Problems with switching med or is it mono relapse?

[MafaldaMay]

Hi,

Last fall, after years of wondering what is wrong with me, I finally got diagnosed with ADHD-combined type. My first appointment with a psychiatrist was at the beginning of this February, which is when I started medication.

She first prescribed me Ritalin 15mg and asked me to pay attention to how long I felt the effect for, so that I could learn when it was best for me to take another pill, as not everybody metabolizes it the same way. She then asked me to see her again in two weeks. She also told me that a low dose of antidepressant (Wellbutrin) would be a good idea later, once I'm well adjusted to the stimulant med, to help with my huge PMS mood problems.

I started Ritalin, noticed the rebound at about 3-hour intervals. It made me a bit more proactive, but the change was not spectacular.

Two weeks later, she gave me two trial prescriptions: one for a free week of Concerta and one for 14 pills of Adderall XR (15mg), which she expected should last about a week. She also gave me a real prescription for Concerta for the two weeks following the trial and preceding my next appointment with her.

I was to start with Concerta, at 36 mg, see what it does, then try 54 mg and see what it does, but not exceed that. At 36 mg, I didn't feel any different than my usual me, so I tried 54 mg, which made me more hyper, more physical, with less difficulty transitioning between tasks, but certainly not more able to concentrate intellectually. I also felt very tense, but I was right in the middle of my montlhy 10-day long PMS, so I couldn't really tell if I was tense because of the PMS, the Concerta (or both).

My switch to Adderall XR was to happen right when I was out of Concerta. Again, the instructions were that I try 15mg, and increase to up to 60mg. As I walked out of the drugstore, I realised that I had to increase dosage every day, as I only had 14 pills in that bottle.

To make things more confusing, my first day on Adderall XR coincided with the first day of my period, which is a day where I wouldn't normally set a foot out of bed if I could afford it. I'm usually extremely tired on that day but I'm back to normal after that. By back to normal, I mean that I start very slowly in the morning and become more and more functional as the afternoon and evening go by, and at my best late in the evening (when I have to quit my day and go to bed... bummer!).

So, on my first day on Adderall XR (15 mg), I experienced a major crash. It just felt like an extreme rebound from stimulant med, but a rebound that lasted all day (although I got an additional big rebound at about 4 p.m., as the medication started peaking down). I was not only extremely tired and weak, but lethargic, not interested in anything and quite depressed. I had a hard time finishing a sentence and finding my words. I felt trapped in my own head. The only thing I could do was waiting for the day to end, hoping that the next day would be better.

On the second and third day, I took 30 mg. No improvement, but I noticed that transitioning was even more difficult than before, so much so that I kept telling myself I should go to bed on those two nights and I simply kept vegging out on my couch, in front of my laptop, doing nothing really, until about 1 am. I was so tired that it doesn't make any sense that I didn't go to bed earlier, especially considering I have to get at 6:30 in the morning.

Anyway, on the fourth day, I decided to try 60 mg. Although I was very, very tired physically, I have to say that I became quite brainy and insightful at that dose and able to focus admirably on intellectual work, but too tired to do anything physical. I would also be very talkative, but not tense. So I took 60 mg again on the 5th day (the last day before I ran out of Adderall and therefore had to switch back to Concerta), and the same thing happened, but I just seemed to be even more physically tired, although just as brainy and transitioning wasn't easier either. For example, as it was credit card renewal time, I spent the whole day calculating in a very detailed way the value of our two travel reward credit cards and if the annual fee was worth it; I analysed different scenarios if we were to only use one card versus the other, etc. I was definitely hyperfocusing and I even wondered for a few minutes if I was not an Aspie, remembering past obsessions on particular subjects, for which I eventually became a real encyclopedia (the Aspie trait) and then lost interest (the ADHD trait).


On that last day on Adderall, I read on this forum that while tittering stimulant med, dosage should only be increased every 3 to 4 days, something that was not mentioned by my psychiatrist. Besides, there is no way I could have performed a successful trial/tittering of Adderal XR with only 14 x 15mg pills...

Nevertheless, as I was to go back to Concerta until my next appointment with my psychiatrist, I decided to start again at 36 mg and wait four days before increasing to 54 mg, should I feel the need to do so.

Again, on my first day of Concerta, major crash, like a day-long rebound (although I do not have an extra rebound at the end of the day like with Adderall XR). I can even feel physical pain in the front of my brain, not exactly a headache, but just the physical sensation of being tired in that part of my brain. It's my third day now, still at 36 mg, and it's just as bad. I take naps during the day and I'm really trying to get good nights of sleep. As a consequence, I seem to be a little less tired today on a physical level, but my brain is still quite foggy and tired and the whole situation is highly uncomfortable.

Somebody pointed out to me that I shouldn’t forget I had mono (EBV) last year, from April to November, and that perhaps I'm simply experiencing some kind of relapse that coincides with the switch in medication. Do mono relapses really exist? Or is what I'm currently going through simply a normal consequence of switching/tittering stimulant med in the fashion I've been doing it? Maybe Adderall XR is not for me and can explain that whole crashing situation? On my next appointment (in 10 days), should I talk to my psychiatrist about a possible Dexetrine/Provigil combo (considering that although I've gained more energy and focusing abilities with stimulants, I've remained quite inattentive (I lost my cell phone again, driving is not easier than before, etc.) and became even more tired than before med)?

I would appreciate your advice. Thanks!

[lars]

Originally Posted by MafaldaMay

Do mono relapses really exist? Or is what I'm currently going through simply a normal consequence of switching/tittering stimulant med in the fashion I've been doing it? Maybe Adderall XR is not for me and can explain that whole crashing situation? On my next appointment (in 10 days), should I talk to my psychiatrist about a possible Dexetrine/Provigil combo (considering that although I've gained more energy and focusing abilities with stimulants, I've remained quite inattentive (I lost my cell phone again, driving is not easier than before, etc.) and became even more tired than before med)?

Hi MafaldaMay, and welcome to the forums. Great post.

Firstly, to the best of my knowledge, I don't think any kind of clinical relapse occurs with Mono.

Concerning whether or not what you are experiencing is a normal consequence of switching/titrating a stimulant, I would have to say that from my experience most people do not normally get to try so many different stimulants in such short a time. I'm not saying that there's anything wrong with any Dr. who wants to experiment with different stimulants as quickly as your Dr is, I'm just saying that it's not normal for most Drs to go that quick.

I started taking stimulants for my ADD in early 1992. I started with Ritalin, and after a few years of different dosages, and different generic versions, my Dr and I tried Adderall, then Dexedrine, Desoxyn, Focalin. The shortest I was on anyone of these drugs was Adderall, and that was for less than 8 to 10 weeks as I recall. We each respond very differently to these drugs, so most people will likely not go through the available options as slow as I did, but I always looked at this as more of a marathon than a race I guess.

Concerning the Dexedrine combo you were considering asking your Dr about on your next visit, I would suggest that you discuss all your options that are available. For instance, Adderall was the only stimulant that caused me to experience pronounced sedation. Dexedrine, which can be found in Adderall, stimulates me. I am not sure why the Adderall works exactly like it does for me, but my point is that sometimes just the slightest change in the way a chemical is formulated can sometimes offer radically different effects. A good example of this for me would be Adderall vs Dexedrine, and also Ritalin vs Focalin. Ritalin was always quite stimulating for me, but it also had a significant amount of negative side effects in the peripheral nervous system which caused me to stop it. Focalin on the other hand offers me all the best stimulating properties of Ritalin without any of the negative PNS side effects of the Ritalin, for me that is.

As far as your driving not being as easy as before, and losing your cell phone are concerned, I would suggest that you talk to your Dr about that. Maybe a different dose would be in order, or maybe another drug would be in order, only your Dr can help you find those answers. It's really important to tell your Dr as much information as possible about your experience. I hope that you are as vivid in describing your experience to your Dr as you are with us. Great post.