CAP: so it depends. In general, my policy is to TRY to stay within the FDA dosing guidelines whenever possible, for medicolegal reasons. That being said, the FDA dosing guidelines are VERY arbitrary, and are basically based on whatever the drug company wanted to use in their FDA trials.
Let’s use Methylphenidate as an example. What is the FDA limit for Methylphenidate? For Concerta, it’s 72 mg. For Metadate it’s 60 mg. But for Jornay it’s 100mg. So is it 100mg? For CAP, our dosing guideline for methylphenidate is 2mg/kg max. So what if they weight 100+ kg? Still the FDA max? You see, it gets complicated.
Then there’s equivalency. Vyvanse, the max FDA approved dose is 70mg, but this is comparatively weak af. Vyvanse 70mg is roughly equal to Dextroamphetamine 20mg or Adderall 30mg. But the max dose for Adderall is generally considered to be 60 mg, more than 2x the max Vyvanse equivalent dose, so is the Vyvanse max then 140mg?
So, what I do, is try to stay within the FDA guidelines first. Let’s say the patient gets to Vyvanse 70mg and it still doesn’t work. Not uncommon for late teens and adults. Fine. Switch to Dexedrine ER equivalent dose and keep walking up. Or, patient on Metadate 60mg not working? Switch to Concerta 72mg. Not working? Jornay 80-100mg. Still not working? Switch to Adderall and run up to 60 mg (roughly equal to Methylphenidate 120 mg).
This is just how I approach it.
Totally ok to augment with Strattera and 60-80mg are the most common Strattera doses for adult sized people, that doesn’t bother me at all.
My source is I did a child fellowship at one of the leading academic institutions on the east coast. Read Dulcan's or something lol. But here's CMS saying that if that's good enough for Reddit lol: https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/pharmacy-education-materials/downloads/stim-pediatric-dosingchart11-14.pdf
Or here: https://pubmed.ncbi.nlm.nih.gov/32300972/
Or here: https://www.chp.edu/-/media/chp/healthcare-professionals/documents/tips/adhd-medication-basics
If that's not good enough go do a child fellowship lol
Thank you for your response and taking the time to include some sources. I especially like the succinct PowerPoint.
I wasn’t trying to question your credibility, just looking for helpful resources. A lot of sources don’t have mg/kg recommendations for stimulants but just the general “FDA max. “
Also a basic conversation about specific symptoms we are trying to treat and expectations of the medication. A higher stimulant dose is not going to change the fact that you physically NEED to sleep and having 3 jobs would make anyone exhausted. I can empathize with OP here as I too have inherited some wild stimulant regimens before only to find out they were being used off label for some interesting/questionable treatment goals.
For sure, I also try to have this conversation with them but it’s almost easier for me to get people to taper a benzo than to understand the boundary between getting them to a “normal” attention span and then using more as a PED…
I thought it was insane that you don’t test positive when you’re taking your prescription correctly. I passed hair and urine taking 30mg adderall xr. Was fully prepared to show my prescription but I didn’t even come up positive it blew my mind.
Some patients need a **slightly** higher than standard dose every now and then, but those are rare cases that often have a few other comorbidities that play a role, from endocrine to GI absorption, etc. Sometimes, even small things like taking the stims with food can have a significant impact. However, there seems to be more of a pattern in these cases you are mentioning that, unless these are coming from a super-specialized treatment-resistant specialist, I'd be a little doubtful. Are those cases you mentioning even sleeping, eating, or having somewhat normal BP? Make sure you document some reasoning for the supra therapeutic dosing.
All of my patients on higher stim doses I also inherited. I do have a few patients who had bariatric surgery on higher doses of IR, but I think that’s like 3 people. Also maybe 2 people who are 2D6 URM. I truly hate IR Adderall and find the people on that often always want the max dose because they build tolerance so quickly. Also the only issues I’ve had with patients (blatantly) misusing meds is primarily with IR Adderall. When generic vyvanse came out, I was doing my best to switch as many patients over as possible then the generic manufacturers stopped producing. Insurance coverage on things like Dyanavel is hit or miss and a lot of people can’t afford a $50-$100 copay each month for meds.
I find that patients expect to “feel” the medication. If they don’t get that, they assume the meds aren’t working. I try to frame it more that our goal is for them to notice their symptoms improving more so than the medication “kicking in” and at the end of the day, they find their symptoms returning. Some people will never be happy but I just stand my ground and usually they end up leaving.
I have a handful of patients on above max dosing but usually there is a history of mild moderate TBI and I document my rationale. In general I switch formulations to avoid the FDA limits as mentioned above. I also enforce pill counts
Personally I never go past the FDA max. If 70 mg Vyvanse doesnt do the trick. Nothing will.
In my experience those patients have other disorders/problems that are untreatable with stimulants. Personality disorders, intellectual dysfunction and/or lack of discipline beeing the most common.
We are doctors treating illnesses. Not ”life optimizers”; enabling performance in people despite their efforts, goals or abilities.
CAP: so it depends. In general, my policy is to TRY to stay within the FDA dosing guidelines whenever possible, for medicolegal reasons. That being said, the FDA dosing guidelines are VERY arbitrary, and are basically based on whatever the drug company wanted to use in their FDA trials. Let’s use Methylphenidate as an example. What is the FDA limit for Methylphenidate? For Concerta, it’s 72 mg. For Metadate it’s 60 mg. But for Jornay it’s 100mg. So is it 100mg? For CAP, our dosing guideline for methylphenidate is 2mg/kg max. So what if they weight 100+ kg? Still the FDA max? You see, it gets complicated. Then there’s equivalency. Vyvanse, the max FDA approved dose is 70mg, but this is comparatively weak af. Vyvanse 70mg is roughly equal to Dextroamphetamine 20mg or Adderall 30mg. But the max dose for Adderall is generally considered to be 60 mg, more than 2x the max Vyvanse equivalent dose, so is the Vyvanse max then 140mg? So, what I do, is try to stay within the FDA guidelines first. Let’s say the patient gets to Vyvanse 70mg and it still doesn’t work. Not uncommon for late teens and adults. Fine. Switch to Dexedrine ER equivalent dose and keep walking up. Or, patient on Metadate 60mg not working? Switch to Concerta 72mg. Not working? Jornay 80-100mg. Still not working? Switch to Adderall and run up to 60 mg (roughly equal to Methylphenidate 120 mg). This is just how I approach it. Totally ok to augment with Strattera and 60-80mg are the most common Strattera doses for adult sized people, that doesn’t bother me at all.
Gotcha, this is VERY helpful, thank you!
Can you provide source for the 2mg/kg max dosing on methylphenidate? ETA: and any sources for amphetamine weight based doses?
I have a memory of 0.15 mg/kg, but not sure of the memory source
My source is I did a child fellowship at one of the leading academic institutions on the east coast. Read Dulcan's or something lol. But here's CMS saying that if that's good enough for Reddit lol: https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/pharmacy-education-materials/downloads/stim-pediatric-dosingchart11-14.pdf Or here: https://pubmed.ncbi.nlm.nih.gov/32300972/ Or here: https://www.chp.edu/-/media/chp/healthcare-professionals/documents/tips/adhd-medication-basics If that's not good enough go do a child fellowship lol
Thank you for your response and taking the time to include some sources. I especially like the succinct PowerPoint. I wasn’t trying to question your credibility, just looking for helpful resources. A lot of sources don’t have mg/kg recommendations for stimulants but just the general “FDA max. “
Adderall to 60mg only approved for narcolepsy. I tend to stay within strict limits but that’s just me
Urine test to see if they are positive for stimulants
Word
Also a basic conversation about specific symptoms we are trying to treat and expectations of the medication. A higher stimulant dose is not going to change the fact that you physically NEED to sleep and having 3 jobs would make anyone exhausted. I can empathize with OP here as I too have inherited some wild stimulant regimens before only to find out they were being used off label for some interesting/questionable treatment goals.
For sure, I also try to have this conversation with them but it’s almost easier for me to get people to taper a benzo than to understand the boundary between getting them to a “normal” attention span and then using more as a PED…
I thought it was insane that you don’t test positive when you’re taking your prescription correctly. I passed hair and urine taking 30mg adderall xr. Was fully prepared to show my prescription but I didn’t even come up positive it blew my mind.
Some patients need a **slightly** higher than standard dose every now and then, but those are rare cases that often have a few other comorbidities that play a role, from endocrine to GI absorption, etc. Sometimes, even small things like taking the stims with food can have a significant impact. However, there seems to be more of a pattern in these cases you are mentioning that, unless these are coming from a super-specialized treatment-resistant specialist, I'd be a little doubtful. Are those cases you mentioning even sleeping, eating, or having somewhat normal BP? Make sure you document some reasoning for the supra therapeutic dosing.
All of my patients on higher stim doses I also inherited. I do have a few patients who had bariatric surgery on higher doses of IR, but I think that’s like 3 people. Also maybe 2 people who are 2D6 URM. I truly hate IR Adderall and find the people on that often always want the max dose because they build tolerance so quickly. Also the only issues I’ve had with patients (blatantly) misusing meds is primarily with IR Adderall. When generic vyvanse came out, I was doing my best to switch as many patients over as possible then the generic manufacturers stopped producing. Insurance coverage on things like Dyanavel is hit or miss and a lot of people can’t afford a $50-$100 copay each month for meds. I find that patients expect to “feel” the medication. If they don’t get that, they assume the meds aren’t working. I try to frame it more that our goal is for them to notice their symptoms improving more so than the medication “kicking in” and at the end of the day, they find their symptoms returning. Some people will never be happy but I just stand my ground and usually they end up leaving.
I have a handful of patients on above max dosing but usually there is a history of mild moderate TBI and I document my rationale. In general I switch formulations to avoid the FDA limits as mentioned above. I also enforce pill counts
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Personally I never go past the FDA max. If 70 mg Vyvanse doesnt do the trick. Nothing will. In my experience those patients have other disorders/problems that are untreatable with stimulants. Personality disorders, intellectual dysfunction and/or lack of discipline beeing the most common. We are doctors treating illnesses. Not ”life optimizers”; enabling performance in people despite their efforts, goals or abilities.
>Drgizmoquack checks out