5 Stimulants for ADHD and depression, List & Instruct.doc

THERE ARE BASICALLY 5 MEDICATIONS FOR ADHD:  

• STRATTERA : similar to an antidepressant; you cannot skip weekends;  you have to build up the dose over a week or two.  It is the “mildest” of the medications, but it has a lower rate of being 100% effective.   It is not a controlled substance.

—like an antidepressant; you take one in AM and it works 24 hours; every day; you need to build up over a couple weekly; mainly side effect of nausea

STIMULANTS: THESE WORK BEST; YOU CAN START AND STOP ANY TIME; YOU RESTART IT ON THE SAME FULL DOSE:

• Ritalin/ methylphenidate– a stimulant, can take it just on days you need it. Controlled substance, so no renewals. In rare cases it can raise blood pressure.  It works immediately.
• Dexedrine / Adderall / Vyvanse– same as methylphenidate, except a little “stronger” and works in even more people than Ritalin works.
• Provigil/ modafanil: a medication used to keep people awake
  [pilots in the air force, for example]. Studies have showed that it definitely helps ADD.   Or:  Nuvigil (armodafinil), 150mg and 250mg pills.

Sometimes it is excellent.  The dose is 100mg:   1-2 pills in AM.   I would start at ½ of 100mg for two days

THESE ARE A LITTLE SEDATING, like blood pressure pills; at bedtime usually:

• Kapvay (clonidine): 1mg bid, increase 0.1mg/wk to maximum of 0.2mg bid.
  • Or Intuniv –somewhat long lasting.  

THERE ARE ALSO THE FOLLOWING MEDICATIONS THAT MAY HELP ADD:

• Wellbutrin, which is an a commonly used antidepressant.
• Provigil (modafanil)
• out with 50mg 2x/day on Sunday  –eg at 8AM and 12 noon;  just in case it has unpleasant effect.   Then on Sunday go to 100mg every AM.  The following weekend you can try to go to 200mg–eg 150 on Sat and 200 on Sun.

• Whether your dose is 100 or 200mg, usually you can stop and start it anytime like Adderall. You only have to build up to the dose the first time—as you don’t know how you will react.  In general, Adderall and Ritalin work better.  If Provigil does not work well enough,  then you can maybe stay on Provigil and get away with less Provigil.
•  
• tricyclic antidepressants, such as desipramine, imipramine, and nortriptyline
• guanfacine/ Tenex [average 1.10mg, range 0.25 to 2mg] a centrally acting antihypertensive with α₂-adrenoceptor agonist properties; ½ life is 17 hrs (10-30; less in children); primarily renal excretion. For BP, usually at least 2mg is necessary for good benefit.
• clonidine/ Catapres: a medication otherwise used for hypertension, same mechanism as guanfacine; ½ life  12-16 hours
• transdermal nicotine 7mg [patch]; nicotine is neuroprotective; it prevents Alzheimer’s; the smoke is what is bad.
• pemoline: rarely used now, because of risk of liver toxicity
• amantadine
•  

STIMULANTS:  wake people up, help attention deficit disorder and help depression .

4-6 HR COVERAGE   Adderall Tablets   5, 7.5, 10, 12.5, 20, 30mg—all are scored and the 30mg pill is scored two ways so that you can break it in ¼’s—i.e., 7.5mg each.

Desoxyn Tablets (methamphetamine) 5mg              

Dexedrine Tablets (dextroamphetamine)  5mg

Dextrostat Tablets (dextroamphetamine)   5, 10

Evekeo tablets (levoamphetamine and dextroamphetamine) 5,10—new 8/2015

Focalin Tablets  (dexmethylphenidate)  2.5, 5, 10, 20

Ritalin HCl (methylphenidate) Tablets  5,10,20

Metadate ER Pills  (methylphenidate)  10, 20mg—for bid dosing  

Daytrana patch [methylphenidate patch] comes in 10, 15, 20, and 30 mg strengths and costs about $5/day.      But these strengths do NOT correlate with oral doses. Start all patients on the 10 mg patch and titrate weekly as needed.  They come in packets of #10 or #30.

INTERMEDIATE , FOR 8 HOUR COVERAGE

Dexedrine Spansule Capsules (dextroamphetamine) 5,10,15

Ritalin SR Tablets (methylphenidate) 20mg –not a consistent release, not good

LONG ACTING FOR 8-12 HOUR COVERAGE:

GENERIC:  Methylin E.R.

Adderall XR capsules 5,10,15,20,25,30

Concerta Tablets  (methylphenidate) 18, 36, 54 mg  (cannot be cut)

Metadate CD Capsules (methylphenidate; can be opened to sprinkle) 10, 20, 30, 40, 50, & 60mg [colors are green & white, blue& white, red & white, yellow & white, purple& white, and white respectively]             [the cheapest of the slow release stimulants; $62 for 30 day supply] 

Ritalin LA  20,30,40  [50% immediate release; the other 50% is released 4-5 hrs, mimicking bid dosing.] 1/13/04: Ritalin LA 20mg worked better than Concerta 36mg and 18mg [Frank Lopez, et al Ped. Neurology, 5/2003]; in a later study 40mg beat Concerta 54.

Focalin (dexmethylphenidate)XR 5, 10, 15, 20, and 40mg capsules; when sprinkled on food it remains slow release.

Daytrana patch (methylphenidate)  10, 15, 20, and 30mg/9 hrs patch.

Vyvanse (lisdexamfetamine dimesylate), 30mg, 50mg, 70mg caps (~same as 10, 20 and 30mg of dextroamphetamine);  oral absorption is also slower; it is more consistently absorbed because gastric acidity does not affect the absorption.  This reduces the chance of euphoria at normal doses…but not at higher doses. That’s why Vyvanse is still a C-II drug.

  Vyvanse (lisdexamfetamine dimesylate), 30mg, 50mg, 70mg caps (~same as 10, 20 and 30mg of dextroamphetamine);

Adderall immediate release 5mg bid =  Adderall XR 10mg = Vyvanse 30mg
Adderall immediate release 10mg bid = Adderall XR 20mg = Vyvanse 50mg
Adderall immediate release 15mg bid = Adderall XR 30mg = Vyvanse 70mg.

• Y.I.: Focalin is the right isomer of methylphenidate. Novartis claims D-isomer is causing the benefit and the L-isomer is causing the side effects. Focalin is twice as potent as methylphenidate.   Focalin: more stomach aches, less headaches and less appetite suppression vs Ritalin/ methylphenidate .    Focalin  may last a little longer than Ritalin /methylphenidate.

MISCELLANEOUS INFORMATION:    Dexedrine is similar to phentermine.

Adderall is 75% Dexedrine and 25% of the levo-amphetamine [amphetamine has two isomers; the right one is dextro-amphetamine {Dexedrine} and left one levo-amphetamine].

Pondimin/ fenfluramine + phentermine (fen/phen) ®  high incidence of pulmonary hypertension and heart valve problems. [Pondimin/ fenfluramine even prior to use in the USA was known to occasionally cause pulmonary hypertension.]

High doses (i.e., overuse) of ergotamine (Ergomar, Cafergot, et al), a medication similar in action to Pondimin/ fenfluramine, caused heart valve problems almost identical to the phen/fen [phentermine/ fenfluramine]   combination – in fact, cardiac surgeons noticed the effect of fen/phen more quickly because of the physical similarity to the ergotamine problem.

Pondimin/ fenfluramine  is somewhat similar to Zomig.   So, theoretically, the combination of Zomig & Dexedrine could cause pulmonary hypertension.

TOLERANCE:  If Dextrostat / dextroamphetamine   or Adderall [“amphetamine salts”] poops out,  often a change to Ritalin/ methylphenidate solves the problem.  You will not be tolerant to Ritalin methylphenidate  even though you were tolerant to Dextrostat / dextroamphetamine.  And after a while (weeks or months) when you switch back to the original stimulant (dextroamphetamine  or Adderall) you usually will no longer be tolerant to it and it will work again.    Some people develop tolerance after 6 months or more, and a few develop it after 3-4 weeks.  If you skip the medication frequently — such as on weekends– you are less likely to develop tolerance.  Many people take it daily for years without any tolerance.

Ritalin/ methylphenidate tablets come in 5mg, 10mg, and 20mg:  for the first few days try: ½-1 pill (but 1^st  day just  ½ ); then go to 5mg  in AM and around noon (to 2PM).  If you take it too late in the day, you won’t sleep.  Some people need 60 to 100mg—then they usually take larger, slow release pills.. The possible side effects of Ritalin are basically the same as coffee, but more so.  If too many side effects, stay lower, even if only 1/2 pill once a day.  You can skip Ritalin/ methylphenidate  the days you don’t need it.   {If you are taking it for depression, rather than for ADHD, then you probably shouldn’t skip it.} Ritalin wakes people up, energizes them a little, has an antidepressant effect and it helps people focus (concentration).

Stimulants for depression

I have always commonly used stimulants as augmentors when response to SSRI’s, etc were not 100%.  Now, of course, I usually try Wellbutrin or Strattera  first.

I have about a dozen pts who take only Dexedrine or Ritalin  for chronic depression–most of them have no benefit from standard antidepressants or excessive side effects–and have been doing well for years.  Some of them were referred to me because I was willing to maintain them.    Most of them do not develop tolerance.  But a few do, and they found they can alternate every few weeks between Ritalin and Dexedrine, and occasionally  Adderall.  Just like in ADD, the stimulants sometimes do NOT have cross – tolerance– i.e., if stimulant benefit for ADD wanes after a year or so–a rare occurrence apparently– a switch to another stimulant works, and after a few months a switch back to original stimulant is possible.

I sent the most dramatic case to Paul Goodnick, MD in Miami [he’s back here now].  She was abusing tiny amounts of cocaine for chronic severe major depression.  She was incapable of smiling, of having any pleasure, of feeling any love for her daughter.  I tried her on many antideps with very partial success, and severe side effects.  She had absolutely no interest in men. When finally put on Dexedrine (15mg?), she became completely euthymic, and stayed that way for years.  She hated being dependent on Dexedrine.  I was in another city and by chance saw large article in a newspaper on psychotherapy, with a prominent picture of her.  She was quoted as attributing all her improvement to psychotherapy.  I had to laugh.

Dexedrine occasionally causes or exacerbates HT—Ritalin virtually never does.

Dexedrine and Ritalin are quite safe with MAOI’s.  I have used the combination in well over a 100 patients.  I usually take the patient’s BP, have them take  Dexedrine or Ritalin 5-10mg, and repeat the BP in a 1/2 hour.   The BP is invariably lower the 2nd time, after sitting around in my office. Maintenance dose is usually 10-30mg.  Even though they do not seem to cause high blood pressure with MAOI’s, the stimulants seem to help treat the orthostatic hypotension caused by an MAOI.

After ~20 years one 55 yo man using Dexedrine 10-15mg as augmenter developed atrial flutter.  The Dexedrine was stopped, and he still had recurrence of flutter.  Scans show he has ASCVD. The Dexedrine  seems unrelated, but it is of concern.  He does well now on Wellbutrin  400/ Lexapro  5mg.

MY USUAL INSTRUCTIONS for starting Ritalin/ methylphenidate

Stimulants:  wake people up, help Attention Deficit Disorder and help depression .

F.Y.I.: PMS is a Serotonin Depression;   Ritalin does not affect serotonin but Adderall does, which may be part of the reason Adderall and dextroamphetamine  is a better antidepressant than Ritalin/ methylphenidate. Adderall helps PMS more than Ritalin does.

At the biochemical level, amphetamine raises dopamine tone by 3 mechanisms, whereas methylphenidate  raises dopamine tone by only one method.  This may be the reason that amphetamine has more antidepressant effect as well as a much higher chance of raising blood pressure than methylphenidate.

Other medication for ADD:

Dextrostat  (cheaper form of Dexedrine= dextroamphetamine). [Available in 5mg and 10mg yellow tablets:  RP 51; RP 52.]  The usual dose is 5mg pills: 1-2 pills 3 times a day , or 3 pills two times a day (AM and noon).  This helps with mood, concentration, and sleepiness.  We could use other things, but wouldn’t kill 3 birds with one stone.   E.g., thyroid helps mood, but only mood. 

Instructions:  try Concerta (methylphenidate, same as Ritalin, but long acting) 18mg, 36mg and 54mg  pills.  You will probably need 36 to 54 mg..   Usually the dose is all in AM.  If you split the tablet, you get inconsistent results, because there are 3 compartments.

The whole dose is usually taken in the morning, but a few people  find  it works better for them to split the dose– e.g.: 2 pills in the early AM and one at noon or in the early afternoon.

#1:  I would go very slowly, starting tomorrow, 1 tablet of the 18mg tablet every AM for a week.  Take it with food the first couple of times.

#2.  Then, after a week, try to increase   to 36mg every AM.   Of course, don’t increase if you get all the way better or if you have significant side effects.

#3.  if no side effects and no huge benefit, then in another week, try to ­ to 3 pills= 54mg.

Ritalin/ methylphenidate tablets come in 5mg, 10mg, and 20mg:  for the first few days try: ½-1 pill (but 1^st  day just  ½ ); then go to 5mg  in AM and around noon (to 2PM).  If you take it too late in the day, you won’t sleep.  Some people need 60 to 100mg—then they usually take larger, slow release pills.. The possible side effects of Ritalin are basically the same as coffee, but more so.  If too many side effects, stay lower, even if only 1/2 pill once a day.  You can skip Ritalin/ methylphenidate  the days you don’t need it.   Ritalin wakes people up, energizes them a little, has an antidepressant effect and it helps people focus (concentration).

MY USUAL INSTRUCTIONS:

Ritalin wakes people up, energizes them a little, has antidepressant effect, & it helps focus (concentration).

Adderall 5mg, 10mg, 20mg, and 30mg tablets.   5 and  10mg tablets are blue; 20 and 30mg tablets are orange, with mg imprinted;   75% of Adderall is dextroamphetamine and 25% is levo-amphetamine, which is just the mirror image of dextroamphetamine, and it works similarly.   . $1.34 for 30mg. 

INSTRUCTIONS:

Try Adderall  10mg XR :  2-4 pills in the AM.    I doubt you would need 6 pills = 60mg, but you might.  The maximum dose is 60mg/day, but usually one is on £ 30mg.  It is very variable what each individual needs.

This XR [slow release] lasts maybe 10-12 hours or more.  If it starts to poop out late in the afternoon or evening, and if you need something, then take regular Adderall [“amphetamine salts”]  10mg: probably 1-2 pills, but maybe only ½ pill – 5mg.   If you take too much you will have insomnia.
If you have a little insomnia, you could take clonidine 0.1mg pills:   1-3 pills at bedtime to help you fall asleep.  This is a blood pressure medication which we sometimes use for Attention Deficit Disorder or as a sleeping pill.   Just watch out for dizziness if you stand up fast, since it lower blood pressure.  We might as well use it since it helps ADD.  Sometimes kids take a clonidine patch during the day but they have to accommodate to a side effect of drowsiness.

Occasionally there is someone who does much better on regular release Adderall than on the slow release.   That person ends up taking Adderall spread out maybe 3 times a day.

You do not have to take the medication every day.  There is generally no withdrawal.  If it happens to make you feel “high” and then you cycle into slump of depression or low energy, call me.  Obviously, do not take this as a recreational drug and don’t give to your friends.  Avoid taking alcohol with it–I have had some patients who became excessively intoxicated by alcohol, apparently because they also took Adderall or Ritalin.

USUAL DOSE IS ~30MG/DAY, BUT 1 FEW  PEOPLE NEED 90MG/DAY AND A FEW ONLY NEED 5-10MG