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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by Peter on September 10, 2003, at 10:58:08
Tomorrow I'm trying the switch from adderall IR to Concerta. I currently take adderall 10mg TID (30mg total). Pdoc said I should replace the adderall tomorrow with TWO 18mg Concerta caps.
I thought I heard somewhere that amphetamines are 2x more potent than ritalin. Is this true?
If that's the case, I would think that 54mg Concerta (not 36mg) would be more equivalent to 30mg adderall. Does anyone know the answer to this one?
What dose of Concerta would be roughly equivalent to 30mg adderall?
thanks,
Peter
Posted by Ame Sans Vie on September 10, 2003, at 12:47:47
In reply to stimulants-equivalent doses, posted by Peter on September 10, 2003, at 10:58:08
"The 7.5-mg twice-a-day dose of Adderall and the 17.5-mg twice-a-day dose of Ritalin produced equivalent behavioral changes. This indicates that a 5-mg dose of Adderall (or slightly less) is equivalent to a 10-mg dose of Ritalin, indicating that Adderall is twice as potent; this potency ratio is similar to the well-known 1:2 ratio between d-amphetamine and methylphenidate."
http://www.addcentre.co.uk/On-Task-August.html
You're right about amphetamines being twice as potent as methylphenidate. I've yet to meet a psychiatrist who isn't aware of the amp/MPH 1:2 ratio, so he probably has a reason for starting you off a bit low. It does seem as if a 56mg dose of Concerta should work best for you, but perhaps your psychiatrist is being cautious because of the peripheral effects methylphenidate tends to cause? Methylphenidate can differ significantly from amphetamines in that regard -- starting with too high a dose could just make you drowsy and dazed, or, paradoxically, miserably nervous and jittery. This could also explain why he's having you take two 18mg Concerta rather than one of the 36mg capsules (which sort of puzzled me at first) -- that way, if the 36mg is too much, you have the option of cutting back on the dose.
Posted by Peter on September 10, 2003, at 13:10:42
In reply to Re: stimulants-equivalent doses » Peter , posted by Ame Sans Vie on September 10, 2003, at 12:47:47
> "The 7.5-mg twice-a-day dose of Adderall and the 17.5-mg twice-a-day dose of Ritalin produced equivalent behavioral changes. This indicates that a 5-mg dose of Adderall (or slightly less) is equivalent to a 10-mg dose of Ritalin, indicating that Adderall is twice as potent; this potency ratio is similar to the well-known 1:2 ratio between d-amphetamine and methylphenidate."
>
> http://www.addcentre.co.uk/On-Task-August.html
>
> You're right about amphetamines being twice as potent as methylphenidate. I've yet to meet a psychiatrist who isn't aware of the amp/MPH 1:2 ratio, so he probably has a reason for starting you off a bit low. It does seem as if a 56mg dose of Concerta should work best for you, but perhaps your psychiatrist is being cautious because of the peripheral effects methylphenidate tends to cause? Methylphenidate can differ significantly from amphetamines in that regard -- starting with too high a dose could just make you drowsy and dazed, or, paradoxically, miserably nervous and jittery. This could also explain why he's having you take two 18mg Concerta rather than one of the 36mg capsules (which sort of puzzled me at first) -- that way, if the 36mg is too much, you have the option of cutting back on the dose.
>>Yes. He also gave me 18mg caps because I was simultaneously starting on lexapro. At first, I began lex 5mg AND switched to concerta 18mg on the same day, and it was hell. The concerta had no effect on me whatsoever, except maybe for some upset stomach and nausea. But the lex was probably producing similar SE's at the same time. So we decided to have me go back to the adderall and do 1 change at a time. Now that it's been 5-6 days on 5mg lex, and I'm not experiencing many bad acute SE's, he wants me to try the concerta again, this time 36mg. I guess you're right as to the reason why he's not having me go up immediately to 54, since we still have some lex SE's in the mix, and it would suck to have more bothersome SE's from the concerta.
Thanks for the info & your response,
Peter
Posted by Ame Sans Vie on September 10, 2003, at 13:23:52
In reply to Re: stimulants-equivalent doses » Ame Sans Vie, posted by Peter on September 10, 2003, at 13:10:42
> Yes. He also gave me 18mg caps because I was simultaneously starting on lexapro. At first, I began lex 5mg AND switched to concerta 18mg on the same day, and it was hell.
Yech... I bet, lol.
> The concerta had no effect on me whatsoever, except maybe for some upset stomach and nausea. But the lex was probably producing similar SE's at the same time.
Yep, most likely. While Lexapro seems to have the fewest side effects of the SSRIs (for most people, anyway), nausea and other G.I. discomfort are pretty common.
> So we decided to have me go back to the adderall and do 1 change at a time. Now that it's been 5-6 days on 5mg lex, and I'm not experiencing many bad acute SE's, he wants me to try the concerta again, this time 36mg. I guess you're right as to the reason why he's not having me go up immediately to 54, since we still have some lex SE's in the mix, and it would suck to have more bothersome SE's from the concerta.
> Thanks for the info & your response,
> PeterNo problem -- be sure to keep me updated on the Concerta! I've had bad responses to Ritalin IR in the past, but if Concerta is more smooth-acting, I just may give it a shot. No reason for me to settle on my current DextroStat without examining all the options. :-)
Posted by Peter on September 11, 2003, at 10:58:02
In reply to Re: stimulants-equivalent doses » Peter , posted by Ame Sans Vie on September 10, 2003, at 13:23:52
> No problem -- be sure to keep me updated on the Concerta! I've had bad responses to Ritalin IR in the past, but if Concerta is more smooth-acting, I just may give it a shot. No reason for me to settle on my current DextroStat without examining all the options. :-)
>> Well, today has been my first day on Concerta 36mg. Yes, it is more even/consistent/sustained in its action, but its action sucks! This might sound wierd, but I feel like I'm on a high dose of depakote - complete emotional blunting, apathy, no energy, and some annoying, sporadic peripheral effects - nausea, shortness of breath, some subtle anxiety waves. It's like that wet-blanket feeling you get on high doses of AC mood-stabilizers.
Great, now I don't know what to do. The adderall at least gave me some more alertness and sociability 1-2 hours proceeding each dose - but then it usually threw me into a low, zombie-like state. I've also tried dexedrine SR, but only for a short time; but the few days I tried it, it just seemed to space me out a lot. What else is there in terms of stims?! If only that initial 1 or 2 hour period of gregariousness and mood lift that I get from each adderall dose could be sustained without dropping me into all those peaks and valleys and eventually leaving me like a zombie by evening! I've tried adderall XR, but it just feels like what it is - 2 doses of adderall released 4 hours apart. It didn't feel even or sustained.
I also take 3mg klonopin; 1mg divided into 2 doses during the daytime and then a single 2mg dose at bedtime. Maybe the klonopin's synergy with the stims is creating these problems?
Meanwhile, it's day 6 on lexapro 5mg. I have no idea if it's working yet or not; I'm taking it for anticipatory anxiety and depressive episodes. SSRI's always posed problems for me in the long-run, as they usually end up making me apathetic and emotionally numb, which in turn causes me to seek stimulus in alcohol and drugs. The only thing that seemed to counteract this numbness in the past was when I combined an SSRI with a stim, as me and my pdoc planned to do again this time. I guess the need for stimulus when taking SSRI's might be some sort of SSRI-induced dopamine deficiency that the stims usually took care of.
But now it's all very frustrating. I don't know what stim to take, if any, because they seem to be affecting me more negatively than positively; and I don't know how the lexapro will do.
Peter
Posted by Ame Sans Vie on September 11, 2003, at 12:22:44
In reply to Concerta report » Ame Sans Vie, posted by Peter on September 11, 2003, at 10:58:02
> Well, today has been my first day on Concerta 36mg. Yes, it is more even/consistent/sustained in its action, but its action sucks! This might sound wierd, but I feel like I'm on a high dose of depakote - complete emotional blunting, apathy, no energy, and some annoying, sporadic peripheral effects - nausea, shortness of breath, some subtle anxiety waves. It's like that wet-blanket feeling you get on high doses of AC mood-stabilizers.
The way you described it is exactly how IR methylphenidate makes me feel... guess I won't be trying this one. Oh well.
> Great, now I don't know what to do. The adderall at least gave me some more alertness and sociability 1-2 hours proceeding each dose - but then it usually threw me into a low, zombie-like state. I've also tried dexedrine SR, but only for a short time; but the few days I tried it, it just seemed to space me out a lot. What else is there in terms of stims?! If only that initial 1 or 2 hour period of gregariousness and mood lift that I get from each adderall dose could be sustained without dropping me into all those peaks and valleys and eventually leaving me like a zombie by evening! I've tried adderall XR, but it just feels like what it is - 2 doses of adderall released 4 hours apart. It didn't feel even or sustained.
Well, there aren't many options left, but there are a few. The most obvious and sensible one seems to be going back on Adderall or Dexedrine, but talk to your doctor about not spacing your doses so far apart. For me, a single dose of Dexedrine (actually DextroStat, but they're both dextroamphetamine) works very well for 5.5 hours then I gradually begin to "crash" over the next hour and a half. So I take my next dose *before* the current dose wears off. This way, as the first dose is losing effect, the second dose is kicking in. It took a little bit of experimentation for me to find exactly how to time this. For me personally, taking my next dose five hours, fifteen minutes after the first provides an absolutely smooth effect. No ups and downs throughout the day whatsoever. To avoid feeling zombie-like at the end of the day, what about adding one final, smaller dose a couple hours before bed? Just for the sake of example, as I don't know which doses of amphetamines work for you or how long their duration is for you, one possible dosing schedule could be something like:
8:00AM -- 15mg
11:45 -- 15mg (about 15 mins. before 1st dose begins to wear off)
2:30 -- 15mg
6:15 -- 15mg
10:00 -- 7.5mgJust an idea.
Also, I realize that most people don't have such an extended duration of effect with immediate release amphetamines. For most, they last more like 2-4 hours, at most. But I've found that mixing the amphetamine with 1/4tsp of sodium bicarbonate (baking soda) seems to extend the duration of action by about 150% and very noticeably increases its strength -- using the baking soda makes each of my 15mg doses seem more like 30mg. Any good prescribing information on amphetamine, d-amphetamine, or methamphetamine will tell you that gastrointestinal alkalinizing agents (such as sodium bicarb) increase the actions of amphetamines. Conversely, acidifying agents decrease their actions (e.g. vitamin C [ascorbic acid], citric acid) -- that's why you're told not to drink fruit juices with amphetamines. If salt intake is an issue for you though, calcium carbonate also works very well. Myself, I actually crush the tablets and stir the powder into a small amount of water along with the baking soda and a little sugar (sugar purely for pallatability -- baking soda has a taste I could never get used to, lol). This seems to work much more efficiently than simply swallowing the tablets and drinking the bicarb solution separately. Also, I've personally noticed that drinking any type of carbonated beverage within an hour of taking my dose *vastly* decreases its effect, often to the point that it simply doesn't work at all.
Have you tried Desoxyn (or the controlled release form, Desoxyn CR)? It's methamphetamine... perhaps it'd be gentler on your system?
Beyond that, the only idea I have is to try some of the other drugs effective for ADD/ADHD like Strattera, Wellbutrin, or Cylert. Each of these medications lasts all day and all night, so no need to worry about the amphetamine crash. If you haven't already tried it, Strattera may be a good first choice, and Cylert (though there are dangers associated with its use) may also be an option. Cylert supposedly acts more like a "true" stimulant than these other drugs, for the most part -- I've never tried it, so I wouldn't know. Wellbutrin, though it may help, is often compared to methylphenidate in its stimulating effects... so if you don't like Concerta, Wellbutrin may not be a great idea either. Who knows.
One final thought -- how about augmenting Adderall/Dexedrine with one of the above medications (or maybe even Provigil?) to help smooth things out?
> I also take 3mg klonopin; 1mg divided into 2 doses during the daytime and then a single 2mg dose at bedtime. Maybe the klonopin's synergy with the stims is creating these problems?
While anything's possible, I doubt that's the case. What you describe sounds exactly like the classic amphetamine comedown and crash. I take Klonopin at 8mg/day (3mg AM, 2mg noon, 3mg PM) *and* Ultram (150mg AM and noon, 100mg PM) along with DextroStat (15mg three times daily) -- no problems. But of course YMMV. I do certainly agree though that there is a distinct synergism between benzos and amphetamines.
> Meanwhile, it's day 6 on lexapro 5mg. I have no idea if it's working yet or not; I'm taking it for anticipatory anxiety and depressive episodes. SSRI's always posed problems for me in the long-run, as they usually end up making me apathetic and emotionally numb, which in turn causes me to seek stimulus in alcohol and drugs.
It's the exact same way for me -- Paxil, Zoloft, Luvox and Celexa all left me feeling dead inside and drove me to self-medication. I'm sure Prozac would have done the same thing, but my doctor never raised my dose high enough for me to find out. If it's any consolation though, Lexapro was the one SSRI that actually didn't cause that horrible apathy/thymoanaesthesia. It did cause the usual sexual side effects (big surprise, huh?), which was my reason for discontinuing. Other than that, it was surprisingly effective, but I was on a much higher dose than you are currently -- 40mg/day for about six weeks before I noticed an effect.
> The only thing that seemed to counteract this numbness in the past was when I combined an SSRI with a stim, as me and my pdoc planned to do again this time. I guess the need for stimulus when taking SSRI's might be some sort of SSRI-induced dopamine deficiency that the stims usually took care of.
I believe that's a fairly widely-accepted hypothesis. I'm not sure of the details, but if I understand it correctly, your brain wants to remain somewhat "balanced". So increased brain serotonin activity may result in downregulation of dopamine/norepinephrine/GABA/who-knows-what-else in order to compensate.
> But now it's all very frustrating. I don't know what stim to take, if any, because they seem to be affecting me more negatively than positively; and I don't know how the lexapro will do.
> PeterWell Peter, best of luck -- I suggest you give consideration to some of the ideas I have about the stims (especially the more frequent dosing and baking soda options). As for the Lexapro, just hang in there and expect that you will most likely have to raise the dose at least to 10mg to reap any true benefit.
~~Michael
Posted by Hattree on September 11, 2003, at 12:55:52
In reply to Concerta report » Ame Sans Vie, posted by Peter on September 11, 2003, at 10:58:02
I've had similar feelings on Concerta when the dose was too low, particularly coming off Adderall. I'm finding it to be a mixed-bag med.
>complete emotional blunting, apathy, no energy, and some annoying, sporadic peripheral effects - nausea, shortness
of breath, some subtle anxiety waves.
Posted by Peter on September 12, 2003, at 12:59:59
In reply to Re: Concerta report » Peter , posted by Ame Sans Vie on September 11, 2003, at 12:22:44
> Well Peter, best of luck -- I suggest you give consideration to some of the ideas I have about the stims (especially the more frequent dosing and baking soda options). As for the Lexapro, just hang in there and expect that you will most likely have to raise the dose at least to 10mg to reap any true benefit.
>> Thanks a lot for all your advice. As for non-stims, have tried strattera (I actually took it along with lamictal, adderall, and prozac, and klonopin, for a few months, but I never got it up to a very therapeutic level. I started getting very symptomatic and we had to taper me off of just about everything and start again from a clean slate. I also tried wellbutrin for a few weeks, but it just made me feel anxious and uncomfortable. But as for using another med to 'smooth over' the adderall, SSRI's have actually done a good job in the past for me of decresing the peaks and valleys of the stim, and that synergy is what I hope to achieve when the lexapro begins working.
>>I spoke to my pdoc yesterday, and I'm back on the adderall, taking 10mg TID, and I'm taking each dose a little less than 4 hrs. apart. So far so good. I also increased the lexapro to 10mg today - no SE's, thank god, and I'm feeling significantly better.
>>Oh-about the sodium/calcium carbonate to extend the action of the adderall - what about if I just chewed 2 TUMS ULTRA with each dose? Each TUMS tablet contains USP grade 1,000mg calcium carbonate. What do you think?
Thanks again,
Peter
Posted by Ame Sans Vie on September 12, 2003, at 14:03:42
In reply to Re: Concerta report » Ame Sans Vie, posted by Peter on September 12, 2003, at 12:59:59
Glad to hear things are working out a little better for you! :-)
As for the Tums, sure, go for it. I use Mylanta Gelcaps occasionally instead of baking soda (when I'm not at home, for example) -- I take four at a time and they each contain 550mg calcium carbonate and 125mg magnesium hydroxide. Baking soda definitely has a more noticeable effect, though.
This is the end of the thread.
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