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WHAT IS THE CORRECT MEDICATION?
At the present stage of medical knowledge, there is not a method of predicting which medication will be most helpful for any individual. At best, physicians can make educated decisions based on information about success rates with individual medications. In general, a large percentage of patients will respond favorably to Ritalin or Dexedrine, and one of these is usually my first choice. If one stimulant does not work effectively, the others should be tried, for experience has proven that individuals may respond quite differently to each one. Many patients respond remarkably well to imipramine or desipramine, and some physicians feel this group of medications is under used. Each family and physician must be willing to try different medications in order to determine the best and most effective therapy. This is the only way to find the appropriate treatment modality. In some patients who have multiple diagnoses such as ADHD and depression, or ADHD and oppositional-defiant disorder, or ADHD and Tourette Syndrome, combinations of drugs are being successfully utilized for treatment.
WHAT IS THE CORRECT DOSE?
If medications work, there is a best dose for each individual. Unfortunately, medical knowledge is not at a point where it can predict what the correct dose will be. This is not an unusual circumstance in medicine, however. For a person with diabetes, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is needed to determine the best treatment. For ADHD medications, there is no magic formula. The dose cannot be determined by age, body weight, or severity of symptoms.
In fact, it appears that the correct dose is extremely individual and is not really predictable. Again, similar to people who need glasses, the kind of prescription and the thickness of the lenses is not dependent on any measurable parameter other than what you say enables you to see well. The dose of medication is determined solely by what ADHD patients need to improve their symptoms. You must be willing to experiment with carefully observed dosage changes to determine your child's correct dosage. Once the correct dosage is determined, it does not seem to change significantly with age or growth. Medication continues to work effectively through the teenage years and into adulthood if needed.
SUMMARY
Individuals with ADHD will present with a variety of well-defined symptoms and behaviors. Medication may be extremely helpful in alleviating some of these symptoms and will make the other forms of accompanying therapies much more meaningful and effective. Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.
MEDICATIONS: OVERVIEW
RITALIN TABLETS (methylphenidate)
Form: Short acting tablets administered by mouth. Ritalin 5 mg, 10 mg, 20 mg Dosage: Very individual. Average 5 mg - 20 mg every 4 hours. I prescribe 5 mg to start and raise by 5 mg every 4-5 days with close observation until correct dose is achieved. Duration of Action: Rapid acting Ritalin starts to work in 15-20 minutes, which is extremely helpful for the child who has trouble starting his day, Some children will need medication 20 minutes BEFORE time to get up. It will last about 3'/24 hours, and so the effective dosage will need to be repeated every 31/2-4 hours to maintain positive effects during the waking hours. By virtue of its short action, Ritalin is discontinued every night and must be restarted each morning. Effects: Ritalin is one of the best and most dependable medications for treatment of ADHD symptoms. It specifically improves concentration, memory, and control of frustration and anger. Possible Side Effects: Moderate appetite suppression, mild sleep disturbances, transient weight loss, irritability, motor ties may occur if dose is too high (will disappear on lower dose). (Patients with Tourette Syndrome -- if Ritalin makes ties worse, discontinue. In some Tourette patients, ties decrease on stimulants.) Overdose effects with stimulants: depression, lethargy, "loss of spark." If this occurs, lower the dose. Pros: Excellent safety record. Very easy to use and evaluate. Very specific control of medication timing. Most dramatic improvement for many individuals. May be used with most other commonly used medications. Cons: Must be administered frequently during the day. Inconvenient to use at school. May experience moderate rebound reaction -- anger, frustration, temper when medication wears off. Possible roller coaster effect during the day as medication level fluctuates.
RITALIN SR 20 (methylphenidate sustained release)
Form: Long acting tablets administered by mouth. Ritalin SR 20. Dosage: Very individual. Two to three tablets may be needed. I use it primarily in conjunction with regular Ritalin to smooth out peaks and valleys and prevent rebound. I give 1/2-1 tablet of Ritalin SR 20 with each dose of regular Ritalin. Duration of Action: Long acting, about 6-8 hours. BE AWARE -- although called SR20 it actually appears to release only 5-7 mg of medication (not 20 mg) over 6-8 hours. Effects: Same as Ritalin tablets. Possible Side Effects: Same as Ritalin. Pros: Excellent safety record. May be most effective when used in conjunction with regular Ritalin. Tends to smooth out the peaks and valleys of regular tablets. Given with regular Ritalin 15-20 minutes before the child gets out of bed in the morning, it will prolong the positive effect of regular Ritalin to five hours (the lunch hour). Cons: Does not always work in a predictable fashion, and sometimes not at all.
DEXEDRINE SPANSULES (dextroamphetamine)
Form: Long acting, administered by mouth, Dexedrine Spansules 5, 10, 15 mg. Dosage: Very individual: Average is 5-20 mg. Duration of Action: Very individual. May take 1-2 hours to be effective. Usually lasts 6-8 hours. In some it may be effective all day. In others it may only last four hours. Effects: Same as Ritalin. Possible Side Effects: Same as Ritalin. Pros: Excellent safety record. May be the best drug for some individuals: longer acting, smoother course of action. May avoid lunch time dose at school. Cons: Slow onset of action. Remember, it takes 1-2 hours to work and may require a short-acting dose at first in the AM to start the day.
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