ADHD Medications: Starting out and titrating

I have spent many days covering a lot about learning and behavioral problems. Topics covered include why and how to get these issues diagnosed, who is involved in the diagnostic process, and treatment options with diet, supplements, and alternative treatments. Yesterday I covered what prescription medications are typically used and side effects they may cause. Today I’ll discuss common ways to choose a medicine, how to titrate it to a proper dose, and when to change to something else.

Tomorrow will discuss final thoughts on how to remember medicines, if it’s okay to take days off, and what to do if parents disagree about the treatment plan.

Getting Started


starting ADHD medicinesThe first step in treating ADHD is getting a proper diagnosis. This should be done with input from parents and teachers since symptoms should be present in at least two settings. ADHD symptoms overlap with many other conditions, and if the diagnosis is not correct, medications are more likely to cause side effects without benefit.

Do not jump into medication until the symptoms have been fully evaluated and a proper diagnosis is made according to DSM criteria.

Stimulant medicines

Stimulant medicines are considered first line treatment for ADHD in kids over 5 years of age.

There are short acting and long acting formulations available for each type of stimulant. There are advantages and disadvantages to each.

Short acting medications tend to last about 4 hours, so can be given at breakfast, lunch, and after school, allowing for hunger to return as each wears off to help kids maintain weight. Short acting stimulants are often used later in the day after a long acting stimulant wears off for teens who need longer coverage.

Long acting medicines tend to last between 6 and 12 hours, depending on the medicine and the person’s metabolism. The benefit is that people don’t need a mid-day dosing, which for school kids means avoiding a daily trip to the school nurse. This can be socially unacceptable for older children. It is also easier to remember once/day medication versus multiple times/day dosing. The downside is that some children don’t eat well midday with long acting medicines.

Which stimulant medicine to choose?

Methylphenidate vs Amphetamine

While some children respond better to methylphenidates, others to amphetamines, some do equally well on either, and some cannot tolerate either.

It is not possible to predict which children will do best on any type, but if there is a family history of someone responding well (or not) to a medicine, that should be taken into consideration of which to start first.

Swallowing Pills

Another thing to consider is whether or not a child can swallow a pill.

Some of the medicines must be swallowed whole.

If you aren’t sure if your child can swallow a pill, have them try swallowing a tic tac. Use a cup with a straw, since the throat is narrowed when you tilt your head back to drink from an open cup.

Another option is to put it in a spoonful of yogurt or applesauce and have your child swallow without chewing.

If your child cannot swallow a tic tac, you can choose a medicine that doesn’t need to be swallowed.

Some come in liquid or chewable formulations. Some capsules can be opened and sprinkled onto food, such as applesauce or yogurt. There is a patch (placed on the skin) available for the methylphenidate group.

Genetic testing

I’ve met many parents who request “the lab to say which medicine will work best.”

There is no lab that does this.

Many companies promote that their genetic test can predict which medicine will be best tolerated, but in truth they do not predict which will work best to maximize treatment and minimize side effects.

There are pharmacogenetic tests that will help to identify if a person has an issue with metabolism that would require a higher or lower than typical dose, but it does not tell which medicine will work best. It also doesn’t verify the diagnosis, so if the diagnosis is incorrect, no medicine is the right one.

Pharmacogenetic testing for ADHD (and other conditions) is still relatively new. It has the potential to significantly change the medication treatment process, a term called Personalized Medicine. Personalized medicine needs to be further validated and its precision improved before it becomes mainstream.

Insurance

I would love to say that cost shouldn’t matter, that we pick the medicine based purely on medical benefit, but cost does matter. Insurance often dictates which medicine we choose. 

Before you go to the doctor to discuss starting medicine look at the formulary from your insurance company. All other things being equal, if one medicine is not covered at all (or is very expensive) and another is covered at a lower tier, it is recommended to try the least expensive option first.

Of course, if the least expensive medicine fails, then a more expensive one might be the right choice. 

Not knowing which will work best in any individual, choosing the least expensive makes sense. Sometimes all approved medications for ADHD are expensive. If that’s the case, see Affording Medications for tips on finding the best price.

Generics historically have been the least expensive, but that isn’t always the case. You must know your insurance formulary to know the cost.

The ADHD Medication Guide is a great resource to look for generics (marked with a “G”), which must be swallowed whole or can be opened or chewed (see the key on page 2).

Age indications

The age indications listed on page 2 of the ADHD Medication Guide are those that have FDA approval at the ages listed, but there are many times that physicians use medicines outside the age range listed.

Some do not even have an age indication listed. These ages are due to testing results, and can be limited because one age group might not have been tested for a specific medicine.

Note that the 17 year and adult medicines are different. Is there really a difference between a 17 and an 18 year old? Not likely.

start low and titrate to best effect

In general it is recommended to pick one of the stimulant medicines and start low and titrate to best effect without significant side effects.

Feedback on how the child is able to focus and stay on task, and reports of other behavioral issues that were symptoms in the first place should be received from teachers and parents, as well as the child if he is able.

There are many things to consider that affect focus and behavior that are not due to the medicine: sleep, hunger, pain, illness, etc. It takes at least a few days to identify if the medicine is working or not or if other issues are contributing to the focus and behaviors.

The younger the child is the longer I usually advise staying on a dose so a parent has a chance to hear from the teacher how things are going. I usually don’t increase faster than once/week in younger kids.

I rely more on the student’s report in middle and high school, since those students can be more insightful and they have so many teachers throughout the day that most teachers are not as helpful. Older students who are in tune with their problems and how they are responding to the medicine might be able to increase every few days, as long as there are no confounding factors that could influence symptoms, such as change in sleep pattern, big test or other stressor, or illness.

Finding the right dose

It is recommended to start with one of the two main classes of stimulants with a low dose, and slowly increase to find the best dose.

Continue to increase until either symptoms are well controlled without significant side effects or side effects won’t allow another increase.

If that stimulant doesn’t work well or has side effects that are not tolerated, then change to the other class of stimulant.

If that one does not work, you can try a different medicine from the class of stimulant that worked best.

If the third medicine doesn’t work, then a non-stimulant can be tried.

I recommend re-evaluating the original diagnosis if the third medicine doesn’t work, since ADHD might not be the cause of the issues and finding the right cause can lead to a better treatment.

Titrating the medicine goes something like this:
  • If symptoms are well controlled and there are no significant side effects, the medicine should be continued at the current dose.
  • If symptoms are not well controlled and there are no side effects that prohibit increasing, the dose should be increased as tolerated.
  • If symptoms are not well controlled (i.e. room for improvement) but there are side effects that prohibit increasing the medicine, consider a longer period of watching on this dose versus changing to a new medicine.

 

Before your visit:

Before you meet with your physician to discuss a new ADHD diagnosis or a possible change in treatment plan, be sure to get the following information and have it available at the visit or the visit will not be as productive as you desire:

  • Insurance formulary
  • Standardized testing from teachers, parents, and other significant adults
  • Verify if your child can swallow a tic tac or pill
  • Any contributing family history (family member responses to medications, family history of heart issues, etc)
Tomorrow there will be more on fine tuning ADHD medications.

Looking for more?

Many parents benefit from support groups to learn from others who have gone through or are currently going through similar situations, fears, failures, and successes. Find one in your area that might help you go through the process with others who share your concerns. If you know of a support group that deserves mention, please share!

ADHD

CHADD is the nationwide support group that offers a lot online and has many local chapters, such as ADHDKC. I am a volunteer board member of ADHDKC and have been impressed with the impact they have made in our community in the short time they have existed (established in 2012). I encourage parents to attend their free informational meetings. The speakers have all been fantastic and there are many more great topics coming up!

Anxiety

Many parents are surprised to learn how much anxiety can affect behavior and learning. To look for local support groups, check out the tool on Psychology Today.

Autism

The Autism Society has an extensive list of resources.

Dyslexia 

Dyslexia Help is designed to help dyslexics, parents, and professionals find the resources they need, from scholarly articles and reviewed books to online forums and support groups.

Learning Disabilities 

Learning Disabilities Association of America offers support groups as well as information to help understand learning disabilities, negotiating the special education process, and helping your child and yourself.

Tourette’s Syndrome and Tic Disorders 

Tourette’s Syndrome Association is a great resource for people with tic disorders.

General Support Group List 

For a list of many support groups in Kansas: Support Groups in Kansas .

School information

Choosing schools for kids with ADHD and learning differences isn’t always possible, but look to the linked articles on ways to decide what might work best for your child. When choosing colleges, look specifically for programs they offer for students who learn differently and plan ahead to get your teen ready for this challenge.

Midwest ADHD Conference – April 2018

Check out the Midwest ADHD Conference coming to the KC area in April, 2018. I’m involved in the planning stages and it will be a FANTASTIC conference for parents, adults with ADHD, and educators/teachers.

Midwest ADHD Conference
The Midwest ADHD Conference will be held in April 2018, in Overland Park, Kansas.


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Generics for Concerta 2017

Concerta is a long acting methylphenidate used to treat ADHD successfully in many kids and adults. It has a unique time release system that makes it preferred over other medications and difficult to recreate. Sadly, there are once again companies that are trying to substitute for Concerta. Generics for Concerta may not be equivalent to the real thing.

Deja vu.

I feel like I’ve been through this before.

Two of my most-read blogs (from my old blog) were about generic forms of Concerta available in 2013-14.

The FDA had allowed companies to manufacture and sell tablets that were not the same as Concerta. People across the country noticed the change immediately.

I started seeing patients who had been well controlled on Concerta for a long time who suddenly were not able to focus, were more angry, and had other focus and behavior problems.

No advance warning

Initially I had no idea there was a new generic, but one mother sent me a picture of the new pill and I knew instantly it could not be the same.

One more time

Now there are new generics from Trigen LaboratoriesMylan and Impax Laboratories that do not use the special delivery system of Concerta once again.

methylphenidate ER
****New March 23, 2018: A patient sent this photo of their generic methylphenidate ER.

I’m worried because it took many many months of people filing reports with the FDA through MedWatch before the FDA finally stopped allowing the substitution.

I hope the newly approved versions work better than the previous editions, but am worried not only because they don’t use OROS technology, but there are several new versions coming to market and each could be different.

Original generic rumors

I have heard that the previously available OROS generic (made in the same factory as the name brand Concerta and the same exact pill but with a different label) will no longer be available.

If this is true, options will be to pay for the name brand or go with a new version of the medicine.

What makes Concerta unique?

Concerta is the branded formulation of methylphenidate HCl Extended Release that has a unique time release system.

This time release technology is called OROS (osmotic controlled release oral delivery system).

Unlike many slow releasing medications that are released as the capsule parts dissolve, the OROS capsule doesn’t dissolve.

There is a little active medicine that is released immediately and then the medicine is slowly released through a small hole in one end of the capsule.

You can tell if you have the OROS tablets if they have a small dimple in one end:

 

The small circles on one end allow medicine to escape from the capsule.

The pill works like a pump. As it pulls water in from the intestines, it pushes the medicine out of the tube slowly throughout the day. This allows for a consistent drug release. See this photo from Medscape:

The new generics

The same active ingredient (methylphenidate) is used in the new pills. I have heard that at least one version of the pills is round, so I know they don’t use the OROS system.

The package inserts do not specify what type of delayed release they will use.

I find it very frustrating that each of the package inserts (Trigen, Impax) appear to be nearly identical to the one for Concerta (including the initial US approval date of 2000, which is not correct for this form).

Older warnings, including a contraindication in those with tics, has been found in newer studies to not be a contraindication.

The fact that they did not push to remove it makes me wonder if they did not want to have to change other parts of the document. Figure 1 and Table 6 are identical with the exception of changing the word “CONCERTA” to “methylphenidate hydrochloride extended-release” and Trigen added an easy-to-read table format.

This makes me wonder if they were somehow able to get permission to make their new tablets based on Concerta’s data, not their own.

We’ll see how it works in people who have previously taken OROS methylphenidate ER. Sadly, one version might work better than another, so you will have to keep track of which brand you are using.

What’s good about the new generics?

Cost

If it’s true that the currently available generic OROS form of methylphenidate ER is no longer going to be available, it’s good that there will be other options to help keep costs down.

Maybe.

Sometimes insurance companies prefer branded products. It’s all how they contract the cost.

If you don’t know how to use your insurance company’s prescription formulary, you should learn. Also check out GoodRx for pricing information.

Will it work?

One might work as well (or better) than the OROS formulation in any individual. You won’t know until you try it.

One benefit I am excited about if these work: 

The Trigen version is available as a 72 mg tablet.

The original Concerta is not able to be made at that strength. You can see from the photos above that the pills get bigger with increasing dosages, and the OROS system has limits to how much it can hold.

For people who need 72 mg, they must take two of the 36 mg OROS tablets. Since patients pay by the pill and they need 60 pills/month instead of 30, this can be quite a bit more expensive.

What should you do if the pills change

Check each bottle when you pick up new medicine before you accept it. Ask if you can return unused tablets if they don’t work for any reason.

Keep track of what each pill looks like and the brand (which should be on the label) so you know which versions work and which don’t.

Talk to your kids about how they think and feel on and off their medicine – some will be more in tune with themselves than others.

Keep in touch with teachers as the pills change so you know if there are school-related issues you’re not seeing at home.

If the pills don’t work or have new or worsening side effects:

Talk to your HR representative who deals with the insurance company.

Call your insurance company directly. Send them e-mails and snail mail.

Ask your physician to write a letter on your behalf.

In each of the above situations, include why your family member needs the OROS technology. Give examples of how it works better than the other extended release methylphenidates. List why the amphetamine class of medication failed (if tried).

Medwatch

People were able to get the FDA to look into the issue the last time a different tablet was substituted by submitting complaints to MedWatch.

It took a long time, but the FDA finally agreed that there are significant differences and the other substitutions were no longer allowed.

It’s easy and free. Please submit to MedWatch if you have any concerns!

Know your insurance formulary

If you need to change medications because the new generics don’t work well, first check with insurance. Insurances have drug formularies that help estimate your costs. It helps to know what other medicines are in the same class so you can look up your formulary coverage.

The ADHD Medication Guide has an easy-to-read format of ADHD medicines. Just look for other medicines in the same colored box as Concerta to find similar drugs.

To limit plagiarism of this wonderful chart, you must click on the user agreement in the center of the page. It is free and easy.

Medications have been arranged on the card for ease of display and comparison, but dosing equivalence cannot be assumed.

Talk with your doctor about what medicines will be best for your child (or yourself).

*The ADHD Medication Guide was created by Dr. Andrew Adesman of the North Shore-LIJ Health System.

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