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ADD, ADHD Medication: Find The Sides of the Therapeutic Window.

Posted Nov 05 2008 4:14am

A carpenters' ruler with centimetre divisionsImage via Wikipedia

7 Essential Tips to Find Those Effective Sides of the Therapeutic Window When Treating ADD/ADHD

The 'Sides of the Window' are Puzzling and Require a Few More Office Questions. The reason to ask the questions is simple: we want to know exactly how the medication is working in the context of time of day, duration of effectiveness, and predictable expectations from the specific medication in question.

I've been talking about the Top and Bottom of the Window
for some time now, so let's check out the sides.

The simplified version of that statement: Cookie cutter medicine based upon weight, age, body size is outdated, and simply ineffective.  - So let's get the details right every time by starting from the same place using the same predictable grid for measurement of effectiveness. These 7 Tips for the Sides of the Therapeutic Window, coupled with measurements from my other articles here on 7 Tips from the Top and the Bottom of the Therapeutic Window will outline precise treatment objectives. I have been using these 'Window Strategies' with thousands of patients for more than 12 years, and I can assure you, they work like a correctly timed clock. Predictable outcomes should be the standard of care.

The 7 TIps For The Sides of The Therapeutic Window for Stimulant Medications.

  1. The Sides of the Window Are Based Upon Time: The Expected DOE - Duration of Effectiveness of that specific medication for that  specific persons metabolic rate,  and must be customized for every person from the outset and throughout the duration of treatment. Every person burns medications at different rates that cannot be predicted by superficial appearances of weight or size. I have an ex-Navy [Nuclear] Commander who stands about 6'6," and looms over me, - has to duck when he comes in the door, - he takes only Adderall 10 mg XR and the DOE is a reasonable 10 hr. We want to have a specific match between expected duration and clinically effective duration.
  2. Know the Medication DOE Expectations from the Outset: Authorities and studies disagree on some of the next points on specific medications I am about to discuss. Pharmaceutical companies have done their homework, and are focused on these same DOE objectives, - I simply disagree with some of their DOE findings based upon my own abundant office experience. Many studies range in the thousands of patient hours over years of treatment using a determined focus on this 'Window' grid. See the 7 Tips for the Top of the Window Article for more details on specific medications.
  3. Start Working: Measure Precisely the Time DOE At Every Meeting: Easy questions: "When did you take it and when does it stop working?" If taken at 7 AM and it lasts until 3 PM - that is the DOE. The Math is Simple: 5 hrs in the AM + 3 in the PM = 8 hrs. A medication might work for 8 hrs, but still keep the person out the Top of the Window if the IR is pushed too high.
  4. The First Side Objective - AM Onset: All meds should be working in 30-45 min after taking the medication. IR [Immediate Release] Tablets have a fast onset, but the sides of the window are too narrow, and the DOE [Duration of Effectiveness] Is out just too fast - meaning it simply lasts only a short part of the day. IR meds need  2-3 times a day dosing because the DOE is far too short. If the AM Onset is more than 45 min the dose is either too little, it isn't  working at all, or it can be too much - see point 4 of the 7 Tips for the Top.
  5. Regulating the AM Onset: Breakfast is Essential, Protein Breakfast Works Best More Often: With meds, since we are now paying attention to the rate of metabolism, the DOE, we are much more interested in "rate limiting steps." Breakfast is an imperative rate limiting step that is essential for all psych meds to prevent irritation of the gastric mucosa [stomach lining]. With breakfast that early side of the 'Window' is more gentle, and less involved with uncomfortable peaks of medication excess.
  6. The Second Side Objective - The PM Release - When They Stop Working: The extended release capsules from Concerta to Adderall XR are all mechanically released, and have unpredictable release times based upon acid base variables in the stomach and bowel - and upon the transit time of the bowel contents. Long transit time often means greater sensitivity to meds and a relative accumulation of meds over time, with a narrowing of the 'Window.' Metabolic challenges with bowel function almost always change the PM release time, when the meds stop working. Vyvanse is not as vulnerable to rate changes based upon acid/base balance or transit time.
  7. The Mystery Objective: The PM Release with Vyvanse: Vyvanse deserves it's own tip because it is so effective, with such an excellent, predictable 12-14 hr DOE. Think of this simple point when measuring the DOE with Vyvanse - the metabolically released stimulant is so different that many don't "feel it working" and therefore miss when it "quits working." Remember with Vyvanse: look for the original cognitive, "mental" objectives, not the somatic, buzzy effects. When Vyvanse quits in the PM the ability to finish tasks is gone.

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