Should I find a new doc?

[ajatho]

So I started 10 mg xr last wednesday. I felt absolutely nothing from it. Still spacey, no focus, nothing. So I started taking 2 a day. One at 630 am and the other at about 1030 am. For awhile in the afternoon I feel like it is working. I am focused and motivated and able to get stuff done. I feel very productive. But then about 330 in the afternoon I get a crash. That is when all my kids get home from school. I can't have this happening. I am exhausted. Way more than I would be if I wasn't taking the medication. I can barely focus.


I called my doc yesterday to let her know I upped my dose, and how I did it, and to tell her about the crash and how I have been feeling. She told me to continue on it twice a day, but to space it out a little more. Take the second dose at about 1230. When I told her about the crash and being exhausted, she said, " This medication is not for energy, it is for focus." Well I am not feeling focused, and the tiredness, I believe, is caused my coming off of the medication. It is just rediculous how tired I am. Then she told me that my body needs to get use to the medication. She wants me to keep taking them at this dose for a month. From what I have been reading about stims, is that they should be working right away if you have the right doseage, and that over time, you can build up a tollerance to the dose that you are on and they become less effective. So if I am on a low dose, like the 10 mg xr, wouldn't it just be less effective when I do start a higher doseage?


I just feel like she is not understanding what I am saying when I am telling her they are not working. She is a young doc. Only 2 years of experience. And she is family practice. I am thinking of maybe going to see a psychiatrist. I feel like they deal with ADHD more, and know more about the medications.

[dprice218]

Probably a good call. Many non-specialists are not comfortable prescribing high(er) dosages.

[sarahsweets]

10 mg is asmall dose. Children have had that dose. Maybe its time to think about xr? Sometimes ot works better than ir and sometimes people take an xr/ir combo.

[BR549]

Originally Posted by ajatho

So I started 10 mg xr last wednesday. I felt absolutely nothing from it. Still spacey, no focus, nothing. So I started taking 2 a day. One at 630 am and the other at about 1030 am. For awhile in the afternoon I feel like it is working. I am focused and motivated and able to get stuff done. I feel very productive. But then about 330 in the afternoon I get a crash. That is when all my kids get home from school. I can't have this happening. I am exhausted. Way more than I would be if I wasn't taking the medication. I can barely focus.

While 10mg XR is a low dose (equal to taking 5mg IR two times over 4-6 hour period), it's always best to start low and slow and move up slowly. That does give your body time to adjust and it does minimize any side effects. Are you eating before or after you take the med? I ask, because for some people, what and when they eat does affect how quickly the medication becomes effective.

If taking two XR 4 hours apart is working, it *could* be that you are overlapping your doses a bit. The first dose hasn't worn off before you take the second and you *might* be getting a bit more of the med for a while. I don't know if this is the case, just a thought.

The crash you are experiencing could diminish over time as you adjust to taking the medication. Another thing that helps with the crash is taking an IR booster. That also provides flexibility with dosing and allows you to overlap your doses so that your coverage is consistent and you don't experience the peaks and valleys as your medication becomes effective and wears off. I will say that there are more peaks and valleys with IR than with XR IMO. YMMV, though.

I called my doc yesterday to let her know I upped my dose, and how I did it, and to tell her about the crash and how I have been feeling. She told me to continue on it twice a day, but to space it out a little more. Take the second dose at about 1230.

Have you done this yet? If you have, does waiting until 12:30 cause you to crash? If you ARE getting 6 hours then your last dose will wear off about 6:30. Right when you are in the midst of homework and dinner Keep in mind that you probably don't know when the first dose has worn off. You could be getting 4 or 5 hours out of XR or you could be getting 6 or more hours. Sounds like she is basing it on 6 hours.

When I told her about the crash and being exhausted, she said, " This medication is not for energy, it is for focus." Well I am not feeling focused, and the tiredness, I believe, is caused my coming off of the medication. It is just rediculous how tired I am. Then she told me that my body needs to get use to the medication. She wants me to keep taking them at this dose for a month.

I started on 10mg XR as well. I was on it for a month. I had previously taken Concerta. I could see improvements on the 10mg. I also knew that it wasn't enough. My pdoc told me the same thing you doc told you. She wanted me to get used to the med and give my body some time to work through any side effects. The reason my pdoc titrated up so very slowly is because I am very sensitive to medications. This worked out well for me, but isn't necessarily the way all pdocs titrate up. The first week I had a bit of anxiety for about 20 minutes a day each time I took it.

Adderall XR DOES give many people energy. It's a stimulant.

One thing I did was I kept a journal of what I saw (and what my family noticed) while I was on the medication and while I was off of it. While I did see improvements, I didn't think 10mg was doing a whole lot. My husband reported several positive things he noticed that I did not. Ask your family to monitor you and let you know if they notice anything positive or negative.

From what I have been reading about stims, is that they should be working right away if you have the right doseage, and that over time, you can build up a tollerance to the dose that you are on and they become less effective. So if I am on a low dose, like the 10 mg xr, wouldn't it just be less effective when I do start a higher doseage?

Many people can immediately tell if a stimulant is or is not working for them. Getting the right dose can be a bit tricky. I thought I was doing great on 20mg XR. My pdoc told me she felt that I would see even more improvement on 25mg XR and upped my dose. She was right. The 25mg WAS just the right dose. It took me about 2-2.5 months to titrate up to the right dose. Perhaps that's slower than most people (due to my med sensitivity), but I am glad that I did it that way because I was able to gauge how the med was working and ensure that my side effects were minimal.

From Medscape, "Getting it right with Adult ADHD Patient", interview with an expert http://www.medscape.org/viewarticle/546188:

Medscape: How much time should the clinician persist with a trial of medication before switching to an alternative if the response seems suboptimal?

Dr. Steinhoff: Well, the most important thing is dosing — with too low a dose, one may get little effect and erroneously conclude that the medication is ineffective for that patient. In children, we often increase dose at 1-week intervals, but that's probably a minimum for adults because it's harder to observe symptom changes. At any rate, an adequate medication trial is not a matter of time per se as much as a process of careful observation of symptom change and dosing to optimal benefit and minimal side effects. Getting the process right is what matters.

If, at the optimal dose of the first medication, the patient has side effects without a dramatic benefit, one would switch medication class. For instance, starting with OROS methylphenidate, one would increase dose until side effects emerged, and if there was inadequate effect, switch to MAS XR. Adults are much better than children about reporting their experience and often are able to articulate subtle differences among different classes of medication and different doses.

As far as tolerance is concerned here's what Dr. Steinhoff says:

Medscape: What's the longest study you're aware of that followed adults receiving psychostimulant treatment, and does one ever see tolerance or loss of efficacy over time?

Dr. Steinhoff: The longest study that I'm aware of is the MAS XR 2-year study.[5] It was the FDA pivotal trial with an initial double-blind, placebo-controlled, forced-dose phase with 20, 40, and 60 mg. Patients continued in a 2-year open-label extension study with individualized dosing. Dose crept up slightly over the 2 years, which is not uncommon.

There's some debate as to whether some patients develop tolerance over time or whether expectations change, such that they grow accustomed to the experience on the medication and hope for a little bit more. It's not clear that it's really a biologic tolerance. If it is, I think it's in a small group and is a very small effect.

I just feel like she is not understanding what I am saying when I am telling her they are not working. She is a young doc. Only 2 years of experience. And she is family practice. I am thinking of maybe going to see a psychiatrist. I feel like they deal with ADHD more, and know more about the medications.

I DO think that seeing a pdoc who specializes in treating and diagnosing adult ADHD is your best bet. GP's, for the most part, don't always know how to diagnose or treat ADHD (and many other mental health disorders).

[ajatho]

Originally Posted by sarahsweets

10 mg is asmall dose. Children have had that dose. Maybe its time to think about xr? Sometimes ot works better than ir and sometimes people take an xr/ir combo.

Did you mean IR instead of XR? I am on the XR now.