Psych Meds: Time, Titration and Tachyphylaxis

ADHD and College: Transitions and Catastrophe
June 12, 2011
Milk Allergies Matter: Foreign Proteins In Food
July 13, 2011

Heavy But Necessary: Tachyphylaxis Explained

Medications Discussed At Disney
Disney Center LA

It was a magic moment: this Missouri and Indiana farm boy arrives in LA to speak at the Disney Center. Well…, not at the Disney Center, but darn close, – in Patina [take the tour of the room], the exquisite restaurant right next to it – see the red arrow

The dining guests dressed impeccably, the physicians in the room: the LA cognoscenti from UCLA, Cedars Sinai and the surround. The evening scene was fresh southern Cally at its resplendent best, and, as you can see from your tour of the room, Patina radiated grand class unlike any restaurant down there in Dexter, MO.

By the way, it was the first time that I entered a dinner meeting room, hooked up my computer to the wall outlet and projected, as you can imagine there near the entrance to the room, my desktop onto a very large plasma screen – no LCD, no shadows with the waiters, – outstanding at that moment. [Now commonplace.]

The Topic: Medications for ADHD

Nope, I won't tell you the specific pharmaceutical company with all of the current ridiculous heat about pharmaceutical dinner meetings, implicit suggestions of mindless drooling docs, and the inferred potential for brainless seduction by pens and post-it notes – why create more problems? Quick take on the attendees: no one was drooling, no one asked for pens, – and the questions were electric, penetrating and without slack. No one was there to party.

The bottom line on the evening: the room was loaded with very smart docs, with deep understandings of psych meds and stimulants, and an abiding interest in growing their deeper understanding of just how this particular ADHD medication worked in clinical practice.

It Works If You Work It

And, for you thoughtful readers out there in the ethers, there was, on that evening, an important discussion that resonates right into this day and this moment. It was a relevant discussion for every medication check, for every doctor and patient interaction across the USA, everyday. The subject in question, introduced by a discerning woman, child psychiatrist from UCLA: tachyphylaxisdoes the drug need regular adjusting because the medication over time diminishes in effectiveness?

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For videos that explain in more detail: ADHD Meds Dosage: http://bit.ly/dosevids

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Short Answer

This particular drug needs less adjustments over time than the average stimulant, a key point for the both the provider and the patient. Medication checks are dollars out of everyone's pocket, create a burden for all, and require more careful medical monitoring than a drug that works consistently over time.

So many psych drugs appear to manifest a roving Therapeutic Window, an unpredictable metabolic pattern that appears to move around and require changing over time – thus resulting in tachyphylaxis.

Metabolism Modifies Efficacy Over Time

At CorePsych the reason we are so vigorously supporting a more evidenced-based approach to core psychiatric issues derives from this all-to-common phenomenon, seen for so many years: roving tachyphylaxis, – created by metabolic challenges and such ubiquitous challenges as immune system dysregulation, and associated with such obvious biomedical problems as changes in transit time.

For videos see this playlist on dosage:ADHD Meds Dosage: http://bit.ly/dosevids I hope you get some use out of this new tachyphylaxis word – and that you use it to dig deeper into the predictable challenges associated with biomedical influences on drug behaviors.

cp
Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
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12 Comments

  1. edd says:

    I suffered from ADHD. I cured myself, will power baby. To hell with drugs.

  2. […] If stimulant meds are added, but then don’t start working until 2-3 hours later, then the meds are likely too high in […]

  3. […] Psych Meds: Time, Titration and Tachyphylaxis (corepsychblog.com)

  4. […] Psych Meds: Time, Titration and Tachyphylaxis (corepsychblog.com) […]

  5. Jim says:

    Hello Dr Parker,

    I’ve read your white paper several times now and am beginning to understand the the different variables that affect titration.  I”m on Vyvanse now at 70mg in the morning (which lasts about 7 hours) and two weeks ago when i took my morning dose, i would get this sleepy feeling where my eyes wanted to shut like i was getting sleepy even after just waking up.  I immediately thought it was a titration issue and my lack of exercise and sleep.  Over the last two days, i’ve increased my work out regimen and this morning, i had the same “sleepy” feeling.  At the instruction of my doctor, i tood a 10mg of Adderal IR and the feeling seemed to go away.  I think this is clearly an indication that my dose needs to be increased.  Since my morning Vyvanse dose starts to wain around 3:30, i take another 10mg of Adderal IR, which seems to take me through the night.  I’ve also absorbed your comments about “leaky gut” and given my BM’s are every 4 days, i think i have an issue with the way my liver metabolizes the medications and thus will need this addressed as well.  I was considering taking the tests available on your website for food allergies, but not sure this is going to address my issues adn wanted to get your thoughts on how to proeceed next short of getting my dose increased on my next Doctor visit.

    Thanks very much for helping us all with this invaluable information.  It’s absolutely a life saver!!

    • Jim,
      At the risk of sounding categorical I can tell you that your Transit Time problem is, as you quite rightly assessed, the main problem with the entire stimulant strategy. Highly likely you can mess with it for years if you don’t get the immune system corrected. Nothing against your doc, but they will highly likely blow back on you – if they don’t look for qualitative IgG to tell the tale.

      If they don’t do it we can get testing done and consult on your situation long distance, do it all the time.
      cp

  6. D3,
    That’s one reason to write it out… learn something everyday for mistakes! Take a look at this post… and take some time to read multiple neurotransmitter posts here, and look at the big page on Neuroscience testing – this is a good post to start written by a guest poster from a testing lab in Atlanta… very bright guy, good basic info:

    http://www.corepsychblog.com/2010/04/depression-5htp-and-l-tryptophan-laboratory-markers-matter/
    cp

    • D3 says:

      yep I read the link.  Sort of was like a gloss over.  The ssri’s all caused what I said above and at very low doses.  The SNRIs were better, but didn’t give any positive benefit.  When dose was increased (albeit apparently too much too quickly the one time), extreme agitation ensued.  lowered the dose.  Agitation went away.  But all in all, has created an overall depression that wasn’t there before the way it is now–feeling down and out for no reason.

      • D3,
        These are all signs of metabolic background noise, often correctable with neurotransmitter and IgG testing. No chickens = no positive effect of chicken catchers! ;- 0
        cp

  7. Hey Nurse,
    Vyvanse and Adderall are two completely different amphetamine delivery systems. Yes, they both are amphetamines, but Vyvanse is a prodrug, and Adderall is mechanically released. Details by just searching “prodrug” here at CorePsych Blog.

    When the therapeutic window is moving around then the problems are likely associated metabolically based. Your doc is right about the dosage parallels in the broader sense, but often don’t work out as absolutes. Your tachyphylaxis reactions are very likely metabolically based – creating moving targets and impervious Tx windows.
    cp

  8. D3 says:

    So….I have a question.  What have you used for patients with severe adhd and ocd/specific phobias?  Every SSRI/SNRI tried has failed. They just give more energy, creating extreme agitation and obsessiveness.  It’s worst when the stimulant is past its DOE.

    Also, a little mistake I caught in the above: “This particular drug needs less adjustments over time than the average stimulant.”  It should be adjustments.  ‘Less’ is used for a non-countable amount whereas ‘fewer’ is used for a countable amount.  Adjustments can be counted, therefore, fewer is the adjective needed.

    Thank you for your input!

  9. HeyNurseG! says:

    Hello Dr. Parker,

    I hope you will be kind enough to enlighten me concerning the questions I have. I was just diagnosed several months ago. I titrated up to 30 mgs of Adderall XR earlier this year. After titrating up to 30 mgs on Adderall XR I also titrated up to 80mgs of Straterra. This was wonderful because I got 24/7 coverage.

    Within about 6 weeks or so, I built up a tolerance to the Adderall. My psychiatrist and I decided to give Vyvanse a try. He stated that Vyvanse and Adderall XR are basically the same drug, but with different delivery mechanisms. Is this correct? I am a nurse and do not see how this could be true. I do know the delivery mechanisms are different.  I was titrated up to 70mgs because supposedly 70mgs of Vyvanse is = to 30 mgs of Adderall XR. I continued with Straterra.

     70mgs of Vyvanse was like taking absolutely nothing to me. I tried it for about 2 weeks, told my psych this and he raised my Adderall to 40mgs daily. My questions is if 70mgs Vyvanse is = 30 mgs Adderall XR and I built up a tolerance to the 30’s then would it not make sense that 70mgs of Vyvanse would not work, but that a higher dose might? Vyvanse cost about 1/3 of what Adderall XR. I pay well over $240 for Adderall XR out-of-pocket and the increase to 40mgs will be around $400. Vyvanse 30’s run around $80 with the discount card my doctor gave me.

    Last, but not least, why do some people build up a tolerance so fast to Adderall. XR was a miracle for me.

    I appreciate you taking the time to  help.

    Thank you.

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