Najem ADHD Clinic

Medications for ADD & ADHD

There are two main medication groups for the treatment of ADD and ADHD : Stimulants and Non-stimulants.

Medical treatment depends on a few things. From my perspective, I always want to use the drug which is easiest, cheapest, and works best. It turns out that about half of the children with ADHD have other neuropsychiatric problems. It is the presence or absence of these other problems which can determine which drug I use. Do they have tics? If so, certain drugs work much better. Are there signs of anxiety and depression? This means certain things will work and other will not. The first choice of drugs for ADHD are the stimulants. The other drugs are all second choice and usually reserved for children who do not respond to the stimulant drugs.

Stimulant medications are the most commonly used for the treatment of ADD and ADHD in both adults and children. There are two main pharmacological agents are in this class:

  1. Methylphenidate
  2. Amphetamine
There are two delivery mechanisms:
  1. Immediate Release or Short Acting (IR)
  2. Extended Release or Long Acting (XR)

Vyvanse

Ritalin

Adderall XR

Non-Stimulants

The Stimulants

Methylphenidate (trade names Concerta, Methylin, Ritalin, Quillivant XR) and Amphetamines (Adderall, Adderall XR) had been studied the most for the past 50 years and used in both children and adults since 1960 for ADD and ADHD. The stimulants work by increasing the Dopamine and Norepinephrine levels in the synaptic junctions of the brain. They allow proper transmission of the thought processes in the brain resulting in the improved performance of the prefrontal cortex which is the center of “Executive Function”. Research indicates that the Amphetamines improve the brain’s networking efficiency, improve performance on difficult and boring tasks and improve the working memory. There is improvement of physical stamina, endurance and improved fine motor coordination. Very high doses of these medications can cause adverse side effects of Psychosis impairment of athletic performance. There is abuse potential and has to be used under direct supervision of adults.

  • Which is the best medicine?

  • The Amphetamine Salts (Adderall) offers the best price/performance of all the stimulants.
  • The choice of medication also depends on the presence of other co-existing psychiatric conditions like Tics, Depression, Anxiety, Oppositional Defiant Disorder, Psychosis or Bipolar disorder.
  • Using stimulants in certain Psychiatric conditions can result in severe side effects. In some patients, Amphetamines can cause intolerance or adverse side effects in which case we can try the Methylphenidate group or non-stimulants.
  • The Vyvanse (Lisdexamfetamine) is a form of Amphetamine with molecular structure consisting of dextroamphetamine coupled with the essential amino acid L-lysine. It is a pro drug with unique ability to deliver a constant and even drug level in the blood which lasts up to 12 hours with a single dose.
  • Many health insurances require that the Adderall and Ritalin should be tried before they allow the usage of the Vyvanse. For more information please visit Vyvanse.
  • Importance of individualized dosing

    We need to customize the dosage for each and every patient in the treatment of ADD and ADHD. Some patients require higher doses than others due to the fact that they metabolize the medications faster. Some patients need much lower levels of medication. At the clinic we start all new patients with a very small dosage and gradually increase the medication while monitoring the side effects and the improvement of executive function.
    read more...

  • Optimal dosing and enhanced intellectual performance

    When an optimal dose is administered, patients experience enhanced intellectual performance. Due to improved fine motor coordination, one can experience enhanced performance at various sports. read more...

STIMULANT MEDICATIONS

Generic Name Extended Release Short Acting
Methylpenidate
Hydroichoride		 Concerta
Daytrana Patch
Metadate
Ritalin, Ritalin SR, Ritalin LA		 Methylin Tablet
Ritalin Tablet
Amphetamie Adderall XR Capsule Adderall Tablet
Lysdexamphetamine Dimesylate Vyvanse Capsule
Dexmethylphenidate Focalin XR Capsule Focalin Tablet
Dextroampetamine Dexedrine Capsule

Special Populations

Preschool

Generally this group would not be treated with medications. In some circumstances, medications are used in this group if the child's behavior is so disruptive that he or she cannot attend a structured preschool program and cause severe disruptions at home as well. It is important to get children with severe ADHD into preschool as it can be very helpful in building their social skills. When other conditions like OCD (Obsessive Compulsive Disorder), ODD (Oppositional Defiant Disorder) or Bipolar disorder coexist, the household is in constant turmoil. Parents can’t cope up with the disruptive behavior of the child. Sometimes the child's behavior is causing severe impact on spousal relationships or other sibling’s daily routines. Overall, these medications are safe when used judiciously and cautiously in this age group. It is very important to diagnose and treat co-morbid conditions.

Teenagers

The stimulant medications are very effective in this group. The immediate release stimulants need to be given 2 to 3 times a day. Long acting stimulants are very useful but they are very expensive compared to the immediate release medications. It is important to look at the insurance coverage before we use them.

Abuse of stimulants

The ADD/ADHD children have a tendency to get addicted to various drugs. There is a possibility of abuse of the stimulants by adolescents and adults. The parents should keep the medications under lock and key and administer the medications under direct supervision. When teenagers with ADHD are treated with stimulants, they are less likely to end up abusing various recreational drugs than teenagers with ADHD who are not treated. The Clinic does drug screening of all of the adolescent and adult patients to make sure that they are not abusing other narcotic medications and recreational drugs

Side Effects of Stimulants

  • 01

    Sleep

    Insomnia is one of the common side effect of the Stimulants. Sleep deprivation cause irritability, poor concentration, and fatigue leading to poor academic and work performance.Remove TV and electronic gadgets from bedrooms.Avoid TV or computer screens for one hour prior to the sleep time. Soft soothing music and reading a book may be in order. There are certain medications we can use to help with sleep if insomnia becomes a persistent problem.

  • 02

    Loss of Appetite

    Lack of appetite and poor food intake is very common with stimulant medications. After all, these are the same family of drugs used for weight loss. I keep track of the weight of my patients at every single visit. If there is too much weight loss, we may have to lower the stimulant dosage and add a non-stimulant to get the effective therapeutic results.

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  • 03

    Rebound

    The short acting drugs (Adderall and Ritalin) often can cause “rebound” effect. When the the drug is wearing off the child has exaggerated symptoms of the ADD/ADHD. This can last 2-3 hours. This problem can be solved by giving a very small dose of stimulant medication at 3:30 – 4:00 pm.

Cost of
Stimulant Medications

Generally it is better to get these medications at Costco, Sam’s Club or Walmart pharmacies. They tend to carry better quality generic equivalent medications at lower prices. You can visit https://www.rxpricequotes.com/ to get best price for a given medication near your zip code.

Name Type Cost for 1 dose
1 Adderall Immediate Release $0.30
2 Adderall XR Extended Release $4.30
3 Ritalin Immediate Release $0.30
4 Ritalin LA Extended Release $8.46
5 Daytrana Patch Extended Release $14.71
6 Vyvanse Extended Release $13.02
7 QUILLIVANT SUS XR Extended Release $3.90

Cost of
Non-Stimulant Medications

Name Type Cost for 1 dose
1 Clonidine Immediate Release $0.33
2 Clonidine ER Extended Release $3.30
3 Guanfacine Immediate Release $0.33
4 Intuniv Extended Release $7.05
5 Strattera Extended Release $12.80

Non-Stimulant Medications

This class of medications are very safe to use and have very few side effects. They is no abuse potential and are non-habit forming. The Immediate release medications – Guanfacine and Clonidine are very inexpensive. However, they cause too much drowsiness and I use them at night time to help the patients with sleep problems.

They work at the prefrontal cortex of the brain improving the connection speed.
The time release versions of these are more expensive and are used in the morning time. Generally it takes 3-4 weeks for these medications to work. They are not as effective as the stimulant medications.

Strattera (atomoxetine) is a non-stimulant and is a norepinephrine reuptake inhibitor and has been in use for over a decade. It has common side effects of abdominal pain, loss of appetite and weight.
It is very useful in cases of co-morbid conditions like anxiety and depression. Once again it takes up to 3-4 weeks for this medication to work. The clinical effectiveness is not as good as the stimulant medications.

  • 01

    Monitoring

    I get an Electrocardiogram on all my new patients to make sure that the cardiac function is normal. I would repeat the EKG depending on any abnormal findings or advanced age of the patient. I get comprehensive lab test to make sure that the Liver, Thyroid, Kidney functions are normal. The labs are repeated every 1-2 years depending on the age and health status of the patients

  • 02

    Administering medication

    Some of these medications need to be administered two to three times a day. The medications need to be securely stored under lock and key and administered by parents under direct supervision. The children usually go to the school nurse or principles office to get the afternoon dose. If long acting medication is used, a morning dose may be the only medication needed for the day.

  • 03

    Controlled Substance Class II

    All the stimulant medications are classified as Controlled Substance Class II. These medications are closely monitored by the Federal DEA and State Authorities. The Physicians are held responsible for careful dosing, prescribing and monitoring the medications and the patient’s health. A centralized computer databank called “MAPS” is used by Physicians and Pharmacists to make sure that the patients are not having multiple prescriptions from different Physicians and that the Physicians are prescribing the medications ethically and responsibly.

Resources

ADHD Medications
ADHD Suppliments
Behavioral Health Topics
Online Testing

Clinic Hours

Mon: 9am-5pm
Tues- Wed -Thurs: 12pm-5pm
Fri: 9am-12pm
Sat: 9am-12pm

Najem ADHD Clinic

26850 Providence Parkway
Suite 300
Novi, Michigan
48374
(248) 348-4200

When you take these medications you may not feel anything different. One can easily assess the clinical effectiveness by doing the following exercise:

It turns out that about half of the children with ADD/ADHD have other neuropsychiatric problems. It is the presence or absence of these other problems which can determine which drug I use. Do they have tics? If so, certain drugs work much better. Are there signs of anxiety and depression? Then we use caution while using the stimulants. The first choice of drugs for ADHD are the stimulant medications. The non-stimulants are second choice. In some cases, I use the stimulants and non- stimulants together. We may have to treat the co-morbid conditions like depression and anxiety disorders with other medications or counselling before we treat the ADD/ADHD.

I call this process “Titration”. One should not increase the medication further when you experience significant side effects. By doing the titration, we can identify the slow metabolizers that require smaller doses and avoid overdosing. I arrive at an optimal dose for each patient (the lowest dosage with best results without major side effects). The loss of appetite and some weight loss are expected in most of the patients.