Should I Make an Attempt to Switch ALL My Patients to Strattera?

As a Family Nurse Practitioner, I am responsible for diagnosing and treating ADD. I also have a 12 yo son on Concerta.

I am wondering if I should make an attempt to switch all my patients to Strattera for a number of reasons:

1. Not a triplicate medication
2. Not a stimulant which requires more monitoring for side effects such as growth retardation, over-stimulation, and insomnia
3. Fewer problems with case management
4. ? possible help with anxiety and/or depressive symptoms

and other issues.

I would like feed-back, ideas, etc. on this idea.

I am seeing about 3-5 ADD children and adults daily in my practice of about 25-35 patients each day.

I am a 46 year old male, and had a number of serious side effects on dosages going up and down on Strattera.

i have to wonder what young adolesent boys and girls will do with genital pain, perseveration in sexual contexts (not even orgasm being "satisfying") etc.

At that same age I'd have lied outright if asked, and have died first before reporting such problems accurately.

It made me so sleepy during the day that my productivity DROPPED when i was not led by the nose. I could not sleep at night. I was like a lithium ized zombie - day and night.

A professional in the field who has been a cheer leader for this drug, today admitted that though he likes his life better, his professional productivity is significantly down. He sees this as becoming more balanced. Perhaps. My productivity dropped to zero, when ever I was not situationally constrained.

I have seen myself and others report "inhibitions" being dropped entirely for driving rules that we otherwise always follow. This can produce sneeky problems and potential serious collisions.

I felt muscularly "drunk" on the drug. Others report this kind of thing. The circulars do not seem to.

I found myself in my psychiatrists office crying suddenly and convulsively, while on higher (80 mg therapeutic) dosages. On smaller dosages i found myself occupied with suicidal ideation in disturbing and concerning ways. In particular, i found it hard to "distract myself away" from such thoughts while on the drug... increase in focus is not all it might be cracked up to be.

Another professional (an attorney) was an adamant cheerleader for this drug, and after 3 or more months of use, abruptly discontinued it because he said "I have to get something done." People notice changes, but an objective 'behavior counting" survey is rarely really done...

This drug is useful to some on this board. I would try it on as many as you would like, but my pharmacist confirmed that my experience in discontinuing the drug for cause was not unusual though some of my details were unique... i would encourage you NOT to think it is the wonder drug it has been advertised to be.

I hope that seems a useful blend of opinions and tales for your use.

I would suggest you read all the notes people have posted about strattera, and watch as some of the most glowing reports turn to people with significant enough problems with the drug to scale back or discontinue.

You could anticipate some "adverse selection" but that is why my pharmacists comments were enlightening to me. Talk to pharmacists in your area.

Good luck.

Check out Sam Goldstein's recent comments on the efficacy of non-drug factors for children with ADHD.

www.samgoldstein.com

No because it doesn't work for everybody. And If I were your patient and taking a med (stim or not) I would be real hesitiant to switch if the med I am already taking were working for me. I would continue to let your patients know about all meds available and let them make an informed desicion.

Why would you switch somebody who has found something that works?

I have heard a lot mixed results from people who have taken Straterra.


Quite frankly as an AD/HD professional myself it worries be that somebody would place all of his clients into one catagory.

As for not having to monitor your clients as closely that doesn't sit with me well either. Straterra is still very new and there are still unknown side effects.

Agree with wheel about the genital pain. It causes prostate problems for me. However, it has been helpful as well. It seems to increase my organiztion. However, I had to cut back from 100mg to 40 mg to ease the prostate pain. I tried 25 mg but it did nothing for me at that level. 40-50 mg works some improvement. I also take it with Welbutrin. My true feelings are that general practitioners should not be handling the dosage and drug selection for ADD ADHD patients. The training for accurate diagnosis and drug efficacy is with psychiatrists, who are looking for subtle signs of the drug effects, and are trained in understanding brain chemistry and what symptoms might indicate which brain chemistry changes, shortages, etc.

Not all ADDers are alike, we are very different, with many diffferent varieties needing many different treatments. There is also a tendency towards co-morbidity, which further complicates accurate prescribing and diagnosing.

If you want to remain in the practice of treating ADDers in your office, rather than referring them to a psychiatrist, then I would recommend additional coursework in the pharmocology for ADD and its comorbid conditions. One of the problems ADDers have is misdiagnosis of subtle underlying or co-morbid conditions and poor prescriptions. Keep an eye out for depression, dysthymia, anxiety, sleep apnea, bipolar, and several more conditions, which may be overlooked due to the ADHD diagnosis.

Jon

I'm a health care professional as well....and likely would not attempt to put a population of patients/clients on a regimen that is known to have benefits for some....and none for others.....and results in serious side effects for still others...

For me it is important to treat all patients/clients as individuals....Each individual has the right to individual evaluation and treatment plan......instead of putting everyone in a box.....

Also as a woman with ADD - I was actually on Strattera for a month last spring and the side effects awful.....BUT my doctor had told me about the med, its possible side effects, and gave me the choice....etc. so I feel that even though the Strattera didn't work out -- he had handled it quite well.....

Strattera was hellish for me. I have responded well to stimulants in the past, but due to high blood pressure for the time being, I had to go with strattera. It worked but it caused horrid side effects, hot flashes so bad I needed multiple showers a day (when everyone else was cool) nausea (which faded over time), body aches... tons of stuff. I got off it after a month. I am on wellbutrin now, which the FDA is in the process of assesing for aproval of add/adhd symptoms, despite the fact that it has been used for that for a while, and I have had ZERO side effects. It's done about the same as strattera for me. Not great, but better. That's my fourty two cents.

Oh, and as far as growth retardation, I'm a female, 5'10, when I was 2 they did the bone test, they said I'd be 5'8-5'10 and I was on riddalin from 6-11 yrs... I am taller than both my parents. at the time if I could have stunted my growth more I would have!!!! Just a thought... Riddalin did good things for me until the dose got too high for my body/hormones and I got bad headaches and stomache aches... I went cold turkey from 11-24, and in that time accomplished a lot, despite the adhd. So strattera... it works for some people. I'm glad it wasn't available when I was a child. I don't think I would have chosen to seek any help as a (high functioning) adult if I had had to deal with the BS strattera caused me as a child.

Thanks for your responses.

Please be assured that I am all to familiar with the need for an individual and accurate diagnosis and excellent and consistant follow-up.

So many things mimic ADD and there are so many co-morbidities.

For example, bright children often appear to have ADHD.

As do abused and depressed children (I am trying to decide if a 5 year old male with a history of physical abuse and neglect who was exposed to substance abuse in utero and who has recently been replaced in his father and step mother's home (not the abusers) and who is in not stop movement from morning to midnight everyday is ADHD, depressed, PTSD, having problems with executive function, GAD, etc. etc. etc. ).

As do children experiencing homelessness and the dynamics that lead to homeless. etc. etc. etc.

It often boils down to a risk-benefit decision to treat as ADD.

I hope you know what I mean.

As to making ADD the relm of psychiatrists, that would be nice, but you must live in mental health heaven.

We have two competent and board certified child and adolescent psychiatrists for a county of 240,000 people.

Neither will work with Medicaid patients!!!

And, unfortunately, I must add that we have had some psychiatrists who do not believe the feedback they receive from their patients about side-effects or toward effects and, in fact, tell them to be quiet because they are the "doctor" and they know what is best.

Watching for subtle medication side effects and toward effects is what all good practitioners should do well. I think the key is adequate observational input, a good history, and frequent follow-up visits.

As to pharmocology - competency in pharmocology is a function of learning, intelligence, experience, mentoring, and observation. This is also what a good practitioner should be doing.

Thanks again for your input.

Tom

Sounds great Tom. Thanks for clarifying. Appreciate the position you are in, and it sounds like you are a very senisitive and observative practitioner, and that counts more than most other factors.

Jon

I was planning for a while to go down to mexico and try to get some strattera from a pharmacy as I'm undiagnosed (hopefully that will change very soon) and mentioned it to a girl I know who works in the pharma industry.

She asked why strattera in particular, and I said because it has the least side effects, (this was about 6 months ago when strattera was much newer) and she said actually it has the MOST side effects of all the ADD drugs, it's just that the side effects were different than the other drugs, and that Lilly didn't do enough testing before releasing it.

Well that's unusual for a pharma co, huh? <--sarcasm