| Key Points to Recognizing the Underdose, it Just Isn't | | | | slowly up - about every 2 weeks when close to |
| working | | | | precision. |
| Remember from previous articles here the importance | | | | - Low Start Requires Bottom Awareness: The axiom |
| of dialing in ADD/ADHD stimulant medications precisely. | | | | for stimulant meds: start low, and go slow, watching |
| You can't have them precisely adjusted if you don't | | | | for the effect to show. When it is working the focus is |
| have clear targets, clear symptoms that your are | | | | better, the impulsivity is down, the worries are |
| addressing. The current diagnostic coding [DSM-IV] | | | | diminished and the patient can get going with projects - |
| makes symptom recognition confusing and limits | | | | overcoming avoidance and procrastination. |
| treatment objectives to only descriptive diagnosis, | | | | - AM and PM Are Your First Markers: When it starts |
| superficial assessment, not functional. See my other | | | | to work: all meds should start about 30-45 min after |
| articles and my website below for more discussion | | | | they are taken in the AM |
| and podcasts on precise functional diagnosis and | | | | - Start Always with Breakfast - Then Next, Give the |
| better targets. Without clear targets the team has no | | | | Med: This simple step will prevent overdosing at the |
| clear treatment objectives to see if the meds are | | | | outset and is often forgotten before the first med |
| working. | | | | check - so the team should always remind the patient |
| First Consider the Therapeutic Window | | | | about a good protein breakfast. |
| The *Therapeutic Window* is simply what it says; the | | | | - The AM Bottom of That Therapeutic Window - it |
| window, is the space, the place in time and symptom | | | | just doesn't work in the morning, or will work for just |
| correction that the ADD/ADHD stimulant medication | | | | awhile - 1-2 hr - and be gone, either with Immediate |
| clinically works best, - the dosage, the effectiveness of | | | | Release Tablets, or with Extended Release Capsules |
| that specific product with that specific person. All | | | | - even with Daytrana. |
| products have characteristic features, they metabolize, | | | | - The PM Bottom of That Therapeutic Window - You |
| they burn, at different rates of speed in different | | | | simply cannot tell when it wears off. This difficulty is |
| people. The way we evaluate that window is by | | | | often seen with Vyvanse because of the slow |
| recognizing the top, the bottom and the sides. We | | | | metabolically related release mechanism - it's as |
| work to make sure all the bases are covered | | | | effective as other amphetamine based products and |
| correctly and the medication is working at it's | | | | as forgiving as MPH [Ritalin] based products. |
| maximum level of expected performance. | | | | - The Therapeutic Window Dosage should last the |
| - Underdose the Start: I always recommend carefully, | | | | entire expected Duration of Effectiveness [DOE] for |
| slowly starting the ADD/ADHD medication at the | | | | that specific stimulant medication. More details in other |
| outset - lower than the expected endpoint. Most of the | | | | articles here. |
| new drugs have different rates of metabolism, and it is | | | | - Adjust the AM Dosage upward until the specific |
| quite easy to overdose the patient. This happened with | | | | targeted AM and PM range of effectiveness [DOE] is |
| Adderall in the beginning, it happened with Adderall XR, | | | | achieved for the extended release stimulants. |
| and it happens with Concerta and Vyvanse even | | | | If you follow these simple guideposts you can quickly |
| today. So start much lower than expected, and move | | | | get past that initial question: "Is it working at all? |