View Full Version : Is it my doctor or is it me?


OddballRoberts
08-04-17, 11:52 AM
Hello all,
Had a question for all of you Vyvanse users out and/or ADD med users in general. I have Kaiser for insurance currently. My old insurance covered Vyvanse which works best for me. Kaiser doesnt allow it unless a patient tried several other meds first which I did. My psychiatrist put me on 70mg daily which is what I was on old insurance. It wears off by afternoon and always has. I asked if I could try a booster for work in the afternoon as i have before. He won't prescribe anything to me with the 70mg Vyvanse does. He said its the max amount you can have per day. He offered to lower the Vyvanse to 60mg and then a 10mg booster of Adderall IR which I agreed to but wtf won't he budge on this? I know plenty of people who get waaaay more than I do. The 70mg works great for work and lasts about 6 hours. All i want is a small booster for the afternoon and I can only get it by lowering the vyvanse. He did something similar to me when I was Dexedrine. I went from 40mg of Dexedrine a day to 30mg a day and 10mg of Adderall. What am I missing here? Any help is appreciated. For reference, i've posted about this before so you can read those old posts if you'd like. Thanks al!

Lunacie
08-04-17, 02:23 PM
Maybe it would help to point out that dosing research is based on children, and
adults may need different doses?

fathom6
08-05-17, 02:05 AM
He wont budge because he does not want to be prosecuted and his license stripped from him, 70 mg is the max cap. Understand, there is a HUGE stigma attached to amphetamines, and doctors are being hunted down by people concerned with amphetamine epidemic - they claim.

No wonder, there are so few psychiatrists around.

Hello all,
Had a question for all of you Vyvanse users out and/or ADD med users in general. I have Kaiser for insurance currently. My old insurance covered Vyvanse which works best for me. Kaiser doesnt allow it unless a patient tried several other meds first which I did. My psychiatrist put me on 70mg daily which is what I was on old insurance. It wears off by afternoon and always has. I asked if I could try a booster for work in the afternoon as i have before. He won't prescribe anything to me with the 70mg Vyvanse does. He said its the max amount you can have per day. He offered to lower the Vyvanse to 60mg and then a 10mg booster of Adderall IR which I agreed to but wtf won't he budge on this? I know plenty of people who get waaaay more than I do. The 70mg works great for work and lasts about 6 hours. All i want is a small booster for the afternoon and I can only get it by lowering the vyvanse. He did something similar to me when I was Dexedrine. I went from 40mg of Dexedrine a day to 30mg a day and 10mg of Adderall. What am I missing here? Any help is appreciated. For reference, i've posted about this before so you can read those old posts if you'd like. Thanks al!

fathom6
08-05-17, 02:25 AM
To further add, many states have a substance abuse database monitoring program, where "schedule II" drugs like Vyvanse get recorded alongside dosages. The docs are on hook and they get flagged (license to practice medicine terminated for like 6 months or so) if they are caught exceeding maximum dosage limits, which I believe for vyvanse is 70mg/day. President Trump right now is under intense pressure from activists to declare opoid over-use prescriptions (another "schedule II" drug) officially as an EPIDEMIC.

sarahsweets
08-05-17, 06:52 AM
Daily recommended max isnt the same as Max to avoid danger or health issues. The studies were mostly on children for adhd and adults for binge eating disorders.

fathom6
08-05-17, 01:40 PM
Would you then shed light sarahsweets what is that "max" amount for Vyvanse?. Because I know, my former Psychiatrist (a wonderful person whose patients sing songs of his empathy and care for patients) is HUNTED down like an ANIMAL for over prescribing medicines including ADHD.

Daily recommended max isnt the same as Max to avoid danger or health issues. The studies were mostly on children for adhd and adults for binge eating disorders.

sarahsweets
08-06-17, 07:30 AM
Here is one bit I found. I cant link to it as I think it advertizes different doctors. Granted I am not trying to promote high doses just using this as an example.

High Dose Stimulant Treatment for Adult ADHD
All ADHD medications that are FDA approved to treat adults have designated maximum daily doses. It is important to understand how these daily maximum doses are determined in order to consider higher doses beyond these thresholds. The FDA receives the clinical registration trial research and it makes a determination of maximum daily dose based on the presented data. If, for example, a clinical trial had a maximum dose of 50 mg a day then the FDA will only approve the drug with a maximum daily dose of 50 mg. An example of this is Vyvanse where the trial looked at 30 mg, 50 mg and 70 mg a day. Maximum daily dose approved is 70 mg.

In some cases where the clinical trial evaluated several doses, the FDA may only approve a maximum dose in the middle dose range from the trial because the higher dose didn’t demonstrate a statistically significant difference in effect. Case in point, Concerta maximum daily dose in the package information is 72 mg, although the U.S. adult trial went to 108 mg a day. However the trial protocols are not designed to answer the question “If you don’t respond to 72 mg a day, will you respond to 108 mg a day”.

Where am I going with this? I have several patients at what would be considered as very high doses of stimulant medication-methylphenidate 400 mg a day, Vyvanse 200 mg a day. Unsafe? Well neither patient complains of problematic side effects for which they would stop the medication. Also, blood pressure and pulse are in normal range. We got to these doses because lower doses didn’t have any effect until we went higher. In each of these cases, I have ordered stimulant blood levels to see if blood levels were too high. In fact, in each case the levels were lower that what was expected by mathematical extrapolation.

The point? There are a group of ADHD adults who are very fast metabolizers who will only respond to very high stimulant doses. Since most of the metabolism of amphetamines and methylphenidate occurs outside the liver, I’m not sure obtaining a liver P450 enzyme profile to determine metabolism will be useful.

If you have ADHD and have not responded to appropriate stimulant doses, then consider seeing an ADHD adult psychiatrist who has experience and comfort with this dosing concept. That’s what true expert clinicians are for.
From drugs.com:

Dosage for Treatment of ADHD
​The recommended starting dose is 30 mg once daily in the morning in patients ages 6 and above. Dosage may be adjusted in increments of 10 mg or 20 mg at approximately weekly intervals up to maximum dose of 70 mg/day [see Clinical Studies (14.1)].

Dosage for Treatment of Moderate to Severe BED in Adults
​The recommended starting dose is 30 mg/day to be titrated in increments of 20 mg at approximately weekly intervals to achieve the recommended target dose of 50 to 70 mg/day. The maximum dose is 70 mg/day [see Clinical Studies (14.2)]. Discontinue VYVANSE if binge eating does not improve.

Dosage in Patients with Renal Impairment
In patients with severe renal impairment (GFR 15 to < 30 mL/min/1.73 m2), the maximum dose should not exceed 50 mg/day. In patients with end stage renal disease (ESRD, GFR < 15 mL/min/1.73 m2), the maximum recommended dose is 30 mg/day [see Use in Specific Populations (8.6)].

Dosage Modifications due to Drug Interactions
Agents that alter urinary pH can impact urinary excretion and alter blood levels of amphetamine. Acidifying agents (e.g., ascorbic acid) decrease blood levels, while alkalinizing agents (e.g., sodium bicarbonate) increase blood levels. Adjust VYVANSE dosage accordingly [see Drug Interactions (7.1)].

fathom6
08-06-17, 12:47 PM
So you agree that FDA has "approved 70 mg as maximum daily dosage" for Vyvanse for xyz reasons. But you also caution that doctors if they are willing can make judgement and even prescribe 200 mg if patient vitals are normal and patient does not complain. That is where I have concerns from a practical point-of-view, there is something gone terribly wrong with the medical profession, because when a doctor prescribes anything above 70 mg she/he is putting their necks on an axe ... literally, and to practically expect that from a doc I dont think is rationale

What I am saying is, there is a huge activism against doctors who are making exactly these kind of judgements, somehow these schedule II drugs are a very big deal (for all the deaths and what not they claim). And I have seen one leading Psychiatrist (85 years and still excitingly coming to his practice, such an angel like spirit, FORCED to retire from his profession) and get his neck chopped off, for exactly doing this. Without naming him, that was his point of view that the dosages "were medically indicated and appropriate under the circumstances". But with different organizations and TV stations creating documentaries on him and so many people after his skin, today he is no a longer a practicing physician.

I dont know I like to see things from the shoes of the other party. I believe, psychiatry profession is not being treated fairly.

If, for example, a clinical trial had a maximum dose of 50 mg a day then the FDA will only approve the drug with a maximum daily dose of 50 mg. An example of this is Vyvanse where the trial looked at 30 mg, 50 mg and 70 mg a day. Maximum daily dose approved is 70 mg.

In some cases where the clinical trial evaluated several doses, the FDA may only approve a maximum dose in the middle dose range from the trial because the higher dose didnít demonstrate a statistically significant difference in effect. Case in point, Concerta maximum daily dose in the package information is 72 mg, although the U.S. adult trial went to 108 mg a day. However the trial protocols are not designed to answer the question ďIf you donít respond to 72 mg a day, will you respond to 108 mg a dayĒ.

Where am I going with this? I have several patients at what would be considered as very high doses of stimulant medication-methylphenidate 400 mg a day, Vyvanse 200 mg a day. Unsafe? Well neither patient complains of problematic side effects for which they would stop the medication.


From drugs.com:

sarahsweets
08-07-17, 04:51 AM
So you agree that FDA has "approved 70 mg as maximum daily dosage" for Vyvanse for xyz reasons. But you also caution that doctors if they are willing can make judgement and even prescribe 200 mg if patient vitals are normal and patient does not complain. That is where I have concerns from a practical point-of-view, there is something gone terribly wrong with the medical profession, because when a doctor prescribes anything above 70 mg she/he is putting their necks on an axe ... literally, and to practically expect that from a doc I dont think is rationale
I dont necessarily agree that the high amounts that my quote references or higher amounts than normal is acceptable or the norm. Its just that when I was looking for something to share with you about what max amounts mean, alot of the sources refer to above board doses that are much higher than the max. I was just trying to illustrate a point about how above max dose stimulants might be the standard but the standard is what the government sets based on research that is usually done on children and that takes nothing about the individual into consideration.


What I am saying is, there is a huge activism against doctors who are making exactly these kind of judgements, somehow these schedule II drugs are a very big deal (for all the deaths and what not they claim). And I have seen one leading Psychiatrist (85 years and still excitingly coming to his practice, such an angel like spirit, FORCED to retire from his profession) and get his neck chopped off, for exactly doing this. Without naming him, that was his point of view that the dosages "were medically indicated and appropriate under the circumstances". But with different organizations and TV stations creating documentaries on him and so many people after his skin, today he is no a longer a practicing physician.

My other "theory" is that some doctors who have a long term relationship with some patients are willing to go beyond the max and what can get them flagged is if they have tons of patients above max doses. I think above max doses is the exception rather than the rule. I take 75mg of adderall a day, I used to take 80mg. The maz is 60 but I have been seeing my doc for 17 years. I dont think she prescribes these amounts easily but I think our relationship has been long term enough where she is comfortable with it.

Arei
08-11-17, 10:39 PM
You really don't wanna go higher than 70 on Vyvanse or you'll feel like the ******* sahara desert. When I was still on it, I accidentally took two pills one day (of 60mg) and boyyyyyyy.

It really didn't affect me in a mental way but my throat was dry as hell. For some people that could increase their heart rate or cause other issues, it's not safe.

But IIRC Vyvanse is like a less potent Adderall. 70mg of Vyvanse is like 30 MG of Adderall XR. Some people DO take Adderall XR 30 twice a day. I've also seen people get vyvanse with a small booster dose of adderall (usually like 10mg) for the afternoon.

Like it was mentioned, your doctor probably doesn't want to get on the radar for overprescribing controlled substances. There's a system that tracks who, where, and how much controlled substances are prescribed to you (at least in many states in the US) and if a doctor is prescribing a lot of controls for a lot of people, in high quantities and dosage, they'll get noticed. They're making it very hard for the pill mills, but it does come at the risk of denying treatment to people that really need such medications (stimulants and opioids for example)

We actually have a regular patient who got fired from their doctor because the doctor didn't want to get in trouble for giving them the high doses of pain killers that they get. They have them for a legit reason, but they got referred to pain management because regular doctors do not want to get flagged for prescribing large amounts of controls like that. I hear it more with opioids than stimulants but the same thing applies to them. Doctors aren't going to give them out in massive quantities and multiple prescriptions for the same reason.

sarahsweets
08-12-17, 05:34 AM
You really don't wanna go higher than 70 on Vyvanse or you'll feel like the ******* sahara desert. When I was still on it, I accidentally took two pills one day (of 60mg) and boyyyyyyy.
I know someone prescribed over 100mg of vyvanse and they say its a lifesaver so your experience isnt necessarily the hard and fast truth.

But IIRC Vyvanse is like a less potent Adderall. 70mg of Vyvanse is like 30 MG of Adderall XR. Some people DO take Adderall XR 30 twice a day. I've also seen people get vyvanse with a small booster dose of adderall (usually like 10mg) for the afternoon.

I take adderall xr 4 times a day due to absorption issues and its been a life saver.

Like it was mentioned, your doctor probably doesn't want to get on the radar for overprescribing controlled substances. There's a system that tracks who, where, and how much controlled substances are prescribed to you (at least in many states in the US) and if a doctor is prescribing a lot of controls for a lot of people, in high quantities and dosage, they'll get noticed. They're making it very hard for the pill mills, but it does come at the risk of denying treatment to people that really need such medications (stimulants and opioids for example)

I think doctors that are in the business of prescribing controlled substances like stimulants or even opiates (pain management docs or psyches) have much more leeway when it comes to prescribing. It would be one thing if a GP had tons of patients on one or both of those types of drugs but when a patient goes to a specific doc that specializes in treatment for things that involve CII substances, I do not think they are automatically flagged or worry about getting in trouble just because a patient needs more than a recommended max. Its their specialty that counts. I think the powers that be weigh the type of doctor, what they treat and what kinds of patients they have before they automatically start nosing around a doc's prescribing practices.