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Intuniv for ADHD: Avoid Drug Interactions

Intuniv Driving And Watching: Possible Interactions Detailed

Wrong Med Turns

Regular CorePsych Blog readers already know that we don’t like wrong medication turns. Intuniv dosing is important. Intuniv safety has been carefully explored. Maps do help, but watching where we are going is even better. Consider this recent comment from a mother worried about Intuniv and Prozac:

Interaction Question:
Mom asks: It is such a relief to find some information from other parents and doctors who are trying Intuniv as it is such a new medication. My daughter has been taking it for about 6 weeks now. We went very slow on dosing just as you have recommended, and it is working wonders. I will say that she has become more irritable and extremely sleepy. I believe that as she adjusts to the dosage that the irritability goes away. However, we have just increased her dosage to 3mg, so she is still adjusting to the extreme sleepiness.

The doctor we are seeing put her on Prozac for anxiety, but have I read correctly that you would not recommend Prozac with Intuniv? She has been experiencing very strange sleeping patterns. She is either staying awake many hours, going to sleep right away and then waking hours early, or so sleepy she falls asleep around 6PM and sleeps through the night. Considering her sleepiness, the doctor recommended giving her the Intuniv at night and the Prozac in the morning, but this has not been helping. Should we be giving her the Intuniv in the morning despite her sleepiness? Also, would you recommend something other than Prozac for her anxiety.

My Reply:
Thanks for your kind remarks, and, yes, you read it right: Prozac and Paxil [and Luvox] should not be given with Intuniv, they inhibit appropriate metabolism, – interfere with Intuniv being processed by the body correctly. – And do skip the idea, suggested by some, that you should ‘simply use less Intuniv and do use Prozac’ – the drug interaction experts entirely disagree with that incorrect strategy. Good guess, bad idea. :-?

Intuniv is a 3A4 substrate, but is not listed on the Prozac and Paxil link just above [is listed as such in the Intuniv PI [package insert]. You will see on this first linked list that they left out guanfacine as a 3A4 substrate, but they did cover the bases with the rest of the inhibitors I just listed. Also, on the induction [making it burn too fast and disappear] side, have to watch Tegretol or Trileptal, as they can both induce Intuniv [cause it to run through to fast requiring higher doses [see the first link], and for those treating bipolar disorder with Intuniv watch for Depakote as a inhibitor as well.

Your girl is very likely accumulating Intuniv by the blockage with Prozac, and is coming out the ‘Top of the Therapeutic Window‘ – with the result that your doc is doing what he/she knows best, changing the dosage time of day to accommodate to the obvious side effect. – Great idea if that basic drug interaction wasn’t the key problem.

In this case I strongly recommend you download and print the above interaction link for your doc, and get off that Prozac. What I find so disconcerting in this interaction scenario: Intuniv gets blamed for this weird reaction, and Prozac [and others noted] are the culprits. I have repeatedly seen this kind of problem with AMP products such as Vyvanse and Adderall for years, as many continue along in denial that the CYP 450 system doesn’t require attention – and the fact that dirty drugs can create significant problems with otherwise clean medications that work very well, if used correctly.

The good meds often get blamed as they are new, and the old dirty ones get off, based simply on familiarity! Sounds like a popularity contest, not science. – Not good form in the context of evolving science – and not implying your doc has any of these attitudes – just reporting they are clearly out there. Please talk to your doc about all these matters.

Drugs that are clean on both 2D6 and 3A4 are Effexor, Pristiq, Lexapro, Celexa, – and Lexapro [see the list] has recently found an FDA approval down to 12 yo. Irritability and sleepiness should go away – but, without knowing more, I would try her just on Intuniv alone before running another med in there, it might work well as a stand alone.

For a very brief ~2 min audio message on this topic: Intuniv at CinchCast -


—————————-

Another Oversight
Over at Intuniv Interactions at Drugs.com they simply aren’t looking at the CYP 450 challenges, and are waiting for someone to report these predictable interactions noted here. On a more positive note I do suggest going over there to look at the methylphenidate [Ritalin family] products as they appear to be interacting with Intuniv for some other unexplained reasons. Adderall, Vyvanse and the amphetamines appear clean and not interactive.

What do you readers think? Please drop your comment on these interaction matters when you have a moment-
cp

94 Comments
  1. My son just started Intuniv. We are just giving one pill right now. He also takes Depakote (250mg 3x daily) to control his seizures. He has Agenesis of the Corpus Callosum, and has a VP Shunt due to hydrocephalus as a preemie. We have added 1250mg of Fish Oil to try to control the hyperactivity without having to give me Intuniv. Today, his teacher reported that he took a nap at school, and after dinner he became so tired on our walk that he could barely make it back home. He’s 12 years old, but small (50 lbs +-). Is this increased tiredness normal?

    • Sharon,
      Unusual w fish oil, but interesting and potentially a good sign. Not trying to make business – you can do this w anyone wherever you are – but if he was my child I would do everything I could to promote and encourage good brain function. Measurement w OATS, IgG and TMA as outlined in this pdf would be recommended: http://corespych.com/tests14.

      Then you know much more precisely what you’re doing w supplements. These aren’t the only answers but they are reasonable in cost, and can significantly help w brain function if out of balance.

      Intuniv can, and often does, create tiredness when dosed too high.
      cp

  2. oops, sorry about the repeat; wasn’t sure if it went through the first time……

  3. Dr. Parker,
    what are you thoughts on Intuniv interactions with vitamin/mineral/aminio acid supplements? my son in on 3mg dose of intuniv and his breath smells like urine (a healthy 12yr boy); i’m wondering if it could be interaction with some of the many supplements he’s taking (EFAs, probiotics, grapefruit seed, magnesium, zinc, sometimes GABA, sometimes Holy Basil, sometimes glycine).

  4. I have a 9 1/2 year old daughter who has been on intuniv 1 mg for a year. I decided not to raise the dose because she seems to be doing okay on 1 mg.
    I am currently waiting for her insurance to renew authorization so that she may continue taking intuniv, but her current supply is almost out & we may not get that authorization for a couple of days. could she have any withdrawal symptoms from not taking the medication for a day or two?

    • Dana,
      Almost no w/drawal at one mg. Most of the probs occur w the higher doses. Do two days at 1/2 mg, split the pill, to assure no issues, – subject to your docs approval. Shire says “don’t split,” but even the researcher confessed that they did.
      cp

  5. CAN 8 YR OLD GRANDSON SAFELY TAKE CHILDREN CLARITIN AND INTUNIV ER 1 MG.?

    • Anna,
      Claritin comes up through my favorite liver metabolic pathway: CYP2D6 “CYP2D6 (Cytochrome P450 2D6) acts on 25% of all prescription drugs. Some 7-14% of the population has a slow acting form of this enzyme and 7% a super-fast acting form. Thirty-five percent are carriers of a non-functional CYP2D6 allele, which especially elevates the risk of adverse drug reactions when these individuals are taking multiple drugs.” Many more details from this quote here.

      Intuniv, as noted in this article, is not broken down/metabolized through 2D6, therefore there is no interaction.
      cp

  6. Any thoughts on intuniv 2 mgs., Zyprexa 15 mgs. and Fluoxetine (prozac) for a 16 year old. The dr. has him taking everything at night to try and stop the sleepiness but now the intuniv doesn’t seem to help much with his focus. Should he be taking the Prozac in the morning so that it doesn’t interact with the prozac? How about Straterra? Would that be a better choice to try? He is diagnosed with Bipolar 1 and has struggled with depression in the past but that is much better. We need to help him focus so his school work can get better. Suggestions?

    • Mellssac,
      Just look up the pathways on the Prozac package insert and you’ll see that it blocks Intuniv [3A4], and it also blocks Zyprexa through 2D6 > http://media.empr.com/documents/22/psych-aa(67)_5255.pdf. The multiple interactions here would encourage me to change almost everything, but I’m not there, and can’t make any specific corrective suggestion – just to tell you likely drug interactions. See the pdf for details.
      cp

  7. I appreciate your raising this question, and have seen no reports or specific concern raised about this issue. As I see it with these alpha 2 agonists the problem is dosage and side effects. Any meds must be titrated carefully and these are, of course antihypertensive meds with the potential for unpredictable hypotensive symptoms/side effects.
    cp

  8. Amy,
    When you have that kind of problem i simply stop throwing meds at the person and know the metabolic variables are the problem. She needs a more careful eval, several things could be going on, the good news is that there are no drug interactions between Intuniv and Vyvanse – but you can’t get it right because of the IgG very likely.

    Download Transit time; Do the corn thing, and get the IgG tested, those will likely improve the possibilities.
    cp

  9. Any thoughts on Intuniv plus fish oil? My son seems to be extra annoying and busy when he takes both. We have had great improvements on the Intuniv though!

    • Eban,
      No probs that i know, and just haven’t heard about any comments like this elsewhere. When someone is annoying I always take a deep breath and ask myself if they are, for some reason either coming out the top of the window, or somehow just not reacting as well as they should. With Intuniv the top of the window is very often tiredness, not increased annoyance.
      cp

  10. J White -
    Yes, one can gain wt on Intuniv, and one can also have a problem with comorbid depression, apathy and indifference with either Concerta or Intuniv. Two quick points to discuss with your doc to see what he/she says – consider a trial of Intuniv at night, perhaps at the next dose up to see if you can get a mix of soporific effect and correction of the ADHD. Secondly go over with your guy the possibility of cognitive depression – a Clint Eastwood apathy that needs medical attention… and this other thot comes to mind: trial of Vyvanse low dose with Intuniv for a more rounded ADHD response if that is the predominant comorbid picture.

    This is one of those with too many unknowns to give a clear rec for your docs consideration – but these are some trial thots.
    cp

  11. Dr. Parker,
    My son who is 11 and in 6th grade was on Concerta for 4 years and it helped him greatly in school and socially. He did have sleep issues and weight gain was a big issue. In June I took him of mess and then started 1 mg of Intuniv and a month later 2 mg. He had some bed wetting at first and that went away. I give it to him in the am before school. He is doing well in school and wants to stay on Intuniv because he likes eating and is more himself. He is tired in the afternoons and has some issue concentrating in the afternoons to study or do activities. Some difficulty with sustained attention completing math assignments and tests but he is a very good student. On the weekends he gets very grumpy and does not want to spend much time on homework and projects. Today he told me he has been waking around 4 am every day sometimes going back to sleep. I am not sure if the intuniv is wearing off and he is underdosed or if this is just a side effect. This may explain the grumpiness and attention issues. He has also gained 18 pounds sine June (64lbs to 82 lbs which is now an average weight). I also wonder if there are weight gain concerns for kids on Intuniv.? Seems the opposite of my old concerns on Concerta.
    Julie

  12. Lisa,
    The fact that he has been on meds since pre-school is often a big sign of immune dysregulation. Added to the history of multiple med trials I would jump on searching for the data on immune system dysregulation with IgG… qualitative not quantitative. If your doc doesn’t agree we can get it done long distance, no prob.
    cp

  13. Melissa,
    Yours is a prime example of a moving therapeutic window based upon metabolic variables. Highly likely you won’t find a consistent dose as his metabolic changes keep the window moving. Do a Transit Time, look at immune dysfunction, check out the IgG and tighten up on those details first – the predictability arrives!
    cp

  14. Dr. Parker,
     My son is 11 and has ADHD. He has been on some sort of meds since he was 3 and in preschool. Currently, and for the last few years he has been taking concerta, 54 mg and clonidine and risperdal at night. Will Intuniv help him during the day along with the concerta? He occasionally takes a ritalin bump during the day, but he forgets to go to the nurse to get it, and he still has problems focusing in at class.
    Thanks,
    Lisa
    Teach4lisa!@aol.com

  15. My son has been on Intuniv for over a year and half now.  We started out at 1mg, quickly titrated to 2mg.  This was good for a few months, but slowly his aggitation creeped back in.  I always suspected anxiety as the culprit for his irritable behavior.  We then gave hm 3mg and that mde him not himself…saying things ghe shouldn’t, behaving oddly, more impulsive, sleeping a lot.  So we bumped him back to a dose of 2mg and a half of 1mg for a desired dose of 2.5mg.  BINGO!  So this lasted another 3 months and we were back to the aggiation creeping back in.  This happened until now, at 3.5mg, he again is presentling with this aggiation.  When he starts a new dose, he does beautifully for some time, but then bam!  We finally got an additional diagnosis of Anxiety along with his ADHD.  I always suspecyed this.  We stared him on 2mg of liquid suspension Lexapro.  It has only been 2 days and we notice a dramatic difference in his behavior.  I worry about this medication (Lexapro) as he is only 7 1/2 and 55 pounds.  Is Lexapro ok to use in such a young child?  What should I look out for in terms of behavior changes?  How long before we know this med is right for him?
    Thanks for this great question and answer forum!  You have helped me in the past.  I look forward to your reply. :)
    Melissa

  16. Janet,
    Sorry to be so late getting back, busy with a relaunch of my book, will be on Amazon and Nook etc, so behind the scenes has been a big summer hectic.

    Prozac, as you know from reading here, is simply not the best choice with Intuniv simply because of the 3A4 interaction. Just pick another antidepressant, for $ sake would rec your doc try Celexa – it’s safe, more clean on drug interactions, has miles of child and adolescent use, and will keep that Intuniv from accumulating… very likely what is going on. One can never of course be sure out here on the Internet without an exam, but that is a common interaction, not frequently appreciated, that’s why I wrote about it.
    cp

  17. Dr. Parker

    My son is 10 years old and has Asperger Syndrome.  He has been on many meds, one of those being prozac.  He has been on this drug since he was around 5.  He is now taking 6mg of Intunive and 30mg of prozac.  Then at night he takes .3 Clonidine and 4 1/2mg of melatonin to fall alseep.  His behavior started getting worse again this summer.  He will for no reason become so irritable and just start screaming at us over everything.  It is like a switch flips in him at 2:00 or so every day.  His OCD has become worse than ever and he is performing morning and evening rituals with lights and fans being turned on and off.  It is as if he doesn’t hear us anymore sometimes.  I took him back to the neurologist who we love and he wants to increase the prozac again.  After reading your blog and information from other parents, I am really confused.  My son has to have meds to function at school but I don’t want him doped up and cause more problems.  We sent our doc your link to look at but have not heard back yet.  What would be your recommendations?  We live in a small town in Kentucky and it is SOOO hard to find someone like you who is so knowledgeable about meds and interactions.  Our doc has been great in trying to help my son but as a parent I am constantly searching for ways to help him.  What would you do?  Thanks 

  18. Dr.Parker,

    I think this was what I was looking for when I asked you about a sudden death interaction between Intuniv and Concerta.

    You wrote up above: “Another Oversight
    Over at Intuniv Interactions at Drugs.com they simply aren’t looking at the CYP 450 challenges, and are waiting for someone to report these predictable interactions noted here. On a more positive note I do suggest going over there to look at the methylphenidate [Ritalin family] products as they appear to be interacting with Intuniv for some other unexplained reasons. Adderall, Vyvanse and the amphetamines appear clean and not interactive.

    So I clicked on the Link and it said this:

    http://www.drugs.com/drug-interactions/concerta-with-intuniv-1606-976-1219-13992.html

    “According to the manufacturer, serious adverse events have been reported during concomitant use of methylphenidate with clonidine. The mechanism of interaction, if any, is unknown, and a causal relationship has not been established. The use of clonidine, with or without methylphenidate, has been associated with rare cases of SUDDEN DEATH and cardiotoxicity including sinus bradycardia and heart block.”

    But it is saying Clonidine, maybe I am not reading this right, could you help me understand this? You can click on the link above to read the whole thing.

    My son has been on this combo for 5 days now.

    Thanks,

    Denise

  19. I am just finding your website and the fact that prozac may not be a good mix with vyvanse. I have been on prozac 60mg for years and my doc just put me on 60mg vyvanse. I’ve been on both for about two weeks now and feel fine so far,…but should I be doing something else?

    • Lindsay,
      Watch it carefully. Over time… usually in the first 3 mos, sometimes up to 6 mos, the problems with irritation, overt anger and decreased concentration arise. May be as subtle as arguing more, may be as obvious as throwing chairs.
      cp

      • Thank you for your quick response. I called and asked my doc and she said there shouldn’t be any interactions (this through messages, you can never talk directly to the doc unless you make an appointment I feel). Thats not what I understand from you and from drugs.com. I’m a littl worried, should I be more aggressive? I have been having really bad headaches off and on and get really really cold in the evenings. Could these be symptoms? Again, thank you so much for your reply, you must be crazy busy!

        • Lindsay,
          Quite natural response, many don’t, at this time, think it’s a potential problem or I’m sure she wouldn’t have written it. I have several links to refs thruout the blog, have seen it hundreds of times, and yet know with the polymorphisms of 2D6 the presentation is variable – common, but varies in time of onset. Other symptoms not likely related.
          cp

  20. Your blog was helpful. I am a child psychiatrist who tries to keep track of these cytochrome P450 interactions (which I don’t believe existed when I was in medical school over forty years ago.) Still, I am told that with a few important exceptions, like say using depakote and lamictal together, often you can adjust one of the doses and do just fine with, say, fluoxetine and guanfacine. Still, it is better to be safe, and Lexapro would be a good option if one really feels they need to add another medicine to the intuniv. Keep up the good work!

    • Dr Nick,
      Many thanks for your kind remarks – quite agree that those interactions often at first appear of little consequence. Having watched these issues for many years and lived downstream of similar thots with longer term interactions… I simply decided to follow the books, and have been more successful with predictable outcomes. Predictability becomes more consistent, and even more fun.
      Thanks again!
      cp

  21. Can you link me to the pdf of the package insert for intuniv that shows and explains why it should not be taken with prozac? I can’t seem to locate it…I had found the guide for adderall and vyvanse, but not for intuniv or prozac. One of my students with Aspergers (mild) is currently taking the two medicines, (don’t know about timing though) and I would like to be able to give the parents the necessary information to know and understand that this is not a good combination. The child (9 yrs) falls asleep regularly at school, the time varies, and the family does not have much of a structure routine at home. So whether it’s a result of poor scheduling or side effects, I’m not sure — but either way, I would just like to be able to pass this information on to them. I did follow the links in your post above, but was unable to locate the information in the way it needs to be presented.

    Thank you,

    Julia

    • Julia,
      It doesn’t say it in the insert, I am reporting this based upon my experience using Prozac for a variety of meds from birth control [a CYP 3A4 substrate] to Adderall, and it backs them up over time… not right out of the box, but down the road, thereby appearing mysterious. See my notes here: comment #56 on this post.

      Hope this helps… do check out the links added here so you can chase down the specific details.
      cp

  22. My son is 7 and currently taking 20 mg of Fluoxetine, 4 mg Intuniv, and 10 mg of Abilify. Overall his mood is more stable, the anxiety is much better, and he is able to focus better. However, we are experiencing tiredness and periods of extreme irritability followed by days of rages. During these periods his impulsiveness is increased – verbally and physically. We are working with a team we trust, however, I welcome your opinion on the current drug interactions, levels, and behaviors? Thank you.

    • Lee,
      As I indicated in this post, the Prozac will likely cause a backup of the Intuniv and create a situation in which the dose cannot be successfully adjusted. Thus the need for Abilify. For starters do take a look at the interaction links provided here, go to your doc for a cleaner antidepressant [Celexa, Lexapro, Effexor, Zoloft - most of those are off label for 7 yo - but better in the end whilst paying attention to the CYP 450 science].

      A child on 10 mg Abilify at 7 needs neurotransmitter testing for the long haul.
      cp

  23. Hi,

    My son is ten and has had an qeeg and neuro testing done. He has ADD, ODD and a little ocd along with a little bit of tics. He has a casein intolerance and doesn’t metabolize proteins well so we were given enzymes along with amino acids and vit B12 and magnesium suppliments to give him. That didn’t improve his well being so we tried Ritalin. Wayyy to overfocused so we stoped that. I had a feeling it wasn’t a good idea. He has been on Intuniv now for almost two months, we are up to 2mg a day which i recently started giving at night. He is on very skinny but eats well and is also very pale looking. He is fair skinned by nature but since he started taking intuniv he’s got dark circles and has been having some side effects. The doctor said down the road we should try introducing vyannse (sp?) He is weepy at times, crying very easily, he feels dizzy and says he doesn’t feel well. I notice that he just sort of seems a little lost. He said that in class yesterday he was asked to read and a word came up that he knew but he confused it and said a completely different word. Could it be lowering his cognition? He suffers from anxiety as well. My irrational concern is that he will grow up and self medicate and become addicted as there is a strong gene in my family for alcoholism. What med direction should i be going in? Stims seem to not be good for him and his emotional state is unstable meaning he cannot control his anger and frustration which also runs in the family.

    • Hi ,
      sorry also, the intuniv seems to have brought on his tics again. I also forgot to mention that the Qeeg said that he could strongly benefit from stimulant med and possibly a mood stabilzer. I think the doctor is trying the safest route before getting into the stabilzers…

      • Darla,
        If our friend Intuniv is creating problems he very likely has a comorbid immune disorder – really have to focus on the gut, qEEG is great if the gut is working. Just like SPECT it is an expensive waste of time pharmacologically speaking if the foundation for his neurophysiologic house is built on shifting sands.
        cp

        • Dr Parker,

          I just had to respond to both you and to Darla. I posted a question to you on here back in January when the doc added Intuniv to my son’s regimen of Focalin XR and Depakote. The Intuniv ended up being a disaster but I think we were headed for disaster anyway. But Darla’s mention of her son’s casein intolerance and your mention of his gut is why I am posting again.

          My 13 yo son had been on meds of all kinds and combination since he was 5yo. Long story short, new doctor last winter, new course of treatment. We did stool and gene testing through Enterolab. Discovered he had malabsorption issues and that he carried the genes [reviewed in this CorePsych Blog Post] for both Celiac disease AND gluten intolerance. We have no known family history for either so this wouldn’t have been obvious to any mainstream doctor I feel. In retrospect it explains some health issues my husband has.

          So, since January he has been gluten/dairy/corn free and with doctor supervised supplement program of APEX products to support his brain health and function, we have gotten him completely off ALL his medications. He is healthier both physically and mentally than he has been since he was 5.

          I so appreciate you mentioning the gut issue. I had no idea how pertinent gut health was to brain health. I thank God everyday for finding us a doctor that practices these theories. And I would strongly recommend myself, as a non-medical professional but as a mom who has tried it all, that Darla further explore her son’s possible food intolerances and gut health.

          • Kari,
            Thanks for your support and weighing in on the issue of evidence and science. Once the evidence is on the table the entire process can become less mysterious!

            I linked to a previous CorePsych Blog post in your comment for those who may have a problem with HLA DQ 2/8 testing for the genetic factors.
            cp

        • So he was doing better after a while on intuniv 2mg. We had to go generic because of cost. He takes 1mg of gaunfacine (tenex?) two times a day. It’s been a week and he has been dealing with horrible anxiety, he had a panic attack the other night. Begged me to take him to the doctors he thought he was going to die. He couldn’t breathe. He has had labored breathing all week. Calling dctr tomorrow to make appt for wenesday per dcts orders if this didn’t stop by MOnday (tomorrow). It the dose to low? It’s the same stuff as intuniv so im thinking he needs 2 mg in am and pm instead of 1mg? Also, if i were to readdress an immune issue, what doctor should i have him see? He has been on gluten free casein free and it didn’t seem to help at all. About six months ago when we had all his labs run his thyroid did come back slightly low and then normal after retesting. What immune issue do you think it could be? And what doctor should I pursue to find out further info? And will it help? Do you have experience with immune system issues and them getting treated, eliminating the need for meds? His behavior is similar to my brothers when we were children, high anxiety anger issues. Now my brother has hypothyroidism and is an alcoholic. Could it all be from an immune issue?

          • Darla,
            I could be from an immune issue, yes. But I hesitate [never ;-)] provide categorical answers as everyone is too complex for platitudes. Testing is the answer, is easily available, and IgG would be the place to start. If that doesn’t provide sufficient answers then Metametrix review is next as recommended the Testing Options page.

            Dosage etc should be handled by your local doc, in practice – not in theory from this distance.
            cp

          • Darla,

            From my own experience as a mom I can tell you that changing the diet can take at least 6 months if not longer before you see results. There were many times in the beginning of our change when I wanted to give up because it was SO much work and we were seeing No benefit. I also will say though that true benefit didn’t come until I was able to take him off all his medication in conjunction with the diet and other natural supplement supports as recommended by our doctor. Especially given your mention of your brother, I would recommend you check out http://www.thyroidbook.com as they have a way on the site to search for a practitioner in your area that works based on all these theories. Good luck.

          • Thanks Kari!

          • Thanks Kari/ Dr. Parker,

            I was just revisiting your posts. It amazes me how sometimes i am myself so hyper focused on some issues that I miss really important points that are posted. Thank you for both postings,very helpful. We are back to getting his diet in check again.. for good this time! Although it overwhelms me, as I am not the most talented cook. It feels like i’m learning a new language! So i can’t find my sons folder at the moment that holds all his medical info, but I wonder if that test HLA DQ 2/8 testing would be worth while. He had amino acid, peptide testing done. I’m not sure if I’m writing this all out correctly so hopefully enough so that you know what I mean. He had a big casein intolerance and a lesser gluten intolerance. Should I test for the HLA DQ 2/8? Or is it likely that he maybe had Celiac? His amino acids were low do to poor absorption of protein from the gluten and casein issue. We have all the supplements that he needs from our current little team of doctors helping us. Would contacting a doctor that Kari recommended help? We tried the diet and supplements but maybe not long enough? It was only a few months of it and to be honest the diet was even less because we thought it should be quicker. He’s on 3 mg of intuniv this week and very tired and crying easily. Maybe I should be getting in touch with a specialist in immune systems?? Not sure. Our doctor is a a physch who believes in the biological reasons of things, thus why we did the testing and supplements. We have spent a lot of money and still owe on various testing. Have we done it all? And if we haven’t, do we know enough to say well he can’t eat Gluten and casein, so what more do we need to know? Isn’t that the bottom line anyways?? Thanks again!

          • Darla,
            Without seeing the tests specifically it is hard to say, but it appears that you have plenty of info to get a good start. Forget celiac, gluten sensitivity and casein is quite enough to get started on those diets. Search here at CorePsych Blog on Gluten and Casein and follow those many links to great sites for more info on diets, and do look at the CorePsych Books on Brain and Immunity for many good references.

            The big trick, just get started, and then supplements and recovery will all be able to work. Without the diet you will be shooting blanks for many more months/years.
            cp

  24. My 10 yr old adhd daughter who also suffers from anxiety and oppositinal disorder has been taking intuniv and fluoxitane together. She has been on this drug treatment for 2 months and has gained 8lbs. She is hungry constantly. After having her on a stimulant for 4 years and not eating much this is a huge change. Any feedback would be appreciated. We go back to her med Doctor in Aug.

    • Maribeth,
      Prozac, as you know from these pages is my least favorite antidepressant on so many levels – including the 3A4 interaction spelled out here. I would suggest a change with the Prozac based upon your work with your doc there. Celexa is off label for 10, but is cleaner by far than Prozac and is generic – suggest your doc thinks about 1/2 = 5mg to start and watch for the Kelsey scale to evaluate response. See this CorePsych Post and comments for details on the Kelsey Scale.
      cp

  25. I child I take care of is 6 years old. Has Autism and ADHD. Has been taking Abilify 15ml daily for the Autism. Recently started on Intuniv. Was ordered to take 1 mg daily x 7 days, then 2 mg daily x 7 days then 3 mg q d. After taking the 1mg dose 4 days he had a episode of uncontrolled crying that escaladed to a full meltdown. Thought this was just his Autism but then after taking 2 days of of the 2mg he had a major meltdown and the doctor said to increase the intuniv to 3mg. 3rd and 4th day later he began to cry for no apparrent reason. Seems to have these crying episodes a couple of hours before he is to take his dose of Intuniv. His sleep pattern has changed also. Are these crying episode related to the Intuniv and is this something that will continue? Does he need change of med or dosage change

    • Ronda,
      Significant problems like this with complicated kids such as those with ASD and ADHD really require careful review with your doc. I always treat these comorbid conditions with a less aggressive titration strategy because so many do have these unpredictable reactions. It is quite likely that the Intuniv is associated with the regressions based upon this recommended and approved dosage strategy, but these kids are just more sensitive to standard med increases – and really need more specific measurement of neurotransmitters in the first place if challenges like this continue.
      cp

  26. Good morning, my son has adhd and pretty close to a full blown odd diagnosis. He has been on concerta until end of January when we started with intuniv. at this point he is only taking 3mg. I have 17 mg of concerta to supplement the intuniv but I am very anxious about giving it to him. any thoughts? He is going to be twelve in July, and has gained about 15 pounds since we took him off stimulants. He has pushed through the extreme exhaustion but is tired a lot. I like intuniv in that he does not have the crazy rebound behavior and his impulsive behaviors are much better. His focus and attention however are not.

    • Robin,
      This is a common finding, and when you say ‘odd,’ I increasingly start thinking about neurotransmitter measurements. Also you could take a look at this CorePsych Blog posting on Intuniv Dosing to help with the issue of finding the correct Therapeutic Window with Intuniv. No drug interaction to worry about, as noted in this post.

      My favorite combo, if needed is Vyvanse, but all those details must be left to you and your doc – and because he is so sensitive [odd] I would go very carefully with the Vyvanse as seen in the Water Titration post from way back in ’07.
      Best,
      cp

      • NOT SURE WHAT YOU ARE SAYING WITH THE NEUROTRANSMITTER MEASUREMENTS.

        • Robin,
          Take a look at this Neuroscience page – and start by downloading the first pdf file right at the top, read that and you will get it.
          cp

          • Dr Parker,

            I have just reviewed your utube videos discussing the 3 types of ADHD, and I totally agree with your with your model that the mainstream diagnosis is based upon desriptors not the actual science going on in the brain. With that said, I believe my son has both the anxiety piece and the leave me alone piece with the exception of he is extremley social kid and thrives. I am struggling at home as well as he has become in this shoty time (a behavior problem). I have for many months struggled with adding focaline 10mg with his intunive dose. He just started yesterday any thoughts. I am slo concerned overall because he is an athlete who participates in intensive physical workouts so I am cocnerned with his cardiac health. any thoughts.

          • Robin,
            Often many improve with the combo: mixing specific stimulants with Intuniv. No contraindications from drug interaction, and no challenge with sports, except to document that sympathetic tone increases may create an increase in heart rate that rarely needs specific medical attention. As with any drug some awareness of side effects is useful, but there are no global contraindications in the literature for exercise with stimulants
            cp

  27. My son is taking Intuniv he is currently taking the 3 mg dose in the am with breakfast. he seems to fall asleep if he is sitting in the car or just sitting in a chair for a while when he is up he seems ok but as soon as he is sitting he is out.it has been about a month since he has been taking the intuniv . how long does this medication take to show improvement of the side affects and how safe is this drug ?. there is not much known about this medication. my son has a blood pressure of 100/58 is that too low for a 14 year old to have he weighs 170 and is 6′ tall.

    • Raquel,
      Sounds like he is out the Top of the Window as far as I can tell from this brief note. I would discuss with your doc backing down to 2 mg even tho he is a big guy. The safety in studies is quite good, with low blood pressure only about 2% more than placebo. It’s a drug that could remotely cause HBP, but the main issue as you present it is the soporific effect, which is very likely dose related. One month is sufficient time to check for side effects, and for adjustment to dosage, so considering dropping the dose would be in order. Hope it works, keep us posted.
      cp

  28. I am currently taking Paxil for anxiety and Adderall for ADD. I have already had a seizure related to serotonin syndrome and now I am ”sweating” all day after taking the Adderall. I have not had this problem before and am wondering if Paxil is the culprit and I should change meds?

    • Angie,
      Strongly recommend to your doc you change antidepressants. Just Search 2D6 here and see all the postings and links on how challenging this problem can become if not corrected. Also here: which ones work best with Adderall.
      cp

  29. Dear Dr. Parker-

    After our correspondence, I worked with our doc and took my son off Intuniv due to the interaction with Luvox (extreme fatigue). We need to give Luvox a chance, because his OCD is most problematic socially. He weaned off Zoloft now that the Luvox is up to 150 mg., so he’s only on Luvox. However, now he’s pretty hyper at school & is having trouble focusing. In your opinion, what if any stimulant meds would be good to try? He had some success a year or so ago with Adderall & then Focalin (but seemed to build a tolerance?). He has OCD/A.D.D./trichotillomania, and Tourette’s which is waning (stim meds haven’t caused tics when tried previously). Thanks!

    • Mk,
      Sounds like you are on the right track. No interactions between either MPH or AMP products with Luvox. My preference from years of experience is always the AMP products if no problems occur, and Vyvanse, as you will see from just a brief tour of CorePsych Blog, is my favorite choice, titrated carefully with any challenging presentation.

      A counterproductive bounce on that combo inevitably will confirm my first impression: that Neurotransmitter testing would be helpful to adjust matters regardless. Complex presentations always encourage a more careful review – and with the success I am having in my office using that testing, I predict all informed psychopharmacologists will be using NT testing in 4-5 yrs – it just makes practical sense, provides more useful evidence, and obviates years of messing around with guessing at intervention possibilities.
      cp

  30. Hi Dr. Parker,

    I just have a quick question. Is zoloft (25 mg.) considered ok to use along with Intuniv? I know prozac is not and my son has anxiety along with the ADHD. Also, if you don’t recommend zoloft, can you recommend another that would target anxiety for an 8 yr old?

    Thanks, Sue

  31. My 8 year old son has ADD and is currently taking 30 mg of Focalin XR/day. Soon after increasing his Focalin dosage to 30 mg, he developed facial tics. Per his nerologists suggestion we added fish oil daily and saw that the facial tics diminshed almost completely. The drug manufacturer that makes Focalin recently release the 30 mg pill so beginning in Jan 2010 my son began taking one (1) 30 mg pill instead of two (2) 15 mg pills (which he did for almost a year). Soon after this change, his facial tics came back and they seem to have gotten worse. His neurologist is suggesting we lower his Focalin to 20 mgs/day and add Intuniv to see if we can get the tics under control. We’ll start with 1 mg of Intuniv for 7 days, then increase to 2 mgs, possibly increasing to 3 mgs. if needed.
    What, if any, documentation has been made on Intuniv and facial tics. I am concerned about the mixing the 20 mg of Focalin XR with the Intuniv and about the addictive nature (if any) of the Intuniv. Thank you for your time.

    • Ellen,
      Have no idea why he would have the tic with the 30 vs the 2×15, – makes no sense, but, honestly, I am never surprised anymore with any reasonable possibilities. Don’t have any documentation on facial tics with Intuniv, and know that it is not addictive. The other variables are way too speculative for me to weigh in on from this distance, sorry.
      cp

  32. My son who is now 14 has been on 20mg of prozac for anxiety/depression for at least 2 years. We just added with the starter pack intuniv of 1 mg on Feb 8th. for more of the ADD symptoms, focus, ittitability, arguing with parents, wanting to be alone, etc. He is not hyperactive. After taking 2 days of his medication my son was a zombie and c/o feeling faint to the extent he felt like he would hit the ground. I received word from his teacher he was indeed a zombie and in another world as well as out of it. I called his MD immediately. I was told to monitor him and see if this was just a sensitivity that needed to be worked through. In the meantime he started the 2 mg for 2 days and yesterday came home from school around 3:30 and fell asleep until it was time to take his medication and then went back to bed. This is when I went investigating on my own calling Shire and then finding you.I was told that these 2 medications were not contraindicated by the MD and Shire when I called to get more info, but I am seeing very clearly on your blogs that they are contrindicated and this is NOT clearly outlined in the packet of info. They also told me that they had no data on the mixture of these medications and there were no and have not done clinical trials on these mixtures. My understanding from you is that prozac, paxil, and luvox should not be mixed. I beleive you are absolutely right as I have witnessed severe side effects from my son. I sent your information to his MD and am waiting to here back from her. I know you just can’t stop this cold turkey. I want to know if we should remove the prozac or the intuniv. The prozac has been working well for his anxiety/depression, but we need help addressing the other issues. It is hard to determine what to do with a teenager as to how much of this is teen behavior, hormonal, or chemical. This product needs to be black labeled in plain english. I have contacted the FDA and reported this. What are your suggestions?

    • Lori,
      These noted drug interactions are often challenging to see, are often subtle, and they lack specific research findings – only occasional voices in the wind provide case report problems.

      The situation is simply this: the pathways are clearly documented to demonstrate that 3A4 is blocked by the three antidepressants listed, but most of the clinical studies are short term, and ‘don’t find an interaction.’ These interactions usually take awhile to appear, from 3 mos up to 6/8 mos, and since no studies run out for that length they remain off the radar – so without studies, no one is ‘believes’ this is happening. I gave a presentation in the vicinity of Atlanta many years ago with two pre-eminent psychopharmacologic researchers, one from Vanderbilt, one from Harvard. Dr Vanderbilt took a diffident, perplexed and holier than thou attitude, the Harvard speaker simply indicated that he hadn’t seen any reports in the literature – indicating from that lofty perch that these interactions didn’t exist. Neither read the specific drug interaction literature thoroughly [like Cozza, et al on Drug Interactions], or they would have taken a different tack.

      In summary there are several issues with your son – from the big picture to what-to-do:
      1. The institutionalization of psychophamacologic research, often mentioned in these pages and best expressed in this linked CorePsych Blog on Institutional Arrest. is clearly at play. Tied with this problem with your son is the strong tendency to encourage commoditization of psychiatry through the flip use of labels as treatment parameters in an effort to simplify the complex and make it cookie cutter for the least informed. Labels are reviewed in this CorePsych Post written a couple of years ago.
      2. When the awareness improves the Prozac & Paxil front they will be addressed in the package insert, as has happened with Amphetamines and these two. Many years after discussing these issues in 1996, they now have warnings. This Intuniv and 3A4 is a new one, so it may take some time to make it through the institutions involved.
      3. On a more personal note: Your doc is simply doing what he knows best, they don’t have time to read every one of these challenges. This interaction does appear to encourage specific problems with your son, if taken at face value – that is, he appears to have come out the top of the Therapeutic Window – another too-often overlooked parameter. I do hope this helps him with next steps.
      4. To be more specific: Your doc is also following FDA guidelines on Prozac as it is approved for use with kids, one of the few, – and so the FDA isn’t sufficiently paying attention to the vagaries of drug interactions themselves in this specific instance – simply because it hasn’t come up for them. No blame here, – all of this is likely new to them simply because of the process of thinking more scientifically about specific interactions.
      5. Finally: the offender with your son is not the Intuniv, as the new drug usually gets the boot, but, without seeing him, just from my own experience, I have seen this reaction, and suggest that Prozac is the culprit, and following your docs plan to change antidepressants would be the next logical step. BTW Lexapro is approved down to 12 yo, and completely clean on 3A4.

      I never write for Prozac or Paxil for these very reasons – it’s just too complicated to keep all this in mind everyday – so why bother. when other products do the job without the headaches?
      Hope this helps.
      cp

      • Dr. Parker-

        My 13 year-old son is on 4 mg. Intuniv, 100 mg Zoloft, and 100 mg.Luvox (doc hopes Luvox will work for his OCD, and then will wean him off Zoloft). He has OCD, ADHD, Tourette’s Syndrome, and trichotillomania. He started on Prozac at age 8, and I feel tremendous guilt that he’s been on so many other things (tried homeopathic vitamins, acupuncture, etc.), some with horrible side effects (Abilify= quick weight gain, Lamictal= suicidal, etc.). Anyway, he has been falling asleep in school most days..switched to taking both Luvox & Intuniv at night, stayed awake a couple days, then fell asleep again. I called Shire, they had to check and called back to confirm that what you say COULD happen, but of course, no data. Wrote the FDA as Lori above did, wondering why the approval process doesn’t involve any interaction clinical trials. Called our doc, he said Luvox could be affecting the Intuniv, but wants him to try it a little longer, as Luvox is the only med specifically for OCD (OCD disrupts his life to an extent). Dr., I don’t know what to do. We can’t have him continue to fall asleep in classes. Tenex seemed to work relatively well for ADD (but so did Focalin last year), then Intuniv 3 mg. did, then it didn’t, then 4 mg. seemed to, then we intro’d Luvox and had the sleep issue. This is our 2nd try on Luvox, we haven’t given it a chance to work. How certain are you that Intuniv won’t work properly when combined with Luvox? What do you think about continuing Luvox, disco’ing Intuniv for now, seeing if Luvox works and hoping the ADD doesn’t cost him grades & friendships? Any thoughts on HeadStrong homeopathic for OCD? Thanks!! p.s., my older son has taken Adderall XR for 6 years with only positive effects…I now wonder if the issues with my younger son (things not working or wearing off after awhile) are because he has always been on either Prozac or Zoloft, & now Luvox, with any ADD med?

        • Mk,
          Your boy’s presentation just loads me up with many questions – and not enough time to go over in every detail. The big question that, in my humble opinion, you must absolutely have answered: What is his neurotransmitter status, and what is troubling his immune system. Only speculation of course, but your guy very likely is suffering from specific food allergies – measurable and treatable. Right now not many understand how to mix meds and NTs, but I am planning some training programs soon, and will include everyone who participates in a medical resource site. You could try NeuroScience to see if providers are there, – and we do provide these evaluations without a personal visit to Va Beach, if you wish.

          All of the med changes are refractory based upon a very corrupted system of neurotransmitters and cytokines… been there, done that [barring, of course, no other deep brain or neurological problem - which you likely have already reviewed with your docs.

          Much as I hate to take issue with my colleagues without knowing who they are, I can tell you quite firmly that I disagree with your doc on several levels: Multiple SSRI's, the drug interaction between Intuniv and Luvox, and his choice or Prozac in the first place. You boy is likely sleepy for several reasons, from too-much-drug on the SSRI side [watch for serotonin syndrome], too-much-drug on the Intuniv side [backed up by the Luvox] as carefully spelled out and documented here. There are comprehensive clinical studies on these matters, some linked here, – but Intuniv specifically is not mentioned in these studies simply because it is a new medication. Take a look at this Drug Interaction book if you have more questions, or if you doc doubts the relevance of my observations. The Prozac and Luvox are both implicated, Zoloft is clean, therefore I don’t think drug interactions are the only issues here.

          When you have ADHD meds, or for that matter any psych meds not working as expected the time will soon come when everyone will be using neurotransmitter testing routinely… like the current Vitamin D3 relevance for psych conditions. It was not on anyone’s radar about 5 yrs ago, now many do it routinely. The psychs, however, remain regrettably far behind the medical folks in chasing down the D3 levels – perhaps Seasonal Affective Disorder is a manifestation of an unconscious regression with Winter? “The data isn’t in yet?”

          Don’t know about homeopathic remedies… I have my hands full just keeping up with the most prevalent challenges!
          cp

          • Thank you. His current physchiatrist didn’t have him on Prozac & all the things that caused issues, & has been supportive when I’ve wanted to make changes, but I’ve never been asked about neurotransmitter status or immune issues. The one neuro doc we saw told me what I knew already & said, in front of my son, it’s the worst/loudest case of TS he’s ever seen. SO, we haven’t been back to a neurologist. I’ll do the reading you link to above, and live in Chicagoland, so we should be able to find someone to address the concerns you raise. He has been on SSRIs for years and nothing has helped with OCD. When I tried to wean, he got too emotional (I think it takes longer than the doc said). Per your comments above, I’d like to eliminate something while researching, but can’t find anything regarding how quickly one can wean off Intuniv. Thanks again. Oh, and I bought a Philips blue light for SAD last week!

          • Mk,
            Excellent on the blue light, but absolutely measure his D3 – for sure.

            Intuniv weaning would be drop down to 1 mg and go every other day for a week, should be no problem.
            cp

  33. hi doc.. my 8 yo son is going to start 1mg -2mgs of intuniv on friday.. he is currently on 50mg of vyvanse and .1 clonidine for sleeping issues. after reading a lot of info it seems that he should not take the clonidine. what do u suggest i tell his doctor.. he will only be taking the intuniv and the clonidine but i have heard that the 2 shouldnt be mixed. please help

    • Lori,
      I don’t want to go on record as telling you what to tell your doc, – but I can tell you that the two meds can encourage a significant problem with blood pressure, as both together could aggravate any possible blood pressure side effects. Best to not mix, and try melatonin for sleep, or a variety of other meds not in the same alpha-2-agonist family.

      Glad you brought this up, important point as clonidine does prove so helpful for sleep without the Intuniv.
      cp

  34. Dr. Parker – can you further explain this statement you made above, “watch for Depakote as a inhibitor as well” as I don’t understand what you mean by inhibitor. Our doctor has put my 12yo son on Intuniv since just before xmas. He has also been on Depakote since age 6, and is taking Focalin XR as well. At first I thought he was responding fairly well, but lately I am concerned that he is too irritable and seeming depressed. Can you comment? Thanks.

    • Kari,
      When you review this post you will see this drug interaction link above on the Package Insert regarding Valproate Meds = Depakote. This interaction would, by increasing the amount of valproate in the blood, likely create more tiredness, more sedation and sleeping in class, and more weight gain, all side effects of too much Depakote/valproate.

      Without seeing him it is hard to evaluate – sometimes the ‘depression’ appearance is more soporific, tiredness and oversedation… if so the interaction would be one to consider with your doc.
      cp

      • Thank you Dr. Parker – so would this then in theory increase the amount of Depakote in his system and would thus show up on his therapeutic level blood work? And in contrast, does this interaction mean the Intuniv is also less effective or less potent in this regard?

        I’m also curious on your opinion of kids like my son going gluten and dairy free? About 3.5 weeks ago we started so with our son but I fear that his medications are getting in the way of seeing any benefit from the diet. Just curious is you have any experience with this. Thanks!

        • Kari,
          Intuniv is an inhibitor of Depakote, not what one might expect, as Depakote is frequently associated with interactions through its own blocking. [This is a revision of an earlier comment - corrected - cp]

          Medications don’t interfere with the process of correcting gluten or casein problems… those problems resolve at different rates of speed for many other reasons – from complicity with the diet, to metabolic changes with the bowel, to secondary nutritional challenges… to other immune dysregulations not identified but co-existing with the original casein or gluten allergies.
          cp

          • Thank you Dr. Parker-
            You say in your response that Depakote levels won’t change. However the drug interaction page you directed me to might suggest otherwise? Or am I misreading?

            Valproate Medications
            Intuniv may increase the level of valproate medications in the bloodstream. To prevent this drug interaction from occurring, your healthcare provider may want to measure the level of valproic acid in your blood and may need to adjust the dose of your valproate medication.

            Kari

          • Kari,
            That’s what I get for starting an answer at 5 AM then rushing to finish later in the day! You are so right, and I turned it around myself, having talked about Depakote as a blocker for years, I got stuck in that rut. You are right – reviewed the interaction, and, yes it clearly could increase his blood levels of Depakote, they do need watching, and watch for the sedation etc as accurately described in one of my other comments at a different time in the AM.

            Thanks for clarification… sorry I got the whole interaction confused myself. Will edit that previous incorrect comment.
            cp

  35. Dear Dr. Parker,

    I cannot find the prozac interaction warning in the Intiniv patient or prescriber insert info. My son’s doc did not agree when I brought up the possibility of the interaction. I cannot find literature from Intuniv to support what you have stated. Could you please point me to some additional data so I can continue to pursue this. Also, why do you call prozac a dirty drug? We are somewhat new to meds over the last 5 months and it has been a rocky road but at the same time, we have seem some amazing possibilities. Thanks.

    OregonRain Mom

    • OregonRain,
      Often Prozac isn’t dirty in the short run, it most often is in the long run… dirty because of the interaction with drugs metabolized by 2D6 see this package insert [page 4]:

      Drugs Metabolized by CYP2D6 – Fluoxetine inhibits the activity of CYP2D6, and may make individuals with normal CYP2D6 metabolic activity resemble a poor metabolizer. Coadministration of fluoxetine with other drugs that are metabolized by CYP2D6, including certain antidepressants (e.g., TCAs), antipsychotics (e.g., phenothiazines and most atypicals), and antiarrhythmics (e.g., propafenone, flecainide, and others) should be approached with caution. Therapy with medications that are predominantly metabolized by the CYP2D6 system and that have a relatively narrow therapeutic index (see list below) should be initiated at the low end of the dose range if a patient is receiving fluoxetine concurrently or has taken it in the previous 5 weeks. Thus, his/her dosing requirements resemble those of poor metabolizers. If fluoxetine is added to the treatment regimen of a patient already receiving a drug metabolized by CYP2D6, the need for decreased dose of the original medication should be considered. Drugs with a narrow therapeutic index represent the greatest concern (e.g., flecainide, propafenone, vinblastine, and TCAs). Due to the risk of serious ventricular arrhythmias and sudden death potentially associated with elevated plasma levels of thioridazine, thioridazine should not be administered with fluoxetine or within a minimum of 5 weeks after fluoxetine has been discontinued.

      I did *not* assert that Prozac interfered with the metabolism of Intuniv, but that it interfered with Vyvanse and Adderall both 2D6 substrates throughout the literature. Please reread this CorePsych Blog post on Intuniv and 3A4, clearly in the package insert – mentioning other drugs that do block 3A4 or can induce 3A4 causing changes in the rate of metabolism.
      cp

  36. Dr Parker: Update on the Prozac. I stopped taking it. I dialed back to 10mg a day in the morning, but by this time was so edgy I thought I would crawl out of my own skin. My MD agreed that I could stop taking Prozac. It’s been a full week and I”m still feeling a bit edgy, but much less so every day. I will say that my depression seemed to lift and I actually felt like myself again for a few days. This is the second time in six years that I have taken Prozac — unsuccessfully. I’m a little at a loss about what to do next.

    • Bee –
      This calls for a tight relationship with your care provider, period. You need a different, clean med, and your provider will know your needs when you see them. The only other one to avoid absolutely is Paxil.
      cp

  37. Dear Dr. Parker, Am a 54-year old, menopausal woman in excellent health. I am on an HRT regimen, having convinced my very traditional gyne to order bio-identical hormones from the Madison Pharmacy in WI. I take 200 mg of progesterone at night and one gram of bi-est cream (E2 .02 + E3 .08) in the morning. I no longer have obvious menopausal symptoms — except severe depression. Please keep reading. I have taken Adderall 20-30 mgs daily for six years with pretty good results, with the exception of slightly elevated blood pressure. My psychiatrist introduced me to Vyvanse about six months ago, and I’ve had good results, but we’re still working on getting the dosage right. I am taking 60 mgs per day at present; 40 mgs at about 6:30 am and another 20 mgs about noon. The reason for this note is to inquire about anti depressants. After a year of severe depression, I asked for an anti depressant. I meditate every day, eat well, exercise, etc… I just can’t put all my energy into battling depression any longer. My MD insisted on Prozac, even after I discussed your observations about drug interaction. My MD’s point is that he has had good results in his practice with stimulant drugs and Prozac, but that Efexor — and he assumes Pristiq, too — are really hard when it comes time to get off. He did agree to prescribe Lexapro, if I’m willing to incur the increased expense of a name brand drug. For about 35 days, I have taken 10 mg of Prozac 2BID, at 8 am and 8 pm — and I am feeling better. The upside is that when I wake up, I”m not feeling edgy from overnight stimulant drug withdrawal; the downside is that I”m waking up at 3:30 am!

    What is your view about withdrawal from Efexor/Pristiq?

    • Bee,
      Looks like the Prozac/Vyvanse interaction is quite predictably already in place – insomnia. Yes, you can have discontinuation syndrome with any SSRI other than Prozac, but Prozac does accumulate, and causes it’s own quasi dementia… some call it ‘Prozac stupid.’ You can get so Prozaced you can’t think or complete sentences – not cool. He’s right, less discontinuation, but discontinuation can easily be handled, and is much less a problem with Pristiq. Not to worry, the interaction can occur 6 mos down the road – so just watch for getting worse later. No pressure, just remain informed, and watch. It will very likely happen in that you will feel irritated, sleep less, and get cranky with those you love. Time will tell,
      The BHR sounds good. But remember, Prozac also blocks estrogen metabolism, and you can become re-estrogen dominant with our buddy Prozac. Watch your E2 and E3 levels.
      Thanks, hope this helps,
      cp

      • Getting off Pristiq is very easy compared to Effexor. I have done it twice. But went back on it a 3rd time cause it WORKS!!

        • Thanks Pat,
          Readers, do take a very good look at Pat Sullivan’s Blog, – Pat is the guy that wrote Wellness Piece by Piece and is a leading national authority on what-works-best from a more comprehensive, inclusive perspective. Very strong insights on brain, body, immune system dysregulation, neurotoxins over there – thanks Pat for weighing in!
          cp

  38. Chuck,

    Great info! Interactions with drugs AND herbs are common and as you know, I have run into several. Thanks for the great info and keep it coming!

    A primer on exactly how Intuniv works and what it does (what you should expect) would be great perhaps?

    Also, tried to re-post this on my site and Typepad logon would not work. Tried it several times rechecking each time to make sure I was typing it correctly.

    Pat Sullivan

    • Pat,
      Great to hear from you, and will try to get that video from Shire, as it is so demonstrative of the action.
      Sorry the TypePad didn’t connect – don’t really know exactly what you had problem with, – another time perhaps!
      Best for the Holidays!
      Chuck

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