it is truely unique, which it is not.

Nothing new.  This drug does not really offer anything new in terms of avoiding potential risks.   It is still causes issues with appetite, sleep, anxiety, emotionality, and other symptoms commonly associated with stimulants in some patients.  In addition, preliminary studies showed up to a 33-41% chance of insomnia in 6 weeks of treatment.  Similar studies done with Concerta showed up to a 12% chance of insomnia.  Since the studies were not done as direct comparisons, it's difficult to know how the risk for insomnia truly compares, but 33% seems high.
Takes longer for it to get out of your system.   If side effects are likely, the big advantage of stimulants is that they are out of your system quickly.  This would not be out of your system very quickly, although likely if your child has severe side effects, such as hallucinations, it would not be more than 24 hours (as compared to 12 with Concerta).

Drug levels likely to take a long time to stabilize.  Clinical studies have not actually addressed this issue, but we often see that long acting drugs often manifest side effects later in the game--6 to 8 weeks later.  We would not expect things to be different with this drug.

Difficult to deal with missing doses.  If you miss a dose, you'll definitely have to wait until the next day.  It would be possible to take a short acting medication to cover the gap, but obviously your morning would still suffer.

Advantages

Works in the morning.  The main advantage of Journay PM is that it allows patients to have the benefit of their stimulant from the time when they wake up, onward through the day.  No waiting for your med to kick in before you can really function.  No more difficult mornings.
Different.  As with any new formulation, a different time release can produce advantages for some patients.  The let down off of Jornay PM may minimize symptoms of rebound, for example. 

Should your child use Jornay PM?
Jornay does not really have an advantage over traditional long acting meds like Concerta except for the hour that it takes a traditional medication to get started.  If mornings are manageable with behavioral strategies, this medication probably would not be worth the cost or the potential for side effects lasting through the night.  However, if your child is truly unmanageable in the mornings before meds and the extra hour of medication effect is worth it to you, then this medication could be helpful.

Should adults with ADHD use Jornay PM?
Adults who really struggle with mornings to the point of being late for work, and who have no one at home to make sure they get out of the house in a timely fashion may find Jornay PM to be helpful.  Jornay PM, unlike Mydayis, is a member of the methylphenidate family and so may be more appealing to patients who find methylphenidate more effective than Adderall.

References:
Jornay PM [package insert]. Ironshore Pharmaceuticals.,  Grand Cayman; Aug 2018.  http://www.ironshorepharma.com/labeling.pdf.  Accessed 8/10/2018.

Mydayis [package insert]. Shire, LLC., Lexington, MA; June 2017. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/022063s000lbl.pdf.  Accessed November 19, 2017

Concerta [package insert]. Jannsen Pharmaceuticals, Inc.,  Titusville, NJ; Dec 2013.   https://www.janssenmd.com/pdf/concerta/concerta_pi.pdf.  Accessed 8/10/2018.

Online Pharmacies and ADHD Medication

Buying ADHD medication online might seem like a great way to save money and certainly is convenient.  However, there are many online pharmacies which promise cheap, easy medication, which deliver more trouble than they are worth.  How can you tell the difference?

Warning signs

There are certain warning signs that a pharmacy is illegitimate or running a scam.  

First of all, most ADHD medications are scheduled medications worldwide.  So it's safe to say that it is impossible to buy ADHD medication legally without a doctor's prescription.  Pharmacies which do this may say that they will have their company doctor write the prescription for you, but if the doctor doesn't see you and doesn't interview you and doesn't really know your case well--it's likely that you're dealing with a criminal enterprise.  Stay away.

Another product of ADHD medication generally being scheduled is that it is very hard to legally ship it across international boundaries.  Generally the only way is if you buy the medication legally (with a doctor's prescription) in your country, and you are bringing a limited supply with you in your bags when you are traveling abroad.  If you live in the US, it's not legal for a private citizen (or resident) to legally buy ADHD meds "from Canada" to ship back to the United States.  

Safe online pharmacies

Generally, if an online pharmacy has a brick and mortar pharmacy that is legal, the online pharmacy will be legal as well.  Retail chains such as Rite Aid, CVS, and Walgreens have safe online pharmacy services.

However, not all online pharmacies have a brick and mortar component.  Some internet pharmacies contract with insurance companies and basically keep their prices down by specializing selling bulk quantities of medications to consumers and not carrying certain other medications (those that are needed for a short time) that a brick and mortar pharmacy would.  Examples of legitimate pharmacies in this category are Merck Medco and ExpressScripts.  Usually your insurance company will only contract with one of these companies and they will tell you which one you must use.

 The Verified Internet Pharmacy Practice Site certification is a program run by the National Association of Boards of Pharmacy, which basically accredits pharmacies throughout the United States.  You should always choose a pharmacy which has been accredited, regardless of whether it is online or brick and mortar, as this demonstrates that the pharmacy is aware of best practices in the field.

Quillivant and Quillichew Shortage: Update September 2018

Pfizer recently posted nationwide shortages of Quillivant and Quillichew on the FDA website due to manufacturing problems.  The Quillichew shortage has been resolved.  Pfizer published an updated doctor letter in March 2018 but the Quillivant shortage is ongoing with an updated resolution date of "unknown at this time".  This situation has not changed since July, our last update.

Quillivant is available in pharmacies, however, there continue to be some manufacturing problems.  The Quillivant that is available may not dissolve properly and has the potential to be less effective than properly manufactured Quillivant.

These medications are popular among younger patients due to their ease of administration.  Quillivant additionally is one of the most easy ADHD medications to titrate due to its being available as a liquid and so it is not easily replaced.

For those patients who are using Quillivant  because of being unable to swallow pills, there are a number of other long acting medications which could be used.  Focalin XR (capsules can be sprinkled on food, and drug (dexamethylphenidate, same class as methylphenidate) is available as a generic) Quillichew (chewable tablet, also methylphendiate) and Cotempla-XR-ODT (orally dissolving tablet, also methylphenidate) are the most similar to Quillivant.

For those patients who are on Quillivant due to difficulty coming to a correct dosage of methylphenidate, the issue becomes more difficult.  Focalin XR can be titrated, but not very exactly.  It's smallest pill size is 5mg and could potentially be split it to half that amount by opening the capsule and dividing up the beads.  Any more division would probably make the dosing fairly imprecise.  Quillichew 20mg and 30mg are scored for easier division and titration.  Cotempla-XR is not made to be divided.    These patients may find that staying with Quillivant, despite the manufacturing issues, may be the only workable alternative.

Patients switching medications should consult their doctor about appropriate dosing.  In addition, they should plan on frequent follow up just as when they were first starting their first medication.

Everything ADHD Medical Disclaimer
Everything ADHD Privacy Policy

Mydayis for ADHD

The FDA has recently approved Mydayis (mixed salts of a single entity amphetamine product) for treatment of ADHD in children and adults 13 years of age and older.

This drug, produced by Shire, is a stimulant.  The active ingredient, amphetamine salts, has been on the market for a long time as a medication for ADHD.    The main difference is the formulation.  It's closest relative is Adderall XR, but unlike Adderall XR, it is the first in it's class of ultra-long acting stimulants, which can be taken at night and be active from 2-4 hours after the patient takes it until 16 hours later, thereby allowing the medication to be active from the first moment the patient wakes up.

Disadvantages

Cost.  Like any new medication Mydayis is likely to be expensive while it is under patent.  However, Shire provides assistance to needy patients who require this medication through its patient assistance program, Shire Cares.  Also, the first 3 months are covered by a coupon/voucher program.

Nothing new.  This drug does not really offer anything new in terms of avoiding potential risks.   It is still causes issues with appetite, sleep, anxiety, emotionality, and other symptoms commonly associated with stimulants in some patients.

Drug levels likely to take a long time to stabilize.  Clinical studies have not actually addressed this issue, but we often see that long acting drugs often manifest side effects later in the game--6 to 8 weeks later.  We would not expect things to be different with this drug.

Not approved for children less than 13 years of age.  Children younger than 13 were noted to have much higher rates of insomnia (30%) and appetite suppression (43% vs. 22%), as well as having higher drug levels after a single dose.  For this reason it is unlikely to be approved for younger children.  
Difficult to deal with missing doses.  If you miss a dose, you'll definitely have to wait until the next day.  It would be possible to take a short acting medication to cover the gap, but obviously your morning would still suffer.

Advantages

Works in the morning.  The main advantage of Mydayis is that it allows patients to have the benefit of their stimulant from the time when they wake up, onward through the day.  No waiting for your med to kick in before you can really function.  No more difficult mornings.
Different.  As with any new formulation, a different time release can produce advantages for some patients.  The let down off of Mydayis, for example, may not be as dramatic as with Adderall XR because it acts for so long.  The timing of Mydayis may also be helpful to some adults who have different workschedules.  

Should you use Mydayis?

If you are an adult or teen and have symptoms in the morning which make it difficult to function, Mydayis may be an option for you, especially if Adderall is a medication which works well for you once it is on board.

References:

Mydayis [package insert]. Shire, LLC., Lexington, MA; June 2017. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/022063s000lbl.pdf.  Accessed November 19, 2017.

Everything ADHD Medical Disclaimer

Everything ADHD Privacy Policy

Cotempla XR-ODT for ADHD

The FDA has recently approved Cotempla XR-ODT (methylphenidate orally disintegrating tablet, extended release) for ADHD in children ages 6-17.

This drug, produced by Neos Pharmaceuticals, is a stimulant.  The active ingredient, methylphenidate, has been on the market for a long time as a medication for ADHD.    The main difference is the formulation.  Similar to Concerta, Quillivant XR, and Aptensio XR, it is long acting, however it is an orally disintegrating tablet, meaning that it can be taken without the need to swallow a pill or manage a liquid.

Disadvantages

Cost.  Like Quillivant and Aptensio XR, Cotempla XR-ODT is likely to be pricey as the orally disintegrating tablet technology is still under patent, and the company is also paying royalties to Shire, LLC.  It will likely not be covered by insurance when it is first released, which is anticipated to be fall of 2017.  Neos Pharmaceuticals does not currently offer any kind of discount or coupon program for this product, nor any other product.

Nothing new.  This drug does not really offer anything new in terms of avoiding potential risks.   It is still causes issues with appetite, sleep, anxiety, emotionality, and other symptoms commonly associated with stimulants in some patients.

Drug levels likely to take a long time to stabilize.  Clinical studies have not actually addressed this issue, but we often see that long acting drugs often manifest side effects later in the game--6 to 8 weeks later.  We would not expect things to be different with this drug.

Not approved (yet) for children less than 6 years of age.  The FDA has asked the company to perform further studies on younger children prior to approving this drug for use in children 4 and 5 years of age. This is standard for new stimulant medications for ADHD because very little is known about ADHD and its treatment in younger children. 

Not as easy to titrate as a liquid.  The orally dissolving technology does not allow the dose of this medicine to be easily divided.  The tablet should not be crushed or broken before being taken.  Unlike Adzenys (another orally dissolving tablet for ADHD), Cotempla XR-ODT only comes in 3 sizes of tablets, which may limit the ease of adjusting the dose.

Purple coloring.  The medication contains grape flavoring and a purple colorant called Lake Blend Purple.  The colorant is a mix of FDA approved colorants but the specific component colorants not specified.  Those patients who are sensitive to blue, red, or other colored dyes should be aware that the colorant may potentially worsen symptoms.  This was not noted in clinical studies, however.

Advantages

Does not need to be swallowed whole.   This drug is likely to find a place with younger patients who cannot swallow pills.

Different.  As with other stimulants, this one has a unique release profile which may suit some patients better than others.

Taste.  Compared to crushed methylphenidate (Ritalin), this pill is designed in a way to mask the bitter taste of the active drug.

Should you use Cotempla XR-ODT?

The ideal candidate for Cotempla XR-ODT falls into one of two categories:

1)  Unable to swallow pills.  Depending on your insurance coverage, Cotempla may be as expensive, or less expensive than Quillivant and QuilliChew.   Focalin XR, which can be opened and sprinkled on food may still be a major competitor, as it is available as a generic.  Focalin XR can probably be titrated more easily because in a pinch, the capsule can be opened and the dose split.    Like QuilliChew, which was approved in 2015, the orally dissolving tablet does not require food, which is slightly more convenient.

2)  Intolerant of other stimulants.  This medication offers another option for patients who are not able to take other stimulants due to side effects.  It is not, however, specially designed to prevent side effects and so is not preferable over other forms of methylphenidate.  It is simply another alternative.

Reference:

Marketing, Benchworks. "Neos Therapeutics Announces FDA Approval of Cotempla XR-ODT™ (methylphenidate) Extended-Release Orally Disintegrating Tablets for the Treatment of ADHD in Patients 6 to 17 Years Old." Neos Therapeutics, Inc. Neos Therapeutics, Inc., 19 June 2017. Web. 24 June 2017.

Everything ADHD Medical Disclaimer

Everything ADHD Privacy Policy

FDA Proposes Withdrawal of Generic Concerta Over Concerns About Bioavailability

On November 4, 2016, the FDA announced that it is proposing withdrawal of approval of certain generics of Concerta (methylphenidate extended release) due to concerns about bioequivalence.    This applies only to the generics made by Mallinckrodt and Kudco, not the one made by Actavis.

Starting shortly after these generics entered the market, the FDA began to receive reports that the generics were ineffective.  This is not unusual, but the numbers of patients lodging complaints was much higher than expected, which triggered an investigation.   At that time, the FDA asked the companies to prove that their drugs were bioequivalent to brand Concerta or withdraw the drugs from the market.   Two studies were commissioned by the FDA.  One, in healthy adults, has been completed and demonstrated that the Mallinckrodt product did not demonstrate bioequivalence under newer FDA standards, and that the release rate of the drug was slower than the brand name equivalent.  This could explain why the drug was not working for some patients.  It's possible that it could have caused other issues as well, such as increased loss of appetite or insomnia.  Another study, in children with ADHD, is still ongoing.

Where does that leave us?  The FDA has allowed pharmacies to dispense generic Concerta while proceedings to withdraw the drugs from the market are ongoing, however, they have encouraged pharamacies not to substitute Mallinckrodt or Kudco generics for brand Concerta.

If you are taking one of the generics being investigated, rest assured that the only issue is bioequivalence/effectiveness compared to brand name Concerta.   There are no other safety issues with these generics.  However, since these drugs are likely to soon to be pulled from the market, you should make an appointment to discuss which medication and dose you will switch to.

If you are taking brand name Concerta or the Actavis brand, just make sure you keep getting the same generic.  You should be fine as the Actavis brand is identical to brand name Concerta.

It's too soon to know for sure if prices will rise, however, users of Concerta or its generics should be prepared for another round of shortages.

Abilify (aripiprazole) and ADHD

Abilify (aripiprazole) is a medication that is typically not prescribed for ADHD.  It has significant side effects and so far, unproven effectiveness.  However, for certain patients with aggressive tendencies, aripiprazole is trending as a popular off label drug, primarily riding on the coattails of respiridone, a similar medication which has significant clinical trial evidence of efficacy.

Effectiveness

There have been at least 7 studies of ADHD and aripiprazole, however, they have been limited to very small sample sizes (all less than 50) and almost all trials have involved children with other disorders in addition to ADHD (bipolar disorder, Tourette’s, ASD).  Some of these trials have noted an improvement in ADHD symptoms, but at least one did not.  As with many small studies, methodologic flaws were present as well, such as lack of blinding, lack of a control group, etc.  Due to lack of better evidence of effectiveness, aripiprazole is not FDA approved for treatment of ADHD, although it is legal to prescribe it “off label”.

Adverse effects

Aripiprazole generally does not cause significant side effects in children and adolescents.  However, major problems can occur rarely, such as neuroleptic malignant syndrome (generally fatal), suicidal thoughts and acts.   These issues are why this medication should not be considered lightly.  More common issues include chronic insomnia, Parkinsonism (tremors, slowness, speech impairment, etc), behavioral changes, psychosis (impaired sense of reality/hallucinations), and weight gain. 

Should aripiprazole be used for ADHD?

Because of it’s potential for fatal side effects and the lack of evidence proving effectiveness, aripiprazole should not be used as a first line agent for ADHD.  However, for patients struggling with violent tendencies, for example, children who are chronically suspended from school due to lashing out at teachers and other students,  this medication may offer the control necessary to avoid long term psychiatric hospitalization or chronic day treatment. 

Everything ADHD Medical Disclaimer

Everything ADHD Privacy Policy

Reference:

Finding, R. L., E. J. Short, T. Leskovec, L. D. Townsend, C. A. Demeter, N. K. McNamara, and R. J. Stansbrey. "Aripiprazole in Children with Attention-deficit/hyperactivity Disorder." Journal of Child and Adolescent Psychopharmacology 18.4 (2008): 347-54. Web.

Jacobsen, K. D., C. H. Bruhn, A. K. Pagsberg, A. Fink-Jensen, and J. Nielsen. "Neurological, Metabolic, and Psychiatric Adverse Events in Children and Adolescents Treated With Aripiprazole." Journal of Clinical Psychopharmacology 36.5 (2016): 496-99. Web.

Lamberti, Marco, Rosamaria Siracusano, Domenico Italiano, Norma Alosi, Francesca Cucinotta, Gabriella Di Rosa, Eva Germanò, Edoardo Spina, and Antonella Gagliano. "Head-to-Head Comparison of Aripiprazole and Risperidone in the Treatment of ADHD Symptoms in Children with Autistic Spectrum Disorder and ADHD: A Pilot, Open-Label, Randomized Controlled Study." Pediatric Drugs Pediatr Drugs 18.4 (2016): 319-29. Web.

Masi, Gabriele, Antonella Gagliano, Rosamaria Siracusano, Stefano Berloffa, Tiziana Calarese, Giovanna Ilardo, Chiara Pfanner, Angela Magazù, and Clemente Cedro. "Aripiprazole in Children with Tourette's Disorder and Co-morbid Attention-Deficit/Hyperactivity Disorder: A 12-Week, Open-Label, Preliminary Study." Journal of Child and Adolescent Psychopharmacology 22.2 (2012): 120-25. Web.

Safavi, Parvin, Ali Hasanpour-Dehkordi, and Maryam AmirAhmadi. "Comparison of Risperidone and Aripiprazole in the Treatment of Preschool Children with Disruptive Behavior Disorder and Attention Deficit-hyperactivity Disorder: A Randomized Clinical Trial." Journal of Advanced Pharmaceutical Technology & Research. Medknow Publications & Media Pvt Ltd, 2016. Web. 21 Oct. 2016.

Tramontina, Silzá, Cristian Patrick Zeni, Gabriel Ferreira Pheula, Carla Ketzer De Souza, and Luis Augusto Rohde. "Aripiprazole in Juvenile Bipolar Disorder Comorbid with Attention-Deficit/Hyperactivity Disorder: An Open Clinical Trial." CNS Spectrums CNS Spectr. 12.10 (2007): 758-62. Web.

Tramontina, Silzá, Cristian P. Zeni, Carla R. Ketzer, Gabriel F. Pheula, Joana Narvaez, and Luis Augusto Rohde. "Aripiprazole in Children and Adolescents With Bipolar Disorder Comorbid With Attention-Deficit/Hyperactivity Disorder." J. Clin. Psychiatry The Journal of Clinical Psychiatry 70.5 (2009): 756-64. Web.

 Zeni, Cristian Patrick, Silzá Tramontina, Carla Ruffoni Ketzer, Gabriel Ferreira Pheula, and Luis Augusto Rohde. "Methylphenidate Combined with Aripiprazole in Children and Adolescents with Bipolar Disorder and Attention-Deficit/Hyperactivity Disorder: A Randomized Crossover Trial."Journal of Child and Adolescent Psychopharmacology 19.5 (2009): 553-61. Web.

Bupropion (Wellbutrin) for ADHD

Bupropion is typically not used for ADHD because there are many stimulants that are more effective and have a similar side effect profile.  However, it is preferred in certain situations, when the patient is struggling with hyperfocus on nonproductive activities (like screen time), addiction, binge eating, or depression, or if the patient hasn’t responded to other medications.

How well does it work?

Bupropion has been studied in a few smaller clinical studies.  A 2015 metanalysis concluded that while bupropion appeared to be modestly effective, further study was warranted.  In this same metanalysis, stimulants and atomoxetine were both found to be more effective than bupropion for ADHD.  Like most nonstimulants, bupropion does work all day once it starts to work, but it is usually several weeks after starting.

What are the side effects?

Bupropion has a well established track record in treating depression and nicotine dependence.  It has also been recently approved for treatment of binge eating disorder in combination with naltrexone.  Since it has been widely used for some time, the side effects and long term effects are relatively well known. 

One downside to bupropion is that its side effects are similar to the stimulants.  Anxiety, appetite problems, and insomnia (in about 40%) are common.  There are some case reports of tics being worsened by bupropion, but generally tics have not been reported as a common side effect.  However, bupropion is not habit forming.

The package label carries a black-box warning about possible increase in suicidal thinking.  This can be seen with antidepressant usage in depressed patients.  It is not seen in nondepressed patients who take bupropion to quit smoking.  No study has examined this issue in patients taking bupropion only for ADHD, as such, it is important to be aware of the possibility.

Pregnancy and Breastfeeding

Until recently, bupropion was considered pregnancy class B, safe in pregnancy.   However, newer rat studies suggested that birth defects could be possible, so it was changed to pregnancy category C, pregnancy risk unknown.  Typically drugs in category C are used only if the benefits outweigh the risks and there are no good alternatives.  For example, if you have ADHD that is severe enough to make you unable to function at work or at home, and you have a history of addiction to speed (i.e. you can’t take stimulants), bupropion may be the best choice for your ADHD, but you wouldn’t want to switch from Adderall (if it worked well and you were otherwise healthy) to bupropion with the thought that it might be safer.

Bupropion does enter the breastmilk in small quantities that would not be expected to cause problems for a nursing infant.  However, two case studies have reported seizures in infants of mothers taking bupropion and it is possible that the bupropion was responsible.  Currently, nursing mothers who are taking bupropion are counseled not to stop breastfeeding, but to inform their health provider if their child has unusual symptoms.

Cost

Unfortunately because it is used in treating nicotine addiction, it is often not covered by lower end insurance companies who don’t want to pay for something more expensive than nicotine patches for people trying to quit smoking.  It’s best to check with your insurance company and perhaps get your doctor to help with getting coverage if you need this medication.

Bottom line

Bupropion is a third line drug for ADHD for a good reason.  It isn’t as effective as the stimulants and has a similar side effect profile.  However, it is nonaddictive and does work for some people.  Additionally, it works all day and has antidepressant properties.    So it could be a good fit for a select group of patients who have failed treatment with stimulants, or who are unable to take them.

This article is part of a series on nonstimulants, including atomoxetine ( Strattera), clonidine (Kapvay), and guanfacine (Tenex, Intuniv).

References:

"Bupropion." LACTMED. US National Library of Medicine, 6 Nov. 2015. Web. 19 Aug. 2016.

Moses, Scott. "Family Practice Notebook." ADHD Medication. N.p., 9 Mar. 2013. Web. 10 July 2013.

Wellbutrin [package insert]. GlaxoSmithKline, Research Triangle Park, NC; March 2013. http://us.gsk.com/products/assets/us_wellbutrin_tablets.pdf.  Accessed May 28, 2013.

Everything ADHD Medical Disclaimer
Everything ADHD Privacy Policy

Harmonyx Genetic Test Runs Into Trouble With FDA

The FDA has recently issued a  letter to the makers of Harmonyx, a pharmacogenetic test that can be used to help determine the best medication to use for ADHD.  This letter cites concerns that the test is being marketed without appropriate FDA clearance.

The company has voluntarily pulled the test from the market as it cooperates with the FDA in its' investigation of the matter.  However, the company denies that the test is being marketed directly.to consumers, and states that it believes that it is in compliance with the FDA's regulations.

11/10/2016
Harmonyx issued a letter to consumers stating that they will not be offering testing anymore because of the overwhelming costs associated with pursuing FDA approval for direct to consumer marketing.

Tics, ADHD, and Medication

ADHD and tics often occur together.  Up to 50% of patients with ADHD may have an underlying tic disorder, while up 70% of patients with chronic tics may have ADHD.  Until very recently, many people in the ADHD community have felt that medication causes or worsens tics.  However, new research is challenging this widely held assumption and changing the face of treatment for people who have both disorders.

To understand the reversal in medical opinion, you must understand a little about tics.  The medical definition of a tic is an involuntary, nonrhythmic movement of any body part.  Tics can include throat clearing or blinking, vocalizations, or even complex actions such as repetitive phrases, picking at clothing, or brushing hair.

Tics come and go in response to a variety of triggers including stress, changes in body chemistry (such as thyroid hormone and blood sugar), or may be seemingly random.  The cause of tics can be genetic, structural (ie brain damage from stroke, trauma or other issues), or unknown.  Once they start, they can stop within a few weeks, months or longer.

Tics are very common in otherwise normal children.  One in 5 children will develop a tic at some point before they turn 10, and most of these children will get better without any treatment.  Because tics are very common, even in normal children, tics are likely to show up coincidentally around the time medication is started in many children.  Tics occur after the introduction of a stimulant in 1 in 5 children who have a known tic disorder and in about 6% of children who have ADHD and no known tic disorder.

Do stimulants cause tics?  NO.

In 2009, a metanalysis of 9 clinical trials in children with ADHD and tic disorder concluded that methylphenidate did not worsen the tic disorder.   Last year, 2015, saw a new metanalysis published, this time examining trials of all children with ADHD who were started on stimulants.  This metanalysis demonstrated that tics were very common, equally common, in fact, both in children who took the stimulant and in those who took placebo.  All of this points to tics not being caused by stimulant medication, even though tics do happen very regularly after medication is started.

Should ADHD be treated differently in patients with tics?  Maybe.

The second article suggests that stimulant medication not be withheld from children with ADHD who happen to have a family or personal history of tics, and that stimulants be continued if tics happen to arise during treatment since in all likelihood, the stimulant was an innocent bystander.

However, in the interest of keeping the number of medications low, patients who have tics and ADHD can be treated with clonidine or guanfacine, both of which are effective for both conditions, and both of which have a fairly safe side effect profile.  However, neither medication is the most effective medication for either ADHD or tics, and treating two conditions with one medication can make dose adjustment difficult.

Should tics be treated differently in patients with ADHD?  Maybe.

Generally speaking, unless tics are very noticeable, it’s best not to treat with medication since most tics will go away on their own.  However, if the tics are bothersome (for example if a child is picking through their skin and leaving scabs) or noticeable (causing disruption in a classroom or workplace) then active treatment may be a consideration.

Treatment for tics generally involves behavioral therapy.  This therapy focuses on habit reversal therapy as well as anxiety reduction/relaxation techniques and has an effectiveness which is comparable to medication, without the same risk of side effects.  The major down side is that it takes time for a patient to learn the techniques effectively.

Medications can be used but sometimes the medication is worse than the tics.  .  Clonidine and guanfacine have both been used effectively in patients with ADHD and tics, but the medication may not be very effective.   The most effective medications for tics, such as risperidone,  can leave a patient with a host of permanent side effects, and so they are reserved for patients who have the most disabling and unresponsive symptoms.  There are other treatments for tics but only clonidine and guanfacine are known to help with ADHD as well.

Overall, clinical trials are starting to point toward encouraging the use of the most effective approach in treating ADHD, toward not discontinuing medication if tics arise, and toward treating tics as an entity mostly independent of ADHD.  Parents of children who develop tics while on medication for ADHD can be reassured that the medication did not cause the tic and that the tic will likely resolve on its own, without change to ADHD therapy.

References:

Thenganatt, Mary Ann, and Joseph Jankovic. "Recent Advances in Understanding and Managing Tourette Syndrome." F1000Research F1000Res (2016): n. pag. Web. 23 May 2016.

Strattera for ADHD

Strattera (atomoxetine) is a nonstimulant drug generally considered a second line medication for ADHD.     That is, it is typically offered if stimulants are not effective, or present intolerable side effects.  This article provides an overview of the effectiveness of atomoxetine for ADHD and it’s side effects.

General information

Strattera (atomoxetine) is supplied only as a capsule.  It must not be opened or chewed, and therefore is not a good option for young children or others who cannot swallow pills.

Genetic testing is available which can reveal if a person is a fast or slow metabolizer of atomoxetine.  This can sometimes assist a doctor at arriving at an effective dose while minimizing side effects.

Effectiveness

Strattera (atomoxetine) is effective for core symptoms of ADHD in adults and children (age 5 and older) , as well as for mood swings and emotional impulsiveness (i.e. temper outbursts) in adults.  Compared to stimulants, it seems to have less of an effect.

Patients will generally not notice an effect right away.  This medication can take from 1 to 4 weeks before any effect is noticed.  Maximum effectiveness can take 6 to 8 weeks or longer. Missing an occasional dose is not a big deal.  No one will probably notice.  If forgetting your medications is a problem, this might be a good one for you.  However, taking medication breaks for a weekend or vacation is pretty much impossible as the long lead in period pretty much wipes out shorter breaks. 

The main advantage of Strattera (atomoxetine) compared to stimulants is that it has a very different side effect profile.  Strattera does not interfere with sleep and does not have an addictive potential.  It does not increase anxiety and preliminary trials suggest that it can reduce anxiety with or without the use of a stimulant.

Atomoxetine has been found not to increase tics compared to placebo.  However, case reports exist that implicate atomoxetine as possibly a cause of tics in certain patients. 

A second advantage of atomoxetine is that it works all day.  Patients who struggle with mornings or nights or with significant rebound symptoms may find this particularly attractive.

Side effects

Strattera (atomoxetine) has some serious, although rare, side effects.   Liver failure, while never reported in any clinical trial, has surfaced in some patients taking atomoxetine.  Likewise, there is an increase in suicidal thoughts in young adults and children who take atomoxetine.  Also, the medication can trigger mania in patients with bipolar disorder.

Most patients who stop atomoxetine will do so due to appetite disturbance, stomach upset, or nausea.  Some children will lose weight although most gain it back again with no trouble. Fatigue can also be a problem.  These issues often fade over the first 6 weeks of taking the medication.

Atomoxetine in high doses has been shown to increase the risk of miscarriage in rats, so pregnant women are encouraged to consider an alternative with the assistance  of their physician.

In summary, Strattera (atomoxetine) is a nonstimulant which is not as effective for ADHD as stimulants, but which offers a distinct side effect profile and 24 hour coverage which may be helpful to some patients. 

This article is part of a series on nonstimulants, including bupropion (Wellbutrin), clonidine (Kapvay) ,  and guanfacine (Intuniv, Tenex)

References:

Childress, Ann C. "A Critical Appraisal of Atomoxetine in the Management of ADHD." Therapeutics and Clinical Risk Management. Dove Medical Press, 23 Dec. 2015. Web. 12 May 2016.

Garnock-Jones, Karly P., and Gillian M. Keating. "Spotlight on Atomoxetine in Attention-Deficit Hyperactivity Disorder in Children and Adolescents†." CNS Drugs 24.1 (2010): 85-88. Print.

Harfterkamp, M., J. K. Buittelaar, R. B. Minderaa, G. Van De Loo-Neus, R. J. Van Der Gaag, and P. J. Hoekstra. "Long-Term Treatment with Atomoxetine for Attention-Deficit/Hyperactivity Disorder Symptoms in Children and Adolescents with Autism Spectrum Disorder: An Open-Label Extension Study." Journal of Child and Adolescent Psychopharmacology (2013): n. pag. Web.

Strattera [package insert]. Lilly USA, LLC., Indianapolis, IN; August 2012. http://pi.lilly.com/us/strattera-pi.pdf.  Accessed April 16, 2013.

Everything ADHD Medical Disclaimer

Everything ADHD Privacy Policy

Meds vs. No Meds for ADHD: A Step By Step Guide to Making the Decision

If you are reading this article, you are no doubt wrestling with a difficult decision.  You have probably read a lot about different medications and their side effects.  And you definitely have seen your child struggle with the effects of ADHD.  Medication is often the first thing that doctors reach for to treat ADHD, but it is not always the first thing that parents want to hear, and it isn’t the best decision for every child.  This is a guide to help you work through the decision step by step, so that you can know for sure that medication is, or is not right for your child.

1)  How much are your child’s symptoms affecting life?

A child who has had long standing trouble with academics or with relationships in the family or with friends, is in greater need of something that will work reliably and well—medication.   You may, at some point, be able to get your child off medication, but for now, you know that if things continue this way, something bad will happen.  Change needs to happen now. 

 You know your child falls into this category if he or she:

Has problems with self esteem, is being bullied, or is depressed due to ADHD symptoms.

Is failing or near failure academically, has had disciplinary consequences such as detention or suspension for behavior problems, or is near being banned from riding the schoolbus.

Has frequent and/or prolonged tantrums for some one of the same age.

Also has a diagnosis of ODD.

Has no friends.

Is causing strain on your marriage to the point where separation or divorce is being considered.

Is a safety risk due to reckless behavior—darting into traffic, jumping out of trees, sticking their hand on the cutting board while you are chopping food, running with scissors, playing with matches/knives/firearms, etc.

A child who does not have these issues has time.  Medication is still an option, but other approaches could first be given a trial.

2)  What have you tried already?

Some children with ADHD may be able to avoid medication for a time, or forever, with other supports and interventions.   In these children, there is a balance, however, between being open to trying different ideas and trying too many things that are likely to be a waste of time and money.  A smart approach is to frequently assess where your child is with regard to question (1), as well to carefully evaluate the various therapies you may want to try. 

3)      Are there other medical or psychiatric issues that need to be taken into account? 

For example, children with seizure disorders, tic disorders, and heart problems should get clearance/reassurance from the appropriate specialist before taking any kind of medication.   Anxiety can be made worse (or better) by medication and sometimes needs to be treated in its own right before ADHD medication can be started.  Children who need to take a lot of rescue medication for asthma may need to wait until their asthma is stabilized before starting certain ADHD medications.

4)  Consider both risks and benefits of medication.

Medication definitely has downsides.  Side effects like seizures, tics, heart rhythm disturbances, insomnia, and appetite loss are all real risks.   Younger children (under the age of 6) may be at higher risk for certain side effects.  Also, some of the medications have an addiction risk—which isn’t a problem if you take the medications as prescribed, but can be a problem if there are people in your house who struggle with substance abuse, or if there are teenagers who are risk takers. 

It’s important to not only know which side effects are possible, but also to have some idea of how likely they are to occur.  Life threatening side effects are rare.  Some of the more common side effects can sometimes be made manageable.  The good thing about side effects is that for most stimulants (the most common medications prescribed for ADHD) almost all side effects will go away within a day or two of being stopped.   

An important point to think about at this stage is whether you are scaring yourself with side effects without thinking about the benefits of medication. Consider what the risk of not giving medication will be.  For this, you need to combine your thoughts on parts 1-3 to come up with some idea of how things could look if no medications are involved.  For example, a child with relatively few symptoms and who has not had any school accommodations might try the accommodations first.  But a child who has mild symptoms, but who has tried a lot of non-medicine therapies already might go to medication as a next step rather than try another round of alternative therapy.  A child with severe symptoms may fail a grade, get suspended, or get hurt if medication isn’t started soon.

3)                  Discuss your concerns with your doctor.

The best chance you have to get good treatment is to communicate with your physician.  If your doctor doesn’t listen to or dismisses your concerns without addressing them, you may want to find another doctor before starting medication, as concerns will probably continue to crop up along the course of treatment.  Usually it is possible to find a doctor—a generalist or specialist—who will work with you to help you come to a decision you can be at peace with.

References:

Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. "ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents." Pediatrics (2011): n. pag. Pediatrics. American Academy of Pediatrics, 16 Oct. 2011. Web. 25 Nov. 2013.

Everything ADHD Medical Disclaimer

Everything ADHD Privacy Policy

Summer Break for ADHD Medications?

Summer break is fast approaching.  What are you going to do with your medications this year?  This is a guide to help you make the decision about whether you (or your child) should go off medication for summer break.  The key to making a good decision about medication is weighing the risks and benefits of treatment with medication during the time when you are planning on possibly taking a break.

What are the benefits of taking a break?
You can decide whether you have developed the necessary coping skills, or have adequate relief from other methods of treatment, to go without medication.

You don't have to deal with side effects like reduced appetite and insomnia, or wide swings of emotion from coming on and off medication.  For some patients, summer is a time to get weight back on that was lost during the year.

You don't have to visit the doctor or pharmacy so often, or be at home when medication is delivered.  These can all be hassles when summer vacation is in play.

Being off medication may allow you (or your child) to appreciate ADHD.  This isn't for everyone, but some people do like some aspects of ADHD and find medication at best a necessary evil.  Yes, you might forget some things and never finish others, but you may also explore areas you would probably not have thought of off of medication.

What are the risks of taking a break?
You may not have the necessary concentration or focus to do what you are supposed to be doing during summer break.  Just because you are out of school does not mean you do not have to focus on camp, a summer job, or summer classes.  It's especially important for a person with ADHD who is learning how to drive to take their medication during the learning process, as this requires extra focus and could result in a serious accident if a person isn't paying attention.

The person watching your child off medication may not be equipped to deal with a child with full blown ADHD.  This is especially true if your child is in a summer camp primarily staffed with teens and college students, or if the adult you have engaged is not experienced with children with special needs.  Combining an unfamiliar environment with unmedicated ADHD could result in meltdowns.

If you will be traveling, changes, transitions, and loss of routine and sleep can all make it hard for a person with ADHD to engage coping mechanisms.  Removing medication from vacation time may not really be much of a break if the person has to deal with other stresses during that time.

Some medications are more easily stopped than others.  If you take a stimulant it is easy to take your medication only when you need it.  But if you take a nonstimulant, it may take several weeks for it to wear off and then several more weeks to get back on again, leaving not much actual break time.

In the end, whether you take a summer break from medication is mostly a personal decision.  In today's busy world, many parents are opting to keep their children on medication for the summer, but some still are giving breaks.

ADHD-Related Insomnia

Many people who have ADHD have difficulty with sleep, on or off medication.  The problem is, if you can’t sleep, it can make your ADHD symptoms worse.  This article is about basic steps anyone with ADHD can take to address a sleep problem. 

Sleep hygiene

Sleep hygiene sounds terrible, almost like someone is accusing you of not showering enough.  However, it really has nothing to do with that.  You can think of sleep hygiene as healthy sleep habits.  Having ADHD can make it difficult to naturally have sleep habits that are healthy, but they are important to getting a good night’s sleep, so it is worth the extra effort to establish and maintain these habits.

Keep a regular schedule.  Going to sleep and waking up at the same time every day trains your body’s pineal gland (a part of your brain that governs sleep-wake cycles) to make sleep hormones like melatonin at predictable concentrations every day.  It helps to set alarms, but if you find you ignore them, enlist the help of a loved one.

Have a regular bedtime routine.  A consistent ritual before bed will train your brain to be ready for sleep.  For example, a bath, put on pajamas, brush teeth, a short bedtime story and a kiss goodnight would be a simple child’s routine.  With children a regular routine also helps them to know when to expect bedtime, and keeps them from fighting you when the time comes. 

Avoid screens close to bedtime.  The blue light from computers, video games, phones, tablets, and the like can trick the pineal gland into thinking it is day time.  Also, if the activity is engaging enough, you can become hyperfocused and not realize how much you need to go to sleep.

Get plenty of exercise during the day.  Exercise doesn’t have to be boring, either.  If you don’t like to go to the gym, consider martial arts, gardening, hiking, walking a dog, or even shoveling snow for a neighbor.   Exercise in the morning also can help you stay focused during the day.

ADHD Medication Management

If your insomnia started, or clearly worsened within a month of starting or increasing your ADHD medication, you may want to consider the following steps with your doctor:

1)      Move your long acting medication dose to earlier in the day.

2)      If you need more coverage in the evening, consider a booster dose of a short acting medication.  People who struggle with a lot of busy thoughts or need to move during the evening may need their medication to last until after they get to sleep.

3)      Consider adding guanfacine or clonidine at the end of the day.

4)      Consider switching to a nonstimulant.

A Word About Other Sleep Aids

Some research suggests that traditional sleep medicines (like Valium or Unisom) do not work for ADHD related insomnia.  Since many of these medications can have addictive properties, or can result in long term harm to your sleep patterns, it’s best to stay away from them.

Medicines that have been used to help with ADHD related insomnia include guanfacine and clonidine.  Some herbal/natural preparations are also showing promise.  Melatonin has been widely used in ADHD related insomnia for a number of years.  It can be tricky to dose, but is generally thought to be relatively safe in most patients, with a few exceptions.  L-theanine is a product that is generally recognized as safe by the FDA.  It has shown possible effectiveness for mid-night awakenings and restless sleep in patients with ADHD.

Some patients with ADHD may also have a sensory processing issue.   This is especially common with autism spectrum disorder.  However, it can occur with ADHD without ASD.   In these cases, a weighted blanket can sometimes offer needed proprioceptive input.  

Have you already taken all of these steps and you are still having problems?  It is possible that you have a sleep disorder, other than garden variety insomnia.  The next article in this series will examine sleep disorders that commonly occur with ADHD.

Everything ADHD Medical Disclaimer

Everything ADHD Privacy Policy

Starting a Stimulant for ADHD: What You Need to Know the First Few Days

Once you have made the decision to start a stimulant, such as methylphenidate (Ritalin, Concerta), dexmethylphenidate (Focalin), Adderall, or dexamphetamine (Vyvanse),  for ADHD there are a few things you need to know to make the process go more smoothly. 

When should I start the medication?    

There usually isn’t time to wait for a long school break or vacation, or for life to get completely stable.  However, it may be a good idea to wait to start the medication on a weekend so that you can be at home should any severe side effects occur.

When should I give the medication?  What about medication breaks?

Most stimulants are given once daily in the morning, but some are given twice, or even three times daily.  You should follow your doctor’s instructions. 

Some people find that it is best to take their medication after breakfast, to allow time to  eat before the medicine kills their appetite.  Other people, especially children who are unable to sit down for a meal, find that giving the medicine before breakfast allows them to focus on eating. 

Most doctors do not recommend routine medication breaks, except in specific  circumstances.  This is because patients often need treatment so that they can get along with their families and friends on weekends, and because sometimes readjusting to medication can be difficult even if you’ve only been off it a day or two.

Should my child give the medication to themselves?

Stimulants are potentially addictive medications with dangerous side effects in overdose.     Younger children should definitely not handle medication on their own.  Impulsive children may need to be monitored well into their teens before they can demonstrate responsibility need to administer their own medication.

 

Young children should be taught to recognize their own medicine, and to never share their medicine with anyone.   Older children and teens should also learn how dangerous it is to share or sell their medicine, and to always take their medicine only in the way it is prescribed.

What if I can’t swallow pills?

Hopefully you got a liquid or something that can be opened and sprinkled on food.  If not, you can learn to swallow a pill, or you can talk to your pharmacist about whether it is safe to crush your medicine.

When should this medicine start to work?

Usually stimulants start to work within an hour of the first dose.  If you do not notice any effect after 3 days of medication, the dose probably needs to be increased.

Stimulants typically treat only the core symptoms of ADHD—inattentiveness, impulsivity, and hyperactivity.  However, other symptoms such as depression, school avoidance, and being picked on by other children may not respond well to medication alone.  In these cases, it is important to consider counseling and/or additional types of medication.

What happens if there are side effects?

Most side effects will occur immediately or shortly after starting a medication.  Some can occur 4-6 weeks into treatment with longer acting medicines as the body starts to balance out blood levels.  Side effects can go away after a couple of days as the brain becomes used to adjusted neurotransmitter levels.  This is particularly true if your child seems a little bit sped up or irritable with the first couple of doses.

Whether or not you stop a stimulant depends on the type and severity of side effect, how helpful the medicine is,  and the number of other medicines you have tried.  There are good ways to continue a medication that is working well if you are having trouble with sleep or loss of appetite.  However, if your child is having hallucinations, becomes aggressive, or develops daily headaches or stomach aches, almost always the medicine needs to be stopped.  Tics used to be a reason to stop medication but now doctors believe that stimulants do not cause tics and they usually encourage patients to try to wait it out or maybe pursue counseling for tic suppression.  The good thing about stimulants is that no tapering is required.  It is very safe to stop immediately.

What about my other medicines?  Is it safe to take over-the-counter medicines when I’m sick?

You should always reveal all the medications you are taking to any medical personnel prescribing you medication of any kind.  Over-the-counter medications are mostly safe to take with stimulants, with the exception of certain cough and cold medicines.

My doctor wants me to increase the dose after a few days.  When do I know it is ok to do that?

With stimulants you can usually get a pretty good idea of how well it is working, and whether you are having side effects within 5 to 7 days of starting the medicine.  If you are not seeing the improvement you would like and you are not having any side effects, it is ok to increase the dose if your doctor asked you to do so.  However, never increase the dose of your medication without a doctor’s instructions as it is a federal offense to do so.

Is there any way to predict what the right medication and dose is?

There are genetic tests on the market that say they can predict which medication is best for your ADHD.  The fact is that they cannot be used to distinguish between stimulants and cannot predict the effective dose at all.  

Otherwise, the reality is that finding the right medication and dose can be a roller coaster.  Almost all patients go through dose adjustments, and many have to try more than one medication before finding the right one.  However, when you are able to find the “right one” the relief is usually worth it.

References:

Rader, Robert, and Larry McCauley. "Current Strategies in the Diagnosis and Treatment of Childhood Attention-Deficit/Hyperactivity Disorder." American Family Physician79.8 (2009): 657-65. Print.

Everything ADHD Medical Disclaimer
Everything ADHD Privacy Policy

Drug Holidays: When Medication Breaks Do (and Don't) Make Sense in ADHD Treatment

Whether you call it a drug holiday, medication break, or structured treatment interruption, the practice is the same:  a person taking medication for ADHD has their dose held on a predetermined schedule for a predetermined period of time, often weekends or school breaks.  Experts generally agree that drug holidays are a matter of clinical judgment--meaning that the risks and benefits are different in each individual case.  This article is meant to help you sort through those risks and benefits to help you decide whether drug holidays are right for you or your child.

Factors favoring medication breaks
Patient wants to know if medication is still necessary.  Bodies change with growth, puberty, childbirth, lactation, and menopause.  Life's demands also change.  Teens, in particular, often need a break to demonstrate whether they need to take medicine for ADHD or not.

Person only needs meds to focus on work, school, or a particular project.  Some patients with milder ADHD may only need medication for high focus tasks like college examinations or major work deadlines.  Stimulants may be prescribed for some patients like this on an as needed basis.  However, there is no research to prove that this approach is safer or better than daily administration.  For example, we don't know if taking medication one day a week might be a higher risk for addiction  or cardiac rhythm disturbances than taking it daily.

Patient has problems with appetite and uses med breaks to catch up on eating/growing.  Sometimes medication breaks are recommended when a patient has problems with appetite and those problems are causing weight loss in a child or pregnant woman.  However, most children who take stimulants do initially seem to grow less when a stimulant is started, only to catch up or even become obese later, so the benefit of a medication break only comes in to play if there is sustained weight loss and the medication is good enough to warrant staying on it despite the weight loss.

Medication affects social functioning during the proposed break period. Medication does change how you function socially.  For most people, it is for the better.  You can pay attention to conversations better, avoid making impulsive remarks, and carry through on what you say you are going to do.  For some people, though, medication can make them less witty and overly focused enough to not be able to enjoy having fun with friends on weekends. This can be a particular issue for young adults.

Patient is pregnant or breastfeeding.    In general, having a baby on board does change the balance of risks and benefits of medicating ADHD.  We do not fully understand how medication for ADHD affects the developing human in utero or through breast milk.  You will want to consider the risks and benefits carefully with their obstetrical provider.  The following article can help:  ADHD and Pregnancy:  Should I Stop My Medication?

Patient is developing tolerance.  There are very few clinical studies on tolerance and ADHD medication.  No one knows for sure how often patients who take low doses of stimulants require higher and higher doses to produce the same effect due to tolerance versus other issues such as increasing body mass or increased cognitive demands (for example, harder school work).  In the same vein, no study has examined the effectiveness of any duration or schedule of drug holidays on preventing tolerance.  With this in mind, if a person is not showing signs of tolerance, it is not a good idea to impose drug holidays with the hope of preventing tolerance, especially if the holiday causes other major problems.

When  medication breaks may not be appropriate
Symptoms affect social functioning during the break period.  If a person is sufficiently impulsive or hyperactive to engage in dangerous behaviors off medication, then they probably need to be on medication every day.  For example, if a child darts into traffic or starts physical fights off medication, then breaks probably are not in their best interest.  A person with comorbid ODD also may need to stay on medication continuously until the ODD symptoms are well controlled for long enough that a break won't cause them to relapse.

The patient takes a long time readjusting to medication after it is restarted.  This can be related to the medication or the patient.  Some medications cannot be started and stopped immediately.  They need to be tapered on and off to ensure that dangerous side effects do not occur, or they just take a while to kick in.  Many nonstimulants fall into this category and cannot be given "as needed".  
Some patients take a day or more to readjust after restarting a medication.  They may be sleepy or seem more wired than usual for a day or two after missing even one or two doses.  This can pose big problem for short, frequent breaks.

The patient is taking breaks to "learn to cope with ADHD symptoms on their own".  Being unmedicated makes it harder, not easier, to learn coping skills.  Medication is also not perfect.  Most of the stimulants do not give all day coverage and do not treat all symptoms, so there is some time built in to learn coping skills off medication.  The bottom line here is, treatment does not have to be only behavioral or medical.  A combination of both is usually needed to address different challenges faced by the person with ADHD.

References:

Ibrahim, K., and P. Donyai. "Drug Holidays From ADHD Medication: International Experience Over the Past Four Decades." Journal of Attention Disorders 19.7 (2015): 551-68. Ibrahim, K., and P. Donyai. "Drug Holidays From ADHD Medication: International Experience Over the Past Four Decades." Journal of Attention Disorders 19.7 (2015): 551-68. 

Swartz, B. S., L. Bailey-Davis, K. Bandeen-Roche, J. Pollak, A. G. Hirsch, C. Nau, A. Y. Liu, and T. A. Glass. "Attention Deficit Disorder, Stimulant Use, and Childhood Body Mass Index Trajectory." Pediatrics 133.4 (2014): 668-76. 

Yanofsky, Jason. "The Dopamine Dilemma--Part II." Innovations in Clinical Neuroscience 8.1 (2011): 47-53.

Everything ADHD Medical Disclaimer

Everything ADHD Privacy Policy