View Full Version : Dosage Difference with ethenic differences


ADD_Serpent
05-27-17, 11:31 AM
I am 46 year old male from India.
I am being treated for ADHD and OCD. Conditions are improving, But I have a doubt regarding medications in General.

I know the Standard rule that "Consult your Doctor for best dosage and medicine suitable for you" which implies that forums like this are not to be used as an alternate for service from a professional.

My family has a good history of Psychiatric disorders and many are under treatment for years and they are 'surviving' too.

When I started using medications for the same problems I started paying more attention to online information and discussions in forums like this where most of the users I believe are from western countries or at least from Developed countries. When following through the discussions and experiences of the users I can understand how the doctors generally start treatment using starter kits and how the dose is being adjusted generally and how they reach or find a suitable dose after titration.

For example regarding strattera

STRATTERA should be initiated at a total daily dose of 40 mg and increased after a minimum of 3 days to a target total daily dose of approximately 80 mg administered either as a single daily dose in the morning or as evenly divided doses in the morning and late afternoon/early evening. After 2 to 4 additional weeks, the dose may be increased to a maximum of 100 mg in patients who have not achieved an optimal response. There are no data that support increased effectiveness at higher doses [see Clinical Studies (14 (https://www.drugs.com/pro/strattera.html#s99))].

The above quote is from a medical site in the web. and if we read through many user reviews of strattera in forums, we can understand this info generally complies with what users are reporting as their doses. so that means this seems the policy at least generally.

In my case my doctor says Starttera (Attentrol in India ) 25mg+25mg is a very high dose which is not to be continued. I am 88Kg with no specific health problems other than this ADHD and its co-morbidity. I asked about this to my doctor about this and he said western doses are not suitable for us because we are racially different.
My commonsense (Or so called gut feeling) cannot accept this. I cannot find this much substantial dosage difference is justifiable with this racial difference.
May I have some input from professionals here regarding my confusion on this?. I have a feeling that our country ( At least in my part of the country) follows the treatment culture of keeping the dose minimum just to survive the patient on a non dangerous level to prevent side effects at the cost of possible maximum benefits.I have the same feeling on many medications my family members are receiving on other psychiatric disorders. This also from different doctors.
I am just trying to understand weather my research and assumptions on this has any meaningful foundations.
btw I am a software professional with no medical background except living in a family where almost all members are under psychiatric medication.
I hope I deserve (Not previlage!) an explanation. :cool:
Thanks for Reading,

Fuzzy12
05-27-17, 02:58 PM
As far as I know (and that's not a whole lot) some psychiatrist are a bit more conservative with dosing in India. Well I know one psychiatrist from india who thought that my dose of dex was very high. I don't know if that's across the country though. Maybe it was just this one psychiatrist.

It does depend a lot on psychiatrist and region though. Eg my psychiatrist here also thought I was on the maximum dose for dex though I regularly hear of people talking a lot more.

I don't have a medical background either but the race story does sound very dodgy to me. There might be some slight clinical differences, eg south Asians are more susceptible to heart disease but I've never heard anything in relation to adhd meds dosing, which doesn't mean much considering I don't have a medical background bit my gut feeling is that he's making it up.

ADD_Serpent
05-29-17, 06:34 AM
Thanks Fuzzy12 for the response.

My Doctor is Very co-operative and understanding in all my problems and discussions and almost every other aspects whatever he conveys in our meetings are very reasonable and complements with my so called "unsolicited supervising" of the doctor whom I trust for solving my issues.

More than Doctors Personal belief system I think this is a school of thought they are being fed with from their mentors who got it from patients non clinical feed backs. For example I know many people who will avoid consuming a paracetamol tablet when a small fever starts. They will say medicine is worst enemy of health and sometimes they will suffer this fever and subsequent difficulties and recovers after few says of suffering, but with the satisfaction of avoiding medication and thereby seems to be having the confidence that they got some assurance that they are sure to live 100 years just because they avoided a chemical that might have damaged their liver!

This is a general mindset we have here. When these people sometimes have to ultimately go a doctor because of a too serious issue, there will be two types of doctors they will possibly engage with. One type of Doctor will give a very small dose which just reduces the discomfort and accelerates the self curing process little bit so that patient will avoid too much difficulties and will be OK soon. But the second one may give the ample doze for the condition along with some other antacids or anti-allergic medicines so that patient will start feeling very comfortable immediately and soon he will be OK. But he may feel little drowsiness or tiredness which any medication normally cause. This second doctor who in my opinion is the good one will be generally labelled as the one "who apply high doses". This at least in my experience is not a good certificate by the general population in rural and semi urban area of my country at least.

This commercial survival policy requirement of Doctors might have infiltrated into the local academic system and as time goes it slowly escapes its original intent and masquerade into the clinicians as a clinical policy. (Just a thought by me regarding this ethnic issue in medication response)

I may be wrong, But I can learn only if somebody speaks something about this!
Thanks for for reading.

namazu
05-29-17, 04:13 PM
Disclaimer: I am not a medical doctor, and you should seek advice from a medical professional before changing your medication.

Short answer:

Your doctor may have some reason to be cautious. However, your race/ethnicity is not a scientifically-supported reason to prevent you from trying a higher dose if you have had an OK response to the current dose and you are not experiencing bad side effects.

-----------------------
Long answer:

About genes and other factors that affect drug metabolism, in general

Drug metabolism is related to gene variants (alleles) that are sometimes more or less common in certain ethnic groups due to the history/geography of those populations.

On average, perople in some ethnic groups may be more sensitive to medications (requiring a lower dose, or experiencing more side effects) or less sensitive (requiring higher doses to see a therapeutic effect).

However, not everyone belonging to a given ethnic group will process medications in exactly the same way, for several reasons:

a) Within ethnic groups, there is genetic variation. Certain genetic variants (alleles) may be more common within one group, but it is unlikely that all the members of that group have identical alleles.

So, even if Malayalis (for example) were more likely to have a particular genetic variant affecting drug metabolism, not every Malayali person would necessarily have that same genetic variant. Some would have it; some would not.

This knowledge may lead a physician to be more cautious about using a drug in a population where a particular genetic variant is common, because on average (if you picked people randomly from the population), the likelihood of side effects or poor effect could be higher. Still, the doctor would need to evaluate the risks and benefits for each individual patient, and see how the patient responds to medications. A person (and their response to a drug) cannot be reduced only to their ethnicity, because not every person of that ethnicity is identical (genetically or otherwise).

b) Metabolism is affected not only by 1 gene. It is affected by many genes, as well as by non-genetic health-related factors.

For example, older people, people with chronic viral hepatitis, people who drink a lot of alcohol, people who have been exposed to environmental toxins, people taking multiple medications, and people who are malnourished may all be less able to metabolize certain medications well, and more likely to experience bad side effects.

About atomoxetine metabolism and gene variants in India:

For atomoxetine/Strattera/Attentrol, the most important metabolic pathway involves an enzyme called CYP2D6. The function of the CYP2D6 metabolism enzyme is affected by genetic variants. [technical info here (https://ghr.nlm.nih.gov/gene/CYP2D6#conditions)]

People with certain variants of the CYP2D6 gene don't produce an enzyme that works very well to metabolize drugs. These people are called "poor metabolizers". They are more likely to have side effects or need lower doses of certain medications than other people.

A few studies in different ethnic groups from around India have found that <5% of the population fall into that category of "poor metabolizers" using the CYP2D6 pathway. [figure/reference (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4071701/figure/F2/)] Those people might be more likely to experience side effects or need lower doses of atomoxetine.

...But that leaves roughly 95% of the Indian population with normal (or fast!) CYP2D6 metabolism. Thus, there is no reason to think that genetics alone would cause Indian people, in general, to need lower doses of atomoxetine than people in North America or Europe.

As I mentioned earlier, drug response reflects many factors, not just a single gene. Even with "normal" CYP2D6 gene variants, people who (for example):
- are malnourished,
- have been exposed to a lot of aflatoxin (a liver poison that comes from moldy rice),
- are elderly,
- have chronic viral hepatitis, or
- take other medications,
may not metabolize the medication normally.

If you are otherwise healthy, then there does not seem to be special reason for concern.

General thoughts

It is always wise to proceed cautiously with medications, working with a qualified medical professional, increasing the dose slowly, and monitoring for side effects. More is not always better, and in that sense, the cautious attitudes of some doctors in your area are wise -- to an extent. Certainly in North America there has been concern about "over-medication" -- that doctors give medications too freely, even when it is not justified.

But given what you've said, I don't see a good reason why your doctor should stop at 50mg of atomoxetine simply because you're Indian. If you have seen some (but not enough) improvement in your ADHD symptoms with 50mg atomoxetine, and you are not experiencing bad side effects, then it could be reasonable to test a slightly higher dose.

If you are comfortable speaking frankly with this doctor, you could ask them to explain their reasoning / justify their claims in more detail. Perhaps they are aware of something in your medical history or of some research that I'm not, and they do have a valid reason for wanting to limit your atomoxetine dose.

If you do not feel like you can speak freely with this doctor, or they seem unaware of the research, perhaps you could seek a second opinion from a different doctor.

Best wishes!

ADD_Serpent
05-31-17, 09:30 AM
Thanks namazu for spending so much time for giving me a detailed reply.

Anyway I have clarified with him (My Doctor) weather there is any Special situation/condition other than this racial thing for the low dosage and he said nothing special about me, but "All this meds ultimately effects brain,so we should not do that much". I though I will take some risk, since I am getting improvements and no side effects on 50mg I myself hiked to 75mg. I am periodically checking my BP and it seems as usual. I am having medication for BP for the past one year.

That 75mg change In my opinion makes a difference. Not very high improvement, but something kicked in than the previous days. It is premature to reach conclusions or reports. I believe I can convince him and continue.

My OCD is also greatly improving (Fluvoxine). But the change I feel when I am crossing a threshold in the dose is very obvious for me. But I know for weighting the effect and side effects, I need to wait for some time and may be able to titrate to a lower level later.

I am just starting to see the world,work, and even life through a different glass. I am really happy and surprised by realization of the fact that what I think I am, is some chemical combination in the brain, If It change,the so called "I" also change!

I can feel I am getting little more talkative and asked my family to give a close watch and I am also feeling that, and it is easily controllable for me now. But that made me more cautious!

Anyway Thanks for all the info available in the forum and will be around here with updates.

aeon
05-31-17, 11:15 AM
"All this meds ultimately effects brain,so we should not do that much".

Hes a quack, string him up, and burn his license. :doh:


Sigh,
Ian

ADD_Serpent
05-31-17, 06:11 PM
He’s a quack, string him up, and burn his license. :doh:


No,No.. My dear friend. Out of the 4 or 5 psychatrists I have experience with, this one is the best, in terms of patients doubts about prescriptions and dosages. I know I cannot speak for the entire Indian situation, but in my opinion, except very few clinicians in metro cities, most doctors response on quieries like the one I am raising will be "Stop googling for supervising my treatement if you want my services". It is like "Either my way or highway!" But it iss not entirely their fault in many cases. Many patients will google here and there and will not study in detail and will argue with doctor in a authoritative way, which obviously will provoke them and ultimately create a "anti-google" mindset.
In my humble opinion the problem with my doctor is that he is not getting out of his own local old school of anti- medicine indoctrination. He may be considering the western medication policy as a medicine abuse.(if at all he is following latest trends around the globe, during his busy practise). As I said in my above post the threat of being labelled as a "High Dose Doctor" is very detrimental for his practice
Doing the maximum research on our condition and possible treatements, , keep constant self monitoring of vital clinical tests and aboove all being ready to face the consequences, will be the best option to follow at least for me.!
Thanks for reading.:scratch:

someothertime
05-31-17, 08:57 PM
Thread re-opened. All members are reminded that taking medicines contrary to law is both illegal and potentially harmful.

As such, it is against forum guidelines to PROMOTE or ENCOURAGE misuse.

Discussion which does so may lead to thread closure, post edit/removal and/or member infraction.

Please adhere to guidelines.



GUIDELINE -> (http://addforums.com/forums/forumdisplay.php?f=75)Please Do NOT do the following & Things Just Not Allowed (http://addforums.com/forums/showthread.php?t=15842)

No posts on O.D.s, illegal or improper use of Meds
NO posts involving O.D.s, illegal or improper use of Medication are allowed

In an effort to protect all who use these forums, no posts will be allowed that encourage or support the illegal or improper use of medication of any kind. We do not condone illegal or improper use and do not wish to be a source of information for people who would use medication this way. This includes talk about overdoses or O.D.'s.

ADD_Serpent
06-01-17, 02:19 AM
I regret the fact that I failed to read the guideline mentioned above and I am really sorry about the assumptions I might have caused to propagate which is against this forum's policy.
I will keep this in mind in my future phrasings or presentation of my actions or ideas.
This is a great forum which is helping me a lot, So rules should prevail!
Thanks for the understanding.