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Re: Lynne: (Re: Focalin XR vs Concerta motherof2plustwins

Posted by ADHDdoc on April 10, 2006, at 19:13:49

In reply to Re: Lynne: (Re: Focalin XR vs Concerta Lynne, posted by motherof2plustwins on April 9, 2006, at 2:03:50

I am a physician; I treat only children with ADHD, and know a fair amount about all the medications that you and others have discussed. Let me add just a few thoughts to what has been said already:

1. ADHD is a CHRONIC condition. Your daughter may have to take some sort of medication to treat her ADHD for at least the duration of her schooling, and she may choose to continue to take medication throughout her adult life, since the impairment from ADHD may be lifelong. Therefore, I think you SHOULDN'T settle for treatment with a medication that causes anything more than mildly inconvenient side-effects! Flattening of the personality on stimulants is not uncommon, but I think it is an unacceptable side-effect for most (kids sometimes describe this as "not feeling like myself," or noticing that they're "not as funny" as they used to be). Marked personality flattening is a GOOD reason, I think, to pursue a clinical trial of another medication (and more than one, if needed) - until you find one that doesn't change your daughter's personality.

2. It's fine to compare notes with others about which medications and doses they take. However, you should be aware that what works for them will give you very little help in predicting what will work for you (especially if you're not genetically-related to one another)! Here are only four of the many reasons why this may be true:
a. It turns out that about a third of ADHD patients do much better on a methylphenidate-based medication (e. g., Concerta, Focalin-XR, Ritalin-LA, etc.), while another one-third do much better on an amphetamine-based medication (e. g., Adderall-XR). And, the final third seem to do EQUALLY well on EITHER amphetamine or methylphenidate! The same variability is true about dosage. I have some patients who do well on 36 mg. of Concerta each morning, and others of the same age and size who require 72 or 108 mg. of the same medication to get an optimal effect. There are small genetic differences in how people metabolize these medication, and these can make your response to a treatment quite different from someone else's. So, please feel comfortable doing what works best for you/your daughter, even if someone else reports that they had a horrible reaction to the exact same treatment. That just isn't going to tell you much about what will work for you.
b. About 70 % of children with ADHD also have one or more additional neurodevelopmental or psychiatric problem (such as an anxiety or mood disorder, or Tourette's Disorder, for example). These additional conditions, sometimes called "comorbidity," also may affect how well certain medications are tolerated or what side-effects are experienced. Someone who tells you that their child also has ADHD may not mention that she has an anxiety disorder, also.
c. You can't know whether someone else's doctor is up-to-date on the best treatments for ADHD. So, even if someone else's medication or dosage is different from yours, it doesn't mean that what you take isn't right for you (maybe what THEY'RE taking isn't so great). Just make sure that the physician that YOU are consulting knows about the latest treatments and how to use them optimally.
d. Most lay people can tell you what has worked best for themselves (or their loved ones), but you need to have experience with dozens, or hundreds (you know, A LOT) of patients with ADHD before you can get much perspective on how well certain treatments really work. You may know two people who didn't do well on a certain medication, but that doesn't tell you much about how well it will work for a third person. So don't pay attention to generalizations based on one or a handful of experiences.

3. Always try to use sustained-release stimulants, if you can. They work more smoothly, for many people, and they often cause FEWER side-effects than several doses of short-acting stimulants. Some stimulant side-effects are worsened because of the higher peak levels that short-acting medicines can sometimes reach, and some side-effects actually relate to the medication wearing off! So, if your medicine wears off 3 or 4 times a day, there is a much greater chance that you will experience uneven coverage and/or more side-effects. Grouchiness or tearfulness when short-acting medication wears off is a good example. In the 1980s and 1990s, I used to see that side effect quite often, just as children were getting home from school, and their 11 am-Noon dose of short-acting stimulant was just wearing off. Since about 2000, when Concerta became available, the treatment of ADHD has been dramatically different (and better, happily). If you haven't tried a new treatment since 2000, you should. We have many more options, and can tailor your treatment to meet your specific needs. I have had a total of only ONE patient since 2000 whose parents noted grouchiness as their son's medication wore off! So, to apply this advice to your situation, if your daughter is going to try Focalin, I'd recommend Focalin-XR, the long-acting version.

4. Although stimulants seem to be the most effective class of medications for treating ADHD, there are some non-stimulants that work well for people who can't tolerate full doses of stimulants. Sometimes, you can take a non-stimulant with a low dose of stimulants, and get an adequate therapeutic effect with fewer side-effects than you had on a full dose of stimulants. The trick is NOT to settle for a treatment that makes you miserable because of unacceptable side-effects, unless you have tried EVERY option available. And these days, there are MANY options, and more are becoming available each year! (For example, the methylphenidate skin patch, Daytrana, is a new product that was approved by the FDA only 4 days ago. It may be helpful fior some children who have problems swallowing pills.)

5. Be sure that your doctor is knowledgeable and comfortable with the many available treatments for ADHD. If the first thing you try doesn't work, and your doctor doesn't know what else to do, try to see a psychopharmacology specialist who is familiar with ALL of the available medical treatments. Be wary of doctors who believe that Concerta always is "better" than Adderall-XR, or vice-versa. They are both excellent medications, for the right patients. However, if your doctor doesn't use both medications a lot, he/she may not be familiar with how to use them best! If you are getting frustrated, ask for a referral to a psychopharmacology specialist.

Good luck!


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