Adult ADD

For information about the dosing and effects of these medications, consult with your physician or the manufacturer’s literature.

Common Adult Dosages for Amphetamines Other Than Vyvanse:
Dosing should always be explored under a doctor’s supervision.  Doses of amphetamine may start at 5 mg two to three times daily, with small periodic increases until the desired effect is obtained. It is recommended that the tablets be taken 30 to 45 minutes before meals, with the last dose of the day taken no later than 4 or 5 p.m. as the medication can interfere with sleep.  The dose range for adults is anywhere from 10 mg a day to over 120 mg per day with most patients falling in the 40 – 60 mg per day range.  In our experience, about 1/3 of patients require a dose higher than  60 mg to get an optimal effect. Take tablets whole, never chew and swallow them.  Do not take any dose higher than that prescribed by your clinician without consulting with him or her.

Common Adult Dosages for Vyvanse:
Dosing for Vyvanse usually starts at 30 mg once per day. After a three to five day period during which the medication’s effects can be assessed, the dose may be increased, usually by 30 mg.

For more information about dosing, click here.

Side Effects:
Most commonly occurring side effects are difficulty sleeping, nervousness, tenseness of jaw, loss of appetite, weight loss, constipation, heart palpitations, fast heart beat, and increase in blood pressure. Occasional side effects include nausea, dizziness, and stomach upset. Rarely, patients experience a mild “crash” when the effects of amphetamine wear off. It’s best to have the effect of the following dose overlap that of the previous dose to minimize this effect. That is, take each dose about a half hour before the previous dose is expected to wear off.

For a more detailed list of side and adverse effects, click here.

Medical contraindications:
This drug is contraindicated for use in patients with glaucoma, uncontrolled hypertension, heart problems, or a history of Tourette’s syndrome. Patients with a history of seizure disorders may experience an increase in the number, duration, and/or severity of seizures. Some patients have experienced paranoia (suspiciousness) and psychotic symptoms from taking amphetamine.

For a more extensive list of medical issues to be considered before taking stimulants, see the Medical History Questionnaire

Interactions with Other Medications
Alcohol: Taking with alcohol will reduce coordination, speed of reflexes.
Blood pressure medications: amphetamine may increase the blood pressure and heart rate in spite of these medications.
MAOIs: Do not take with an MAOI antidepressant medication such as Parnate or Nardil.
Antidepressants: Patients taking tricyclic antidepressants such as amitriptyline (Elavil) or imipramine (Tofranil) etc. may require some dosage adjustments for these medications.
Other medications: Warfarin (Coumadin), Phenobarbital, phenytoin (Dilantin), primidone (Mysoline).

Over the counter cough and cold preparations and diet aids. Avoid medications that contain ingredients such as phenylephrine (nose sprays and eye drops), pseudoephedrine (Sudafed, Actifed, and others), and phenylpropanolamine (Dimetapp, Dexatrim, and others), and health food store preparations containing Ma Huang. These may increase the side effects of nervousness and insomnia with further increases in blood pressure and heart rate and in some cases cause a major psychotic episode or even a stroke.

Missed doses should be taken as soon as possible, but not closer than 4 hours apart. Do not double up doses.

Discontinuation symptoms:
Aside from some temporary tiredness and the return of ADD symptoms that had been controlled by the medication, discontinuation or withdrawal symptoms are very rare.

Storage:
Always keep tablets dry, tightly capped, and at room temperature. Keep away from direct heat, light, and moisture. Keep out of reach of children and pets. Discontinued medication must be carefully discarded.

Adderall (Mixed amphetamine salts)

Adderall consists of

• Dextroamphetamine Saccharate
• Dextroamphetamine Sulfate USP
• Amphetamine Sulfate USP
• Amphetamine Aspartate

Mechanism of Action
Amphetamines are non-catecholamine sympathomimetic amines with CNS stimulant activity.  Peripheral actions include elevation of systolic and diastolic blood pressures.

Formulations

• Mixed amphetamine salts tablets: 5, 10, 15, 20, 25, 30 mg
• Adderall tablets: 5, 10, 15, 20, 25, 30 mg
• Adderall XR capsules:  10, 15, 20, 25, and 30 mg

Dosing
Give first dose on awakening; additional doses (1 or 2) at intervals of 4 to 6 hours.  For treatment of ADD, start with 5 mg bid and increase every three days by 5 to 10 mg until an optimal effect is achieved or the patient develops unacceptable side effects.  Sometime it is necessary to give slightly more than is optimal during the initial trial period in order to find what the optimal dose is.

Where possible, drug administration should be interrupted occasionally to determine if there is a
recurrence of behavioral symptoms sufficient to require continued therapy.

Contraindications
Advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to the sympathomimetic amines, glaucoma, agitated states, and patients with a history of drug abuse.

Do not take during or within 14 days following the administration of monoamine oxidase inhibitors (hypertensive crises may result).

Warnings
Amphetamines may enhance the activity of tricyclic or sympathomimetic agents. Using d-amphetamine with desipramine or protriptyline and possibly other tricyclics causes striking and sustained increases in the concentration of d-amphetamine in the brain; cardiovascular effects can be potentiated.

Amphetamines have been reported to exacerbate motor and phonic tics and Tourette’s syndrome.
Therefore, clinical evaluation for tics and Tourette’s syndrome in children and their families should be carried out before stimulant medications are given.

The amphetamines are a Schedule II controlled substance.

Amphetamines have been extensively abused. Tolerance, extreme psychological dependence, and severe social disability have occurred. There are reports of patients who have increased the dosage to many times that recommended. Abrupt cessation following prolonged high dosage administration results in extreme fatigue and mental depression.

Manifestations of chronic intoxication with amphetamines
These include severe dermatoses, marked insomnia, irritability, hyperactivity, and personality changes. The most severe manifestation of chronic intoxication is psychosis, often clinically indistinguishable from schizophrenia. This is rare with oral amphetamines.

Pregnancy, Teratogenic Effects, Pregnancy Category C:
Amphetamine has been shown to have embryotoxic and teratogenic effects when administered to mice in doses approximately 41 times the maximum human dose. There are no adequate and well-controlled studies in pregnant women.  Amphetamines should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Infants born to mothers dependent on amphetamines have a higher risk of premature delivery and low birth weight. Also, these infants may experience symptoms of withdrawal as demonstrated by dysphoria, including agitation, and significant lassitude.

Usage in Nursing Mothers:
Amphetamines are excreted in human milk. Mothers taking amphetamines should be advised to refrain from nursing.

DRUG INTERACTIONS
Antidepressants, tricyclic: Amphetamines may enhance the activity of tricyclic or sympathomimetic agents; using d-amphetamine with desipramine or protriptyline and possibly other tricyclics cause striking and sustained increases in the concentration of d-amphetamine in the brain; cardiovascular effects can be potentiated.

Acidifying agents: Gastrointestinal acidifying agents (guanethidine, reserpine, glutamic acid Hcl, ascorbic acid, fruit juices, etc.) lower absorption of amphetamines.

Alkalinizing agents: Gastrointestinal alkalinizing agents (sodium bicarbonate, etc.) increase absorption of amphetamines.

Urinary acidifying agents: (ammonium chloride, sodium acid phosphate, etc) increase urinary excretion thereby lowering blood levels.

Urinary alkalinizing agents (acetazolamide, some thiazides) decrease urinary excretion and, in this way, increase blood levels.

Adrenergic blockers: Adrenergic blockers are inhibited by amphetamines.

MAO inhibitors:. A variety of neurological toxic effects and malignant hyperpyrexia
can occur, sometimes with fatal results.

Antihistamines: Amphetamines may counteract the sedative effect of antihistamines.

Antihypertensives: Amphetamines may antagonize the hypotensive effects of antihypertensives.

Chlorpromazine and Haldol: Chlorpromazine blocks dopamine and norepinephrine reuptake, thus inhibiting the central stimulant effects of amphetamines and can be used to treat amphetamine poisoning.

Lithium carbonate: The antiobesity and stimulatory effects of amphetamines may be inhibited by lithium carbonate.

Meperidine: Amphetamines potentiate the analgesic effect of meperidine.

Norepinephrine: Amphetamines enhance the adrenergic effect of norepinephrine.

Phenytoin: Amphetamines may delay intestinal absorption of phenytoin; co-administration of phenytoin may produce a synergistic anticonvulsant action.

Propoxyphene: In most cases of propoxyphene overdosage, amphetamine CNS stimulation is potential and fatal convulsions can occur.

ADVERSE REACTIONS
Cardiovascular: Palpitation, tachycardia, elevation of blood pressure. There have been isolated reports of cardiomyopathy associated with chronic amphetamine use.

Central nervous system: Overstimulation, restlessness, dizziness, insomnia, euphoria, dysphoria,
tremor, headache; rarely psychotic episodes at recommended doses.

Gastrointestinal: Dryness of the mouth, unpleasant taste, diarrhea, constipation, other
gastrointestinal disturbances.

Allergic: Urticaria.

Endocrine: Impotence, changes in Libido.

OVERDOSAGE
Individual patient response to amphetamines varies widely. While toxic symptoms occasionally occur as an idiosyncrasy at doses as low as 2 mg, they are rare with doses of less than 15 mg. Thirty mg can produce a severe reaction, yet a dose of 500 mg is not necessarily fatal.

Manifestations of acute overdosage with amphetamines include restlessness, tremor, hyperreflexia, rapid respiration, confusion, assaultiveness, hallucinations, panic states, hyperpyrexia and rhabdomolysis. Cardiovascular effects include arrhythmias, hypertension or hypotension and circulatory collapse.

Gastrointestinal symptoms include nausea, vomiting, diarrhea, and abdominal cramps. Fatal
poisoning is usally preceded by convulsions and coma.

Fatigue and depression usually follow the central stimulation.

Treatment of overdose
Consult with a Certified Poison Control Center for up to date guidance and advice.