Meds and Metabolism ...

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Registered: 03-26-2003
Meds and Metabolism ...
4
Tue, 06-10-2003 - 2:56pm
(Geez, these short discussion titles are tough, LOL!)

I have a question for you wise people: Do any of your kids seem to metabolize their meds more quickly than "average"? My ds did very poorly on Concerta last year - it didn't last anywhere NEAR as long as it should have. He wound up taking Ritalin (the "regular" variety) three times a day. When he developed a facial tic, he was switched to Strattera. He now takes 18 mg of Strattera twice a day (i.e., 36 mg total), after taking a lower (more appropriate for his weight) dose of 25 mg per day for a couple of unimpressive months. (He is almost 7 YO, about 45 pounds, so this new regime is a pretty big dose, and I *really* hesitated to put him on it!)

Our problem (okay, one problem!) is that it just doesn't seem to last him for 24 hours (or 12 hours and 12 hours). Depending upon when he gets his evening dose, we either have a cr*ppy bedtime (if I wait until just before bedtime to give it to him) or a cr*ppy morning (if I give it to him shortly after dinner so that bedtime is pleasant). I did speak with his PED recently, and the PED said that there is a lot of anecdotal stuff floating around about Strattera NOT being a 24 hour drug like it is cracked up to be. (Haven't discussed that far with the p-doc yet).

Has anyone else had the same experience? What did you do to counter the effect? Increase the number of doses, or increase the dosage, or both? The p-doc did mention that it might be a "metabolism issue" - that ds is just metabolizing the stuff too quickly. I DON'T want to boost his dose anymore if we can help it, but there seems to be very little documentation of dosing Strattera more than twice a day. I think that we also need to try to re-introduce a small dose of a stimulant med (assuming we can do so without the tic reappearing) because the Strattera is doing diddly for ds' concentration. Anyone else doing that combo?? Comments?? (please!)

DS also seems to have a VERY fast metabolism in terms of how his body metabolizes his food intake (something that others of us would LOVE to deal with, I know, but in ds' case it has resulted in an all-muscle beanpole). Could the two metabolic issues be related?? Any words of wisdom? I actually find this to be a kind of interesting issue in the abstract ... but I wish my life were a bit *less* interesting sometimes!! ;o) Thanks, all! ~ ruth

edited to add: OOPS! sorry to have posted this in the wrong folder -- hope everyone finds it okay!!


Edited 6/10/2003 3:36:11 PM ET by meshuggenamom

Avatar for kellystee
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Registered: 04-29-2003
Wed, 07-09-2003 - 5:23pm
Two things about your message:

1. I'm surprised you got a doctor to give you that big of a dose of Strattera. My ped. cut us off at 18mg and would give no more. He was pretty adamant about it too. And you've found the higher dose to be effective?? I am now a strong disbeliever to Strattera. That drug did nothing for my son (or my family) but make our lives miserable and stressful (and doc just kept saying give it time). Two months later (as of today, actually) he's back on Adderall. My problem is that he becomes very tolerant to these medications. :o(

One thing. . .we did try the combo and that seemed to work pretty well. I think that would be something to try. I guess the bright side is that the meds ARE working; just wearing off fast.

2. My son also has a high metabolism (also skinny as a bean pole to the point where the doctor is slightly concerned about his weight) but doesn't seem to have the same problem with the meds.

Although none of this helps you, thought I would respond. Good luck!

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Registered: 03-26-2003
Wed, 07-09-2003 - 10:34pm
Hi, thanks for the feedback. I guess I'm surprised at your surprise, LOL! ... Strattera is dosed by weight (as I'm sure you know); the "recommended" dose for my approximately 45 pound son is 25 mg, which was his initial dose. Maybe the 18 mg dose was just too *low* to be effective for your son??

When the p-doc upped the dose to 18 mg twice a day (i.e., 36 mg per day), I ran it by our PED before filling the script. He (our PED, who I trust implicitly) told me that, even though the manufacturer had initially indicated specific weight-based doses based upon a mg per kg calculation, there is a lot of movement now toward the higher doses. I'd be less-than-honest if I didn't admit that I was hesitant to give ds a higher-than-"officially"-recommended dose, but the fact that my usually not-quick-to-jump-on-the-bandwagon PED okayed it without hesitation, coupled with the fact that I had read some other articles reporting that it was safely being used in this manner, persuaded me to at least try the higher dose for ds. Even though the p-doc prescribed 18 mg twice a day, he told me that, if our prescription plan wouldn't cover 60 pills a month (2 x 30) ds could take a single 40 mg pill of the drug each day. As a matter of fact, he wrote ds *two* scripts, to cover either contingency. (Okay, I thought *that* was a little cavalier -- not worrying about the "extra" milligrams in an already high dose. Fortunately, our plan covers the 60 pills per month, so I didn't have to deal with deciding whether or not to go to 40 mg.)

I'm really sorry that Strattera didn't work for your son. At this point, it works marginally for mine: mostly for his impulsivity, and very little with regard to focus. We have an appt with a new p-doc at the end of the month, so I am hoping that he will come up with a "magic bullet" combo of something that -- in conjunction with the behavioral therapy from our psychologist -- will work well in all realms. We are hoping that we will have a good combo in place by the time school starts again in the fall. But, I know that Strattera *is* working well for many, many people, so I hesitate to call it a "worthless" drug even though it's had less-than-fabulous effectiveness for my ds as a solo medical therapy.

Thanks again for your input -- much appreciated!!

Avatar for kellystee
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Registered: 04-29-2003
Fri, 07-11-2003 - 5:49pm
Okay, so I said all that stuff two days ago and now I'm beginning to have a totally different opinion (wow, how things have changed!). It's amazing what you forget! I started Justin on Adderall about two days ago, and it has been soooo depressing re-living and dealing with all the nasty side effects of stimulants again! In the past two days I have learned that Strattera DOES curb a lot of his hyperactiveness - enough at least so that we could live with him for two months and be pretty happy with him (because now in the morning and at night I'm back to living with a monkey - a LOUD monkey that is!!). It didn't help at all though when he is around other children, at school, or even with other groups of people. This is when we saw him really lose control and the medicine just wasn't strong enough to control that. And it didn't help with the schoolwork and focus, just like you said.

The good things, though, about Strattera that I now miss (and are were MANY!) is that he had such an 8-year-old personality!! It was like we had a totally new kid!! He wasn't clingy, or shy, or easily embarrassed or upset. He also started eating soooo much better (he gained 8 pounds in 2 months!! He was really under-weight) and sleeping better and even using the bathroom better (kindof gross, but because he ate so little on the stimulants, he was having these "accidents" constantly that suddenly went away). He used to have headaches on the stimulants, so that went away. His crying and whining ceased too. I vowed I would NEVER put him back on a stimulant after what I saw when we took him off of them - I said "no more zombie-kid for me", but after two months of pretty much daily notes and calls from the teacher from a very miserable teacher and a whole summer camp incident where they are threatening to throw him out after 4 days, I've just given up. I think it hurts his confidence and self-esteem so much to constantly be labeled "a bad kid" and have to be constantly disciplined. And he constantly cries and tells me how he's so sorry he's so bad and he tries so hard to be good (heart-wrenching literally! And I never even tell him he's "bad").

Putting him on Adderall, though, has caused all of those "bad" stimulant symptoms to surface overnight and I've just been in a real state of depression over it. It's a no-win situation. He's so irritable on the Adderall - cries over the smallest things; he doesn't eat a thing; and I guess the dose has been SO strong for him these past two days and his body is not used to it that he was up from 1am to 4am last night!!! WOW!!! That's a new one for me!!

After you mentioned the 25mg dose, I'm beginning to think that is what he was taking. I need to go find the prescription bottle. I'm also considering talking to the doctor about the higher dose like you've done. I just don't know if I can handle the stimulants again. When he "comes down" off it, he is just out of control!! :o( This is a bad week for me.
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Registered: 03-26-2003
Sat, 07-12-2003 - 11:00am
{{{hugs}}} to you! I know that "between a rock and a hard place" feeling, too!

WRT to possibly increasing your ds' Strattera dosage: Who is prescribing/monitoring your ds' meds? For my ds, the higher dose of Strattera was prescribed by a child psychiatrist; our PED told us that he was at the outside limits of his comfort zone with these meds (he was the one who had prescribed ds' ritalin, concerta, and the initial dose of strattera), and that he recommended that we seek the care of a p-doc to go further in ds' meds. The PED still, obviously, is our "primary" doctor for ds, and we have every report and file sent to his office from the psychiatrist and psychologist, but for "med management" we are now using a child psychiatrist who specializes in ADD and ODD kids. (DS falls into both categories.)

We did have a little bit of a tough time finding a p-doc who accepted our health insurance (and we have a very good PPO from a major provider) ... many of them didn't accept ANY insurance, for some reason. It was frustrating, but I finally did find a couple of practices who covered us. (If I hadn't, we would have certainly found a way to come up with the $150+ an hour for the p-doc, but it's nice that it didn't come to that.)

DS actually did relatively well on Ritalin (his impulsivity/oppositional issues are almost exclusively limited to when he is with dh and me, and he is ADD-inattentive, with no hyperactivity component, so the effects of the ADD even at school have been limited) but he developed a facial tic after awhile; that's when we switched over to Strattera. Concerta (which we tried before switching from twice-a-day ritalin to three times a day ritalin) was pretty much worthless for ds - again, I think that goes back to the "metabolism" issue. So, we are hoping that our end-of-the-month visit to our new p-doc (wish us luck!) will yield a "magic combination" of meds that is effective for both the impulsivity/oppositional issues and the focus issues.

Oh, also ... did you "wean" your son down from the Strattera/up on the Adderal dose or just switch over all at once? When ds was starting Strattera, we gradually reduced his ritalin dose and started him out on a smaller initial dose of Strattera, per our PED's instructions. The "change-over" took place over, I think, four days. From what I have read, an abrupt switch may have something to do with his reaction to the meds.

I'll be thinking about you and hoping that you, too, find the "magic combination" of meds for your son. Hang in there!