Tips for Vyvanse a new, third generation stimulant:
You already know our regular CorePsych theme with ADD/ADHD and emerging brain science: the more we know the more we can have a positive impact. Not knowing can bring years of frustration, missed opportunity and unfulfilled dreams.
-And you know that ADD is one of the most misunderstood clinical conditions, as many in this world consider it a belief system not a proven medical condition.
As you also know from these pages, I advocate for what works, what works best, and what works with the fewest problems for patients and families. Vyvanse, in the short time on the market has set some very impressive records.
From a launch date July 1, 2007, here in the States, I have written about 100 new scripts for Vyvanse treating ADD, and the results have proven quite remarkable. Simply put: almost 0 complaints to the reps, and coming back to my office after the first visit. Unusual launch. -But a few slight problems can occur - thus this post.
These easy tips will help you understand how it works here so that you can communicate easily with your medical people. [Full disclosure: I do speak for Shire, the company that makes Vyvanse, and have for years made a considerable effort to teach medical colleagues around the country how to use stimulant meds more effectively. I have presented for Adderall since its launch, Adderall XR, Focalin XR, and Daytrana as well as Vyvanse.]
Tips and Treatment Notes for Vyvanse:
- It is a prodrug with a slow and forgiving delivery process: No heavy AM hit, no big drop in the PM
- Both studies and clinical experience show that it is more efficacious [post hoc review] than Adderall XR, and Adderall previously held highest efficacy ratings on comparison studies.
- The prodrug delivery system provides a longer duration of effectiveness, with no need for a PM "kicker" dose to complete homework or home chores.
- Methamphetamine addicts don't like it: as measured, get
this, on a "likability scale." Because it is a prodrug you can't snort,
chew, or inject it with any buzz success [peak Cmax about 4 hrs post ingestion]. In research they injected Vyvance into a meth
addicts arm: their conclusion: this is not "likable" - no fun, no buzz. This is an excellent outcome, not previously reported with any stimulant, and in the package insert. It may be abusable, but it will be nearly impossible.
- Always start at the lower dose: 30mg which roughly equals Adderall XR 10mg. They may be on higher doses, even 40 mg of the Adderall XR, but always go low and slow. It's more efficacious, and if you start at 50mg which roughly equals 20mg Adderall XR, it can give them an unpleasant feeling. Been there. Go slowly.
- If the duration is out at ~ 2PM the dose is one click too low. Move up to the next dose.
- With a medication sensitive child/adult you may want to divide the dose in 1/2 to get started: Take the capsule, pour contents into 2 oz of water in mixing cup, drink 1 oz each of the first 2 - 4 days to start slowly. I have two children perfectly dosed with only 1/2 capsule/AM in this manner.
- All psych meds are better tolerated and more effective with a protein breakfast,- please review my breakfast posts linked here.
- Always remember the ADD 3R's, discussed in my first post, in reference to medical treatment for ADD: Right Diagnosis, Right Medication/Intervention, Right Dosage.
Please send along any comments: this is an opportunity to work closely together and let people know how this medication can be used most effectively. -Look forward to our discussions.
Wendy,
Shortness of breath is not a typical side effect, and the fact that it persists suggests strongly that you should seek specific medical attention and review as soon as possible - might be something more serious.
If it is just a very unusual side effect, about 24-48 hrs.
cp
Posted by: Dr Charles Parker | January 23, 2009 at 06:54 AM
I have been off of the vyvanse for about 24 hours now and am still very short of breath. how long can I expect this to last?
Posted by: wendy | January 22, 2009 at 02:30 PM
Kristin-
Your comments from the front will help others who share your same concerns. On of the biggest problems I am seeing every day is the downstream effect of not thinking carefully about stimulant medications - not using a clear system for intervention.
- Glad Vyvanse is working for you and your son.
One the 'challenge' side, the 'problematic' side of these matters, you may be interested in this article on how we physicians can contribute to ADHD non-recovery:
http://ezinearticles.com/?ADHD-Denial---Medical-Ambiguity-Creates-Significant-Problems&id=1843156
Without a specific treatment structure problems abound.
Tnx
cp
Posted by: Dr Charles Parker | January 17, 2009 at 12:31 PM
You are right on the money about the "not being able to control" the effects of the high, and "looking high", if a person attempts to abuse Vyvanse. My experience in viewing this individual was he was extremely red, hot, heart racing, and eyes were glazed. Everyone noticed. I want to make myself clear that I am a strong advocate of Vyvanse. My son has been on several ADHD meds, all of them had terrible side effects which were the sole cause of why they did not work for him. We are having succuss with this one! I could not be happier or more hopeful. Parents with children who struggle, know what I mean. He has made it through an entire week of school without one "checkmark" for the first time all year, since he began the Vyvanse. And homework is completed without tantrums or tears. Thank you for your valuable advice.
Posted by: Kristin | January 16, 2009 at 10:30 AM
Kristin,
Sleep walking is seen when the dose it too high. We always watch for sleep changes in the DOE process outlined here. If the DOE objective is followed no sleep issues should be occurring - if they are, we recommend dosage changes for our patients - decrease.
And yes, I have heard occasional abuse of the Vyvanse, but far fewer than Adderall, and not consistent abuse, because the buzz is too hard to achieve and completely troublesome... they can't control it - and look like they are high, creating discovery of the abuse.
My resources who are those most likely to abuse, the college kids, - and they affirm these findings with their friends and associates. Just home from Christmas break they are quite enthusiastic about the improvements they have experienced in this regard, and the positive reports on Vyvanse at the schools.
cp
Posted by: Dr Charles Parker | January 16, 2009 at 06:55 AM
Wendy,
Those side effects are common if the dose is not correct, or if breakfast is sporadic. Protein breakfast is a must, then what appears to be missing is an appreciation of the specific DOE objectives. Please read the Elusive Top of the Window at the EzineArticles button here, if you are near or at 12 hr you should not be having these problems unless no breakfast or on paxil or prozac - sometimes Wellbutrin.
cp
Posted by: Dr. Charles Parker | January 16, 2009 at 06:32 AM
I was just reading through more of the past blogs and saw that you were interested in hearing information on abuse of Vyvanse. I get the medication for my teen son, and have personally seen it's abuse. His pills were stolen at one point by an individual. We all realized who had done it when we saw the behavior (we knew this person). He was "wired". For a period of three days, this individual was bouncing off the walls, and then crashed very hard. I have no idea how many pills he took at one time, or each day. But he undoubtably had a buzz. I had to fight hard to get the Rx refilled again, as the Dr. explained that theft of these meds is very common, and often abused. I now keep the Vyvanse in a combination locked box.
Posted by: kristin | January 16, 2009 at 12:59 AM
My son, 13yrs old, was recently prescribed Vyvanse 60mg.. He has had the typical side effects I have read about, however, he has just experienced a prolonged sleep walking episode. He actually ran, and took a bath before waking. Do you think this is related to the medication, the dosage, or just lack of sleep? Or have you heard of any links between Vyvanse and sleep walking? Thank you.
Posted by: Kristin | January 16, 2009 at 12:29 AM
Hi,I was diagnosed with adult add and put on vyvanse about 2 months ago. I tried the 30 mg for 2 weeks and tolerated that well. I was then put on 50 and that was good too. I was then moved up to 70 and started to have just the slightest shortness of breath. as suggested, I immediately told my dr about that and he moved me back down to the 50 mg dosage. now I am still having a bit of the shortness of breath when I did not have it at this dosage before. the first 3 pills were normal again and when I got to the 4th I had the shortness of breath. could I still be recouperating form the 70 mg dosage? why am I having the side effects at the same dosage that I did not have them before? I only took 5 of the 70 mg tabs. Also, I do not take my with protein as I just learned was recommended. will that help remove the side effects? how about caffeine? I have not stopped caffeine and with the combination with vyvanse could that be causing the shortness of breath? I really want to continue taking vyvanse, and wonder if the side effects will subside.. I am somewhat concerned because that is a side effect that is considered rare and to call dr immediately. He did not seem that concerned and only lowered the dosage. what do you think?
Posted by: wendy | January 15, 2009 at 10:34 PM
Mary Ellen,
I do have patients, very few, on 150 mg with good result. You could very well be a fast metabolizer, or you could have, and strongly suggest that you check out, other concomitant metabolic issues. I have not seen a person on the high dosage side of matters that doesn't have unrecognized immune, hormonal or nutritional contributions.
Best of luck in your nursing career, and do check out any changes first with your doc. In nursing and in medicine, you will soon see that even casual discussion might imply taking responsibility, and I encourage you to keep that in the hands of your specific on-site doc.
Best wishes,
cp
Posted by: Dr Charles Parker | January 07, 2009 at 06:15 AM
Chels,
Always check with your doctor before changing anything, this forum is not to give specific med advice - but I never have any problems with what you are asking, no withdrawal, and no interaction if not taken together.
cp
Posted by: Dr Charles Parker | January 07, 2009 at 06:08 AM
Hi, I was actually prescribed vyvanse today but i forgot to mention to the doctor that I had previously been on Wellbutrin 150mg. I haven't taken the wellbutrin in about a week so do I need to delay starting my vyvanse until it gets completely out of my system? and if so, how long?
Posted by: Chels | January 06, 2009 at 07:13 PM
Hi,
I'm wondering about high doses of Vyvanse. I am a 37yo female, approx. 160lbs, 5'4, with no other health issues. I am holding @ 100mg of Vyvanse per doctor with an Adderall boost when needed (YUCK). I have requested to move up to 150mg (I have been as high as 130mg prescribed and he decreased it) but he says that I'm just throwing away my $. He says that a persons body can only metabolize a certain amount of this medication & the rest is wasted. I have recorded daily when I lose the 100mg ~ I start to yawn, need a nap, fiddle, ect. around 11:30am (I take my meds @ 6-6:30am. I have very long days I work part time & a full time nursing student, with class ending around 8:30pm. I have used Adderall & XR but hated the rollercoaster feeling! I have been on Vyvanse since July '07. Looking for some help!
Thanks,
Mary Ellen
Posted by: Mary Ellen | January 06, 2009 at 03:53 PM
James,
Vyvanse with either Effexor or Pristiq [daughter of Effexor] is IMHO the best combo for depression with ADHD, absolutely no problem, clean on 2D6, and those two are, in my opinion, the two best antidepressants available [stand with Stahl and others on that one] even tho they don't work for everyone.
Sounds like your DOE is off, shoot for 12 hr DOE, don't go over 14 hr on dosage, no noon dose on Vyvanse.
More info on this duration article here below, - and then just Google DOE here at CorePsychBlog for more details on many posts. This is a common problem.
http://ezinearticles.com/?ADD---ADHD-Medication-Treatment---7-Tips-on-Finding-the-Challenging-Sides-of-the-Therapeutic-Window&id=1650524
Thanks, hope this helps,
cp
Posted by: Dr Charles Parker | January 01, 2009 at 05:13 PM
Grace-
Word finding problems can arise from several feeds, and can be associated with the meds.
1. The Vyvanse can be slightly too high in dosage, see this article for details on the Top of the Window:
http://ezinearticles.com/?ADD-ADHD-Treatment---7-Tips-on-Finding-the-Elusive-Top-of-the-Therapeutic-Window&id=1257427
2. Another frequent problem, without outright asking you about bowel function, is the increased sensitivity seen with increased 'transit time' = less than 1 BM/day. No, I won't be asking you for feedback, but many don't know about this connection. The 'metabolic issue' seems to be more a function of relative liver compromise than medication dosage per se, as once proper frequency is established, the Vyvanse works at the same dosage without side effect.
3. Stimulants in general can at times increase anxiety, and if the anxiety is secondary to a comorbid depression, and the antidepressant is not correctly adjusted, then anxiety will be increased.
4. Sleep is a big one. If you aren't sleeping well you can feel quite demented, and word sorting can become more obvious.
5. If you are taking Prozac you must ask your doc to change that one out. Prozac and Vyvanse do not work together as noted here:
http://www.corepsychblog.com/2008/12/add-adhd-medications-amphetamines-2d6-drug-interaction-update.html
- and Prozac can cause an increase in frontal lobe, executive symptoms all by itself - with Vyvanse on top of it you might have trouble remembering your best friend's name.
This are a few quick thots, more there if we have the opportunity to chase down the details.
Hope this helps!
cp
Posted by: Dr Charles Parker | January 01, 2009 at 05:03 PM
Can Vyvanse cause severe word-finding problems? This was not experienced before taking Vyvanse. Seems to happen more in stressful situations (presentations, conferences, etc.). Would combining with an anti-anxiety med help? This is a real dilemma for me ... the need to be focused, alert, and articulate.
Posted by: Grace | December 31, 2008 at 04:02 PM
Dr. Parker,
I am currently taking Vyvanse with favorable results compared to Adderall. However, with both, I find the duration of effect to be quite less than the typical estimates. Long story short, I am also taking 75mg/day of Effexor XR, and I cannot find a conclusive answer to whether or not the Effexor could be affecting the stimulants. I would ask my doc, but I don't see him for another month.
One more thing... Would switching from Effexor to Wellbutrin be a wise change in anti-d's and possibly curb the issue with my ADD meds as well?
Thanks for the help.
Posted by: James | December 31, 2008 at 01:43 AM
Lisa,
No prob with throwing it away, no prob with using only a portion of the capsule... my main bias in the water titration strategy is simply penury - saving every last bit for the next dose-
Glad it's working for you - and on fine tuning the dose don't forget the *breakfast policy* mentioned elsewhere here - meds often will feel like too much without breakfast-
cp
Posted by: Dr Charles Parker | December 22, 2008 at 12:48 PM
Hi Dr.
Thank you for your response to my question about changing from Metadate CD to Vyvanse. You suggested that I could also mix the contents of the capsule with water and use a portion of the water mix. Could I, instead of mixing with water, open the capsule, dispose in the trash some of the contents, close the capsule and take the remaining contents? that is what I used to do with Metadate CD when originally the 30mg capsule was too high of a dosage, but the 20mg capsule was too low of a dosage. Please advise if opening and closing the Vyvanse capsule impacts its ability to be correctly processed by the human body. Thank you.
Posted by: Lisa | December 21, 2008 at 05:42 PM
Lisa,
I did the math for someone on another of these comments and can't immediately find it - bottom line: it does not work mg/mg - Vyvanse has a completely different mg dosage pattern that MPH products.
20mg is a good place to start, and for me I am even more careful depending on a variety of variables - and will use 1/2 of the 20 in water titration if I have any doubts at all.
Seems reasonable to me-
cp
Posted by: Dr Charles Parker | December 21, 2008 at 11:08 AM
If a person takes 30mg of Metadate CD in the morning only, what is the equivalent of Vyvanse? The doctor is changing the medication. I was surprised that she ordered only 20MG per day of Vyvanse to replace the 30mg of Metadate slow release. Does this seem correct to you? Thank you
Posted by: lisa | December 21, 2008 at 12:51 AM
Julie,
Even a big guy can get toxic and it sounds like better off than on... do need to check with your doc.
I never give Vyvanse 2X/day, duration is just too long - have seen many who don't appreciate the simplicity of the DOE, but he surely sounds like too much.
- BTW this is not a rule out for Vyvanse, just work with your doc to go down... most folks just don't want to try a lower dose after all of that - thus my admonition to stay so low at the first.
Good luck, and do check with your doc,
cp
Posted by: Dr Charles Parker | November 23, 2008 at 09:10 PM
I need help As soon as possible, David has used Vyvanase , but after about 1 1/2 weeks he becomes very aggressive Ht 5 foot 9inches 180 pounds and he also on on Buspar and Resperidal, and Tenex
When he is on the Vyvanase he is more focus for the period of 1- 1/2 weeks then gradually he becomes aggressive. He has had a couple trial and last trial was 30 mg am and 30 mg 12noon . When Vyvanse was stopped he slept very hard for 3-4 days and immedicately the aggression stopped ...now off this medications he is having aggression but not quite as serious as before
Help me please, the school has suspended him and he my have to go into resiential home. I do not wish that for him Thank you
Posted by: Julie | November 21, 2008 at 09:56 AM
Rebecca,
Challenging questions - my best shot: The onset seemed to have too many side effects. Appetite, over focus and racing thots are all signs of too much. See some of the Therapeutic Window Posts [top] I have been writing over at EzineArticles on the badge on the right here.
Sounds like it was too much, going down on dosage was a great move, but my take at this moment is that you were at first starting [in hindsight, no disrespect to anyone] too high, couldn't accommodate, and then went too low and are simply trying too hard, too quickly moving the dose to get it right.
I agree with your suggestion: Start all over at 20, expect that is likely not enough, but take it there for about 10-14 days, then go to 30. This will give your metabolic pathways an adjustment time, and you won't be hitting so hard at the outset. Then when you go up to 30 watch for the 'cognitive' changes on the PM drop, not the feeling changes. The cognitive changes are more subtle, and if you actually 'feel it' for ~ 14 hr - likely too much.
Also sounds like you might have an associated metabolic issue with your atypical reaction to Ritalin. Big question: Did you eat your breakfast girl?
You are thinking exactly right, need to slow down on the expectations... not easy in law school, but he wait should tell the tale.
cp
Posted by: Dr Charles Parker | November 20, 2008 at 08:42 PM
Hi there, I have found your website to be extremely informative and helpful. I am a 26yr old law student who was just diagnosed with ADD about 1.5 mo ago (after taking phentermine for a few months) and have been looking to your blog for guidance re meds and info ever since.
I started out on 30mg Vyvanse and for the first 2 weeks, it seemed to be working wonderfully with DOE of roughly 12 hrs ( maybe less) with an onset at 45 min after taking it. Mental cognition and verbal expression were sharper than ever, the ability to focus and pay attention in class were through the roof. I did however experience racing thoughts, mood elevation, intense motivation, and suffered from lack of hunger most of the day. It also seemed as though in the evening I would have onset of anxiety and depression.
The following two weeks however were a completely different story. It was sort of like I was slipping into a fog with no ability to focus. I had very little concentration or clairity and sort of just wanted to sit and stare. I wouldnt feel an onset until roughly 3 hours and ( it would only feel as though it was sort of working)then I would have a terrible crash after 6 hrs of taking it. I would become completely ravenous and want to eat anything and everything. I had become extremely exhausted with an overwhelming desire to just sleep. There was one occation where I became sick and feverish, nauseous with a terrible headache and left class early to go home and sleep.
I stopped taking it for about 3 days and then started up again to see what would happen... and it was slightly working although not very effective as it had been when I first started and seemed to feel as though it was wearing off quickly.
There was one incident where I took the vyvanse as well as some liquid vitamin B and suffered from chest pains and shortness of breath for several hours. I stopped taking the vitamin B and that seemed to get rid of the problem.
I also tried to cut the does in half (15 mg) using the water tritration method and it seemed to be somewhat effective in terms of increasing self expression. Although I was tired and suffered from lack of motivation, anxiety and depression.
My doctor thinks that my reaction to the meds is strange and he took me off the Vyanse and put me on 5 mg of ritalin - which is completely awful! I just suffered from crying bouts for no apparent reason and bouts of aggression and hostility with very little changes in mental cognition. He thinks that my body does not like the method of delivery the vyvanse offers and he said we may try adderal if the ritalin doesnt work out.
I would like to stick with the vyvanse and am convinced I just have to find the correct dose. It seems as though the benefits of taking it outweigh the negative. Do you think that possibly the does it too high and maybe I need to decrease to 20mg or maybe the does is too low? Its difficult to figure out since the top of the window can look like the bottom.
Posted by: Rebecca | November 16, 2008 at 02:23 PM