For professional guidance about the diagnosis or treatment of a specific individual you know, please contact a health professional. Do not use the information on this site to diagnose or treat yourself or others. Please be aware that reading this site does not establish a doctor-patient relationship between you and the professionals associated with it.
The questions and answers on this page are one that have been asked recently. They are in reverse chronological order so new questions and answers (and old questions with revised answers) will be first in the list. For answers to questions I answered longer than a month or so ago, click here.
Question: I’ve been on 70 mg of Vyvanse now for about 6 months. At first it would last me about 8-10 hours, but now I’m lucky to get 6 good hours before I can tell the effects are wearing off. Have you had any patients go back to Adderall XR after trying Vyvanse for a few months?
Similar question from another person: The pharmacokinetic profile of stimulant medication doesn’t necessarily match the way it works for me. (ed note: pharmokinetics is the study of how drugs are absorbed, distributed through the body, metabolized, and eliminated.) For example the profile of Adderall XR or Vyvanse suggests that the blood level at 4 hours after a person takes the medication is the same as the blood level 10 hours after they take it. But I’ve found that the effect of these medications are strongest after about six hours then, for me, it's downhill from that point.
Dr. Schwartz's response: In my experience, about 15% of people taking any of the stimulants may need to increase the dose a few months after they found the right dose in order to get the same benefit they got at first. This might mean taking a higher dose each time they take the medication or taking it more often. Be aware that taking a higher dose of amphetamines usually increases the length of time they work, but this generally does not work with methylphenidate stimulants (e.g. Ritalin, Concerta, and others).
It is uncommon, but not unheard of, that some need to increase the dose a second time. If the dose needs to be raised more than two times over time after a good effect was achieved, it sometimes means that it will keep on happening and that no dose will work. It is important in these cases to be sure the dose is being raised to increase the effect of the medication on thinking functions, like focus and concentration, and not for their energizing effects. A decrease in the energizing effect over time, which is not uncommon, is usually caused, in my experience, from increased stress or reduced sleep and, except in special cases, for a limited period of time and only under a doctor's supervision, should tiredness be the target for treatment with stimulants (including Provigil).
Occasionally the level of the medication builds up in the brain and this interferes with its action. Sometimes in these cases, periodically stopping the medication for a few days and then restarting it works. I have one patient who does this weekly and a few who regularly take their medication only two or three times a week because they get disturbing side effects if they take them more often.
In my experience, the pharmacokinetic studies of medications usually report the effects of medications on the average individual. This can overlook the fact that there are enormous variations in pharmacokinetics between individuals, and there are even variations within one individual depending on diet, stress, illness, exercise, and other factors.
It is also clear that different effects of the stimulants have different pharmacokinetics. For example, the medication effect that interferes with sleep lasts much longer in most people than the effect that improves focus. The effect that increases blood pressure or that causes dry mouth may last for days after the medication is stopped.
The practical conclusion from all this is: always work with your doctor to try to find out what dosing and timing is best for you, and don't rely on what is best for the average text-book patient.
Question: Have you ever prescribed the medication Desoxyn? From reading on the various ADD forums on the internet it appears to be the least used medication due to the stigma attached to it, but also one of the most (supposedly) effective medications with the least side effects. There appears to be very few published studies on this medication.
Dr. Schwartz's response: The only patient I treated with Desoxyn was taking it at the time I first saw him. He raved about its wonderful qualities, and I continued him on it. But I guess there can be too much of a good thing because it turned out he was also getting it from two other doctors. I think the general experience with Desoxyn is that it is much more addictive than the other legal amphetamines.
Question: My single daily dose of 70 mg Vyvanse lasts for maybe 4 or 5 hours. Your web page on “high” dose stimulant treatments makes a lot of sense. I’m a 6’1, 220 pound (athletic build) male and am 27 years old. It is rational that the highest dosage of Vyvanse (70 mg) which was initially created for children, could be ineffective in adults such as myself.
I have experienced the advertised benefits of Vyvanse when taking a dosages of 100 mg and 140 mg in a day. Given the manner in which Vyvanse is released in the body, for individuals taking two 50 mg or 70 mg capsules per day, does it matter whether you take both capsules at the same time or take the capsules individually with several hours in between? I’m curious which manner of taking the medication would be most effective for focus and attention and provide the lengthiest coverage in a day.
The cost of Vyvanse is very high. I’m also wondering if you see any issues with being prescribed perhaps one 70 mg capsule of Vyvanse a day plus two tablets of 20 mg short acting generic Adderall, one as a jump start in the morning and the other as a booster in the afternoon?
Dr. Schwartz's response: Higher doses of amphetamines usually last longer than
lower doses (this is not true with Ritalin type medications), so taking both
Vyvanse pills at the same time will probably make the medication's effect last
a bit longer. But the higher blood level of the medication you will get if you do
this gives you a greater likelihood of having side effects.
Taking a second dose about a half hour to an hour before the first dose wears
off is an approach more commonly effective in increasing the length of time the
medication works. The problem with this is that sometimes the second dose, if
taken later in the day, lasts so long that it interferes with sleep.
One way around this problem is, as you thought, to take a short acting
amphetamine a little before the Vyvanse wears off in the late afternoon. Since
Vyvanse is dextroamphetamine, taking Dextrostat or any dextroamphetamine generic
might be more likely to mimic the Vyvanse effects than will generic Adderall,
which contains four different amphetamine salts.
Some people find, as you did, that Vyvanse does not "kick in" for them quickly enough in the morning. Some find a small dose of dextroamphetamine (for example Dextrostat) taken with the morning Vyvanse speeds up the process.
Some people who are concerned about the high cost of Vyvanse switch to a
combination of long acting Adderall and (short acting) generic Adderall. For
most people, the dose of Adderall that is equivalent to 50 mg of Vyvanse is 20
mg, and the equivalent to 70 mg is 30 mg (about a 2 1/2 to 1 ratio).
You and your doctor will have to figure out what is the best dose of Vyvanse and
of short acting dextroamphetamine is for you by trial and error. It may take a few
weeks, but the experimentation is usually worth the time spent.
Question: I am 25 years old and have extreme difficulty concentrating and organizing my thoughts. I procrastinate and have anxiety and severe restless leg syndrome at night. In addition, at night it is difficult to get my mind to stop wandering and go to sleep at bedtime. I am currently studying law. With this condition it is very hard to focus on material that requires dedicated study. When I was younger I was diagnosed with ADD and was treated with Ritalin. I took this all the way through high school, but I stopped after graduation. I think I may now have adult ADD.
I was concerned about the anxiety and told my doctor about it, and he prescribed Lexapro, which helped marginally with the anxiety but did not help the concentration problems. A friend with ADD gave me a capsule of his Ritalin. I took it at 5:00 pm, and it seemed to calm me down. It even alleviated the restless leg syndrome, which my wife was pleased about. If I inform my physician about this do you think he will agree that it is adult ADD. I am becoming increasingly concerned because of the effects it is having on my studies
Dr. Schwartz's response: It is not a good idea to take medication without a doctor's supervision, but I can understand someone with your symptoms wanting to see whether a stimulant could help. A fair number of new patients I see have have tried stimulants of their friends (or children) and had a good response to it. (Those who had a bad effect probably don't call an ADD clinician even though in some cases they may actually have ADD but just took the wrong dose or the wrong medication.)
It is hard to be sure of what to make of your response to Ritalin. Some people have a good response to stimulants initially because of the placebo effect. But most who respond well to the medication with their first dose continue to do so. The fact that you were diagnosed with ADD and had responded well to Ritalin when you were younger makes it more likely your response was not just a placebo response.
Whether you should tell your physician or not about your recent experience with Ritalin depends on your judgment about the physician. Many doctors would view your experience with Ritalin as suggestive that you have ADD, but some might be critical of what you did. I don't know how your doctor will respond.
To help your doctor evaluate your ADD, you might want to print out the questionnaire on my web site, complete it, and bring it with you to your appointment with him. It might also help if you brought your wife along, and she reported her impressions of your symptoms and how they affect your life and functioning. As you may know, ADD does persist into adult life in over half the people who had it during childhood.
With regard to your anxiety: while the stimulants do not have usually a direct anti-anxiety effect (and can sometimes make people jittery), it is not uncommon for people with ADD to feel anxious about their memory and general level or mental functioning. These people often find that once the medication works and their mind begins working well, their anxiety disappears.