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ADD/ADHD Medications: News and More Tips for Vyvanse

ADD/ADHD Medications: Frequently Asked Questions on Vyvanse
A recent ADD/ADHD treatment question came up on another post comment, and I thought to share it with all of you.
So many are wondering how to get Vyvanse correctly titrated – and good news: Shire has the new doses out – just last week. [I have updated the pages at this Squidoo lens on Vyvanse for additional easy reference]

Doses now available 20, 30, 40, 50, 60, 70 mg - may have to wait at the pharmacist for a few days, but they can be ordered. No more messing around with all of the water titration strategies.

This recent question from a reader:
“My 14 yr old son has been on
Vyvanse 70 mg. of about 3 weeks. He was on Adderall xr for a couple of
years and it didn’t seem to be working as well as it used to, so the
dr. switched him to this vyvanse and he has been more irritable and his
sensory issues seem to be more pronounced. I upped the Vyvanse to 100
mg. for a couple of days and he seemed to do better. I called the
doctor and she said to stay at 70 mg. for a little longer, that there
are no studies that have been done over 70 mg., I called Shire and
asked about 100 mg., they also said no studies over 70mg.


Do you think it would effect him in a neg. way, by taking 100 mg.?
There was such a difference in him those couple of days that I had him
on 100 mg., but if it’s not safe, there’s no way. He’s 6 feet and
weighs 128 lbs.”

My Answer:
The description of “isn’t working” sounds like it may be the *bottom of the Therapeutic Window*

For the important answer to the question of *Duration of Effectiveness – DOE* needed to get the dose dialed in most precisely – see this post on DOE

As noted in several posts: weight, age, gender, level of hyperactivity… none of these characteristics will help with the dosage individuation necessary to get the right dose for the specific rate of metabolism with any person. No groups have specific characteristics – so his size and age are truly unimportant. Each person, each dose pattern must be customized.

Important details follow:

What is important:
1. Even though no “studies have been reported” we have experienced in
our office, and heard many reports from colleagues that 100 mg Vyvanse
is not “too high” a dose – if it is titrated correctly, as indicated in
these previous posts. I have several folks on 140 mg, all are adults,
but they are the exception rather than the rule, and only arrived at
that dosage after much care with titration.

2. Your doctor is the final common pathway… I can only report what
is working, and add this common-sense point: 100mg Vyvanse = about 40mg
Adderall XR – 40 mg of XR is well within the standard of practice.

3. Vyvanse tends to work consistently better than Adderall, but
there are some exceptions wherein individuals [for reasons I have not
yet heard reported or understood myself] actually need a bit more
Vyvanse than the expected dose based upon the previous rate of
metabolism with Adderall.

4. Always remember the theme here at CorePsychBlog: ADD is almost
always more than *just ADD.*
Metabolic differences occur for many different medical, nutritional and biological reasons – so if your
medical team is having a problem always look for other factors rather
than simply chalking up problems to the medication itself.

5. With other concurrent *metabolic problems*
the therapeutic window narrows, and until the associated conditions, from gluten sensitivity,
to brain injury, to heavy metal intoxication, will create a situation
wherein “nothing seems to work right.” The only solution: complete
analysis of comorbid conditions.

These new dosage sizes significantly improve the necessary titration strategy, and will make it even easier to “start low and go slow.”
The low and slow idea is timeless in application, specific in time measurement. ;-)
cp

31 Comments
  1. I’ve just started to take Focalin and I feel like my penis is shrinking ? Am I hallucinating ? I also am very still I could barely talk or move .

    • Anon,
      Never heard of a penis shrinkage, but the sympathomimetic action may contribute to some vasoconstriction. If you can’t talk or move the dose, very likely, is too much – even if it is low. Talk to your doc and consider metabolic challenges.
      cp

  2. Are you on Shire’s payroll? Every posting about ED or sexual dysfunction/ penile shrinkage is met with a “comorbid metabolic challenge” response. That is BS. Please call a spade…a spade. No problems before Vyvanse. No problems after Vyvanse. No other problems. Perhaps it’s the Vyvanse that creates the so-called “metabolic challenges.”

    • Not,
      Certainly Vyvanse, Adderall and all the stimulant medications can directly cause sexual problems as side effects – not in question. What I attempt to communicate in these missives is the fact that many of these sexual problems do arise from associated, unrecognized and untreated metabolic problems. Never do I say “all” or “every” – rather I do hope readers will explore additional metabolic possibilities rather than stop useful meds that could be corrected if the comorbid condition is addressed.

      And, no, I’m not on Shire’s payroll. They wouldn’t pay me to make these statements – it would prove counterproductive for them to pay for anecdotal reportage.
      cp

  3. Doctor:

    I have had problems with erectile disfunction on strattera and vyvanse as well. Straterra worked wonders for 5 months, more than wonders…. but the sexual side effects were to profound. I am taking vyvanse with moderate results( which is good enough) but i think i might have problems keeping a firm erection, bottom line I am not having the best erections i have had before. I am 24, very atlethic and I have had hormonal tests before, even had high testosterone. I am very confused and I have seen a doctor in the US and one in Mexico because i Live in Mexico City. I dont know if i should do more test for hormonal imbalances or in fact these medicines are interfering with my sexual function. Do you do charged( to the credit card) phone consultations?
    Thank you

    • David,
      Anyone at your age w the reactions to meds you have also has, most of the time, comorbid metabolic challenges. Your neurotransmitters are off even though your hormones measure out well, and those imbalances are quite likely challenging your sexual function. Yes, more testing would be helpful including TMA [Tissue Mineral Analysis] mentioned with links for more info in this Trace Element posting – and see the links at the bottom as well.

      Yes, we regularly do consults long distance – download options on the Services page here and set up with our Patient Care Coordinator. – I look forward to talking,
      cp

  4. Dr. Parker-
    I began taking Vyvanse 50 mg last fall, and then bumped up to 70mg as told it would last longer. Although it was fine a 50mg. I also have been on Testosterone 10% cream twice a day and have a very stressful job as a sales manager. So I have been on Vyvanse 5 months now, and a particular stressful morning after a 3 mile walk in the cold morning, got back an had a temporary case of right hands getting cold where I had white fingers show up. It was a new batch of Vyvanse pills so I thought that it must have been a bad pill. I went to the doctors office & it was over in less than an hour but seemed to me to settle down when I settled down in the office. The Dr. said that he did not see this in Vyvanse patients and had me do some blood tests. The very next morning they called me to tell me that I showed positive with Lupus or Polymysositis. Ofcourse when I looked up Lupus knew that had to be wrong as I had no other symptoms such as the rash, etc, + my wife used to get a false positive when pregnant. When I read the Poly ana I flipped out, as I am 52, but in very good shape and run 3 mile several times a week at 9 min pace and lift weights – curling 45 lbs, 3 sets of eight among other routines. I do get cold hand now, but read time and time again how a lot of people have that. I have no pain, but do have dehydration which cause my joints to pop, and see that as well. Thinking of getting off both vyvanse and testosterone and get another blood test, but also read how you can spend hundreds and hundreds as they take muscle biopsy, and it could remiss, so you don’t really know. Any help on this? Thanks.

    • Dr Charles Parker

      Chris,
      Short answer: Never have seen that distal finger development, – but we live in VA, and even tho I consult out of town in the North Country, never have seen that phenomenon. From a common sense angle, however: Stimulants are sympathomimetic, they could constrict blood vessels thus the warning, and often seen rise in blood pressure. The fact that you had some autoimmune markers pop up does figure in with metabolic background noise, and possible quiescent immunity, in spite of your obvious fitness. I can’t tell you the numbers of metabolically imbalanced folks I’ve personally seen who look outstanding, function well, but have issues like chronic IgG problems and trace element imbalances with downstream adrenal and thyroid modifications and some mild, chronic, malabsorption.

      Recommendation:
      1. Qualitative IgG by someone who knows and can read it – often not a traditional allergist who is focused on life and death targets, not brain function.
      2. If inconclusive: look at trace element testing, again with someone who can read it.
      3. This is the ADHD, Brain and Gut video tutorial: http://bit.ly/mindgut

      Final point. Dial that Vyvanse in even more precisely. I never jump from 50 to 70 as a rule – get your dose right through careful DOE [Duration] observation: See this Dosing Video Playlist for details: http://bit.ly/dosevids

      Hope this helps,
      cp

      • Chris, what a coincidence that you posted this/I randomly read it, etc. I went to my Rheumatologist this week because once again my ANA test came up positive. It’s been hinted at for years that there may be a form of Lupus that hasn’t reared it’s full, ugly head yet but could explain 10 years of issues for me. Luckily, my appointment went well and there’s nothing to write home about. However, my discolored hands/fingers were alarming to a previous dr and something we addressed in this appointment. As soon as she heard I was taking Vyvanse, she let out a breath of ah ha–she said this is a side effect of it and could very well explain it. Hope this helps. Just as the dr above stated, unfortunately, fitness doesn’t determine an autoimmune condition, but perhaps, as you aren’t showing any other signs of having one, it might be the vyvvanse that is contributing to your cold hands and white finger tips. Best of luck

  5. Anon,
    I always look at the DHEA in association with adrenal function, as testosterone lives downstream from DHEA, and DHEA is frequently altered by immunity and issues.

    Another inquiry: consider a good review of heavy metals and trace elements. We can get this done with a colleague here even long distance – a specialist in heavy metals and minerals including zinc balance. These specifics can contribute to hormone imbalance as well.

    For much more invest in this excellent book on the Testosterone Syndrome – more than simple testosterone supplementation: http://bit.ly/testsoln
    cp

  6. Simply stated: possible, of course, but categorically, every time, no, just not happening. There is no specific point, but rather a general point that varies with multiple variables including testosterone levels, adrenal function, immune dysregulation, etc,
    cp

  7. Dr. Parker , Just a couple quick questions Since taking Vyvanse I have had issues with maintaining a full erection and when I can obtain one it doesnt stay around fully for long. My doctor has supplied me with samples of Cialis 5 mg for daily use . Clialis at this dosage works quite well and other samples of Levitra work well also but with my screwy schedule as a police officer, and my wifes schedule it becomes very hard if not impossible to try and “schedule” sexual activity. Can you provide me with any advice to give my Physician to submit to my insurance company to possibly cover the Cialis? Prior to this I was on Focalin which worked quite well but did not seem to stay in my system long enough for my needs. Can you help me at 39 years old I dont expect my “friend” to be as good as in the past but when it becomes difficult if not possible at all to achieve a full erection it only adds frustration to my disability which I have finally been able to get under control.

    I look forward to your reply

    Jason

    • Jason,
      When anyone begins to have downstream sexual side effects from psych meds – SSRIs or stimulants – I always dig deeper to evaluate underlying hormone dysregulation which preceded the med addition. Psych meds do effect the levels, but those with problems are already metabolically off – in your case could be DHEA a testosterone precursor, could be a number of things. Adrenal review and all hormones would be your best bet, and would jump on it rather than hope it changes.

      Honestly, trying to help with insurance companies – I know I can’t help you. – Especially since I don’t know which one is the culprit. Many live a life of their own, beyond science and reason. Testing should help turn the tide.
      cp

      • Dr. Parker, I’m having similar sexual side effects to the two commenters on this article.  With some Google searching I found that there are also many other people posting on other sites about similar issues as well.

        I’m a male in my early 30′s.  I’ve been on ADHD meds for almost 3 months.  I had no sexual problems prior to starting the ADHD meds.  My Psychiatrist tried me on various dosages of both Adderall and Vyvanse before finally settling on 40mg Vyvanse in the morning and an optional 5mg IR dextroamphetamine tablet as needed in the afternoon to extend the effects.  This combination is working very well to treat my symptoms with no bothersome side effects other than the sexual issues.

        I had none of these issues prior to starting the medication.  When the Vyvanse (or Dextroamphetamine) is active in my system my penis in its flacid state seems to “shrink” to an unnaturally small size.  When stimulated it goes back to a more normal size and I’m sometimes able to get and maintain a semi-flaccid erection long enough to have sex, sometimes not.  I’m never able to get as solid of an erection on the medication as it is off of the meds.  When the meds are out of my system (around 3 hours after my ADD symptoms return) my penis goes back to normal size and I’m able to get and maintain erections normally.

        While I was taking Addreall I didn’t experience any of the “shrinkage.”  Everything looked normal sized when flaccid.  I did experience some of the E.D. issues, but much less than with the Vyvanse/dextroamphetamine.  Unfortunately Addreall gave me other side effects such as sweating, rapid heart beat, and a general nervous, paranoid, jittery feeling.  I get none of these with the Vyvanse/dextroamphetamine.

        My questions are:

        1.  Any idea why the sexual side effects are so much more severe for me on the Vyvanse as opposed to the Adderall?  Does Vyvanse generally cause more vasoconstriction than Addreall or is there possibly some other cause more specific to me causing the difference?

        2.  Any ideas on how to combat the problem?  I’ve seen mentions online of using ED drugs to counteract this effect but I feel like I’m young and healthy enough that I shouldn’t need them.  I’ve also seen suggestions for many different supplements ranging from arginine to increase blood flow to magnesium and zinc to increase testosterone precursors.  Do you have any comments on the effectiveness of any of these or any other suggestions that might help?

        Vyvanse (or IR dextroamphetamine) seem to be the only ADD drugs that work well for me without side effects (aside from the sexual issues).  My life has changed greatly for the better since starting the meds, but the sexual problems are very frustrating and embarrassing. 

        Thanks for any help or insight you can provide.

        • Anon,
          Interesting questions, and the same puzzling side effects appear with folks in my office as well. My take: Two points ->
          1. that the neurotransmitter differences make a difference and for some reason the NE in the Adderall [norepinephrine] contributes to the ability to have an erection and
          2. almost everyone of the guys with these problems [only a few women experience the sexual side effects on the AMP products] has an associated metabolic challenge, often with some low grade adrenal compromise that likely contributes.

          If you haven’t tried Viagra and don’t wish to I have a product called Libido Stim that seems to make a difference for many, without having to modify the dosage to have sex. It’s at the CoreBrain Store up on the Nav Bar, under the Designs for Health “aisle.”

          Finally, if it does get worse jump on metabolic testing rather than just hoping for the best.
          cp

          • Dr. Parker,

            Thanks very much for the reply.I’ll certainly look into the metabolic testing.  What specific tests should I ask my doctor for?  Would I have better luck going to my general practitioner, my psychiatrist (who prescribes my ADD meds) or directly to a specialist?Also, there’s a new twist to my story:  A few days ago I started taking an OTC supplement called “ZMA.”  The supplement in the dosage I’m taking provides 20mg Zinc, 300mg Magnesium, and 7mg vitamin B6.  I take it once daily just before going to bed.  I started taking it because I had read that it helps with sleep and that it slows down the development of amphetamine tolerance.  I’ve seen no conclusive proof of this, just anecdotal evidence online, but I figured it couldn’t hurt.  Since starting the ZMA supplement my sexual problems have gotten much better!  The change was almost immediate the next day after I started taking it.  I’m still not 100% back to normal, but functioning much better than I was before.  The improvement has lasted for several straight days now and I’m hoping it will continue.So, it seems that adding supplemental Zinc, Magnesium, and vitamin B6 to my diet greatly improved my sexual side effects while still taking the same amounts of ADD medication.  Does this help to further narrow down a possible root cause of the problem?Thanks again!

          • Anon,
            If you don’t find anyone locally, we do all that testing long distance. – Can’t render direct medical care, meds etc, but can make recommendations from the testing. The lab we find considerable applications from: http://www.traceelements.com/EducationalResources/HTMA.aspx There would likely be some more answers there, and hormone testing would like be useful as described in detail elsewhere here… see the htttp://www.corepsychblog.com/neuroscience page

            Best of luck!
            cp

  8. My 13 year old daughter was on Concerta for 2 years until the 54mg totally stopped working a few weeks ago. Her doctor did not want to go up on the Concerta any more and switched her to Vyvanse 40mg. She has been on it for 10 days and seems irritable and hyper with very little change in her concentration or behavior. Is it too soon to say that it is not working? Does she need a higher dosage?

    • Diane,
      Can’t tell from what you report here. Most likely is too little if there is absolutely no effect, and too much if the ADHD appeared to be dramatically aggravated with emotional overtones not previously on the table.
      cp

  9. I am a 24 yr old male college student. I was “diagnosed” with ADHD about 8 months ago and it has changed my life. My doctor has me on 70mg of vyvanse and I absolutely love it! I started out taking Adderall and didnt feel much of anything but Vyvanse works tremendously well for me. Which brings me to my issue. Since being on Vyvanse I have developed an alarmingly bad case of erectile dysfunction. I do not want to switch meds because after two different dosages of adderall vyvanse has been the only thing to work and I need it. I work 40hrs/wk and am a full-time engineering major, I simply cant aford to risk switching to an ineffective med. What can I do to help the issue without giving up vyvanse? I have read a couple blogs suggesting Viagra, Cialis, etc… Would this be the best or at least a good solution? HELP!!!

    • Sean,
      Short term yes, those two meds could be helpful, but if you were in my office I would work you up for significant hormonal issues. You are too young to have erectile problems, and if they occur with stimulants I have almost always seen those symptoms secondary to other metabolic and hormonal issues which are quite correctable.
      cp

      • Thank you for the reply. I did, about a year ago, have labs done to check my hormone levels. The labs done by my primary care physician did show some low test levels , which I was then referred to an endocrinologist who was very rude and unhelpful. The fact is, A few years back I did take some legal over the counter supplements, which I was told were nothing too serious but it turns out they were a full blown pro-hormone and basically one hydrogen molecule away from the actual steroid. With my misconception of what I was taking, I did not cycle on/off the way one should when taking a supplement like that and its my guess that this would most likely be where the issue stems from. When I mentioned this to the endocrinologist he completely shut me out and basically refused to help me, aside from his predetermined judgment he already made because of my physical appearance. The main reason I did look into the matter was because I began noticing tenderness in my nipples, which lead me to do some research on the product, which I should have done first. I understand the precautions that need to be made when considering prescribing testosterone and the risk for abuse but this Dr. did not evn give me a chance. He just assumed that I had a hidden agenda for seeking treatment and that was pretty much it. I have o intentions of abusing a prescription if I ever got one. My main concern is my health and I just want to fix the problems that developed from my one misinformed bad decision. I do not believe in taking steroids and I honestly never had the need. I was only looking for something to help with recovery NATURALLY. So I know thats a lot of info but my question to you know is what kind of test should I have done? What should I be looking for or asking for when talking with my DR.? Thanks again.

        • Sean,
          I can tell you an easy way to get the testing, and, in fact, we can send you a kit from our office for phone review. That endocrinologist is an exception, as many are interested in estrogen dominance and are happy to pursue the details. If you would like us to send you a test kit [no cost to send it, and many insurances pay for it], just send a note to Sarah our Patient Care Coordinator on the Services link on the nav bar.
          cp

  10. hi,
    my doctor just recently put me on 70mg vyvanse and the first day i took it i could not sit still. i was very hyper ,very energetic. i felt as if i could run 50 miles ad still have energy left.but now as the days go on and i take it every morning when i wake up to got to school oh by the way im 15 and a sophomore in high school. ive been getting very irritable and emotional , and i never eat i don’t have an appetite at all. should i be worried?

    • Zana,
      Your well intentioned doc just started too high. Check with them to start all over at a much lower dose, and work up. Until you speak to your doc I would simply hold it, no harm in the long run, and that reaction does not preclude a restart at a lower dose.

      I am so conservative I appear liberal. If you have any comorbid metabolic issues I always start very low on new patients with any med. Search here using Vyvanse for the water titration strategies as it may help your doc with their mission to care for you.
      cp

  11. Hi Dr Parker I am (49 yrs old) currently on 30MGs/day of Vyvanse but it is making me very anxious to the point where I am havng intrusive thoughths what should I do ? I am also a very anxious person bu t have never been treated for anxiety. I have been on stimulants since 1998.

    My Dr told me to break the capsule and take a lower than 30 mgs dose; even that is not getting rid of my anxiety.

    Please help !!!!!

    • Start with your docs recommendation, sometimes with slow burners the lower dose can completely do the job… I have a 45 yo on 7.5 mg [1/4 of 30] – he has clear metabolic issues, and has done well more than a year on this low dose with a 12 hr DOE – many need a metabolically accurate custom titration.

      Some Caucasians [7-10%] and African Americans [3%] genetically cannot take AMP products, and they can switch to MPH products easily if lower doses don’t satisfactorily achieve correct metabolic objectives [Vyvanse= 12-13 hr DOE].
      cp

  12. Benjamin -
    Many thanks for your personal insight and experience… Stimulants used correctly can significantly change the way we think and perform our *executive* functions.

    I’m sure others will appreciate your remarks as I do. So often the good news is diminished while the challenges become the hot topic. Many thanks,
    cp

  13. My name is Benjamin Mardell and i would like to show you my personal experience with Adderall.

    I have taken for 1 years. I am 46 years old. This drug completely changed ny life. I no longer feel constantly irritable like I’m about to explode. I can focus and complete tasks, I’m nicer to people. I just had my performance review at work and my boss said my work had been exceptional and wants to promote me to a senior policy advisor positiion. My compulsivity has also been reduced- I don’t overeat and rarely drink anymore. I also sleep better and no longer need a sleep aid.

    Side Effects :
    Brief euphoria when I first started taking it and hypersexuality. Both sx have since moderated.

    I hope this information will be useful to others,
    Benjamin Mardell

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