The Immediate Release Bottom: The Duration of Effectiveness [DOE] Application Using Immediate Release [IR – often generic] Medications –
Managed Care Creates A Significant Problem
With the increased influence of managed care, the choices of medications for thousands are limited to the generic [often less expensive] immediate release medications. IR medications are less than satisfactory in the first place, for reasons listed below.
Ineffective treatment incurs greater long term costs on many levels. Why managed care would encourage the use of less medically effective products and create greater cost, coupled with that inferior patient care, is a challenging subject beyond the scope of this brief overview.
Clinical Implications of IR Medications
On first thought, one might guess that the IR medications would almost always be adjusted correctly, as they have been around for decades, and appear at first as more simple, less complex intervention strategies.
The most difficult aspect of this unhappy circumstance: IR choices with stimulant medications regularly seem to invite insufficient attention to adequate adjustment.
Denial of Problems with IR Stimulant Medications
On the contrary, IR medications appear to encourage denial of the deeper implications of incorrect dosing. In fact, while IR medications have almost no redemptive value except for cost, they continue, quite surprisingly, to remain the treatment of choice for many.
Many simply are not paying attention to the IR stimulant details. If they did, they would regularly prioritize the extended release medications as first choice products.
Said yet another way, IR stimulant medications for ADD often inadequately cover the Therapeutic Window, for several reasons.
These 7 Tips will help explore that mercurial bottom with the IR meds.
- The Immediate Release Challenge: IR medications require more specific questions [more precise and in greater number], not fewer questions. This point underwrites the challenge with IR medications, as specific questions must be asked about each DOE of each dosage throughout the day. Three doses demand three specific answers, not one. This arduous process is time consuming, and with those who suffer from inattention, a challenge to rethink on every medication check.
- Immediate Release [IR] Means Short Duration of Effectiveness [Efficacy]: IR meds have their own specific half-life that must be considered from the outset. Average Durations of Effectiveness are: Ritalin 4 hrs, Dexedrine 5 -6 hrs, Focalin 4 hrs, Adderall 6 hrs, Methylphenidate 4 hrs. A 12 hr day requires 3 doses, not 2. If the PM dose is not given in time it is quite often forgotten. If it is given too late, it will cause sleep disturbance. Everyday all of these details require relentless attention, so patients often disregard the dosage, and compliance drops dramatically leaving large portions of the day uncovered, ineffective, and inattentive. Many just go with a morning dose and forget the rest of the day, leaving more than 8 hrs uncovered.
- Difficult Adjustment of Specific Amounts Through the Day: This point may sound obvious, but is often overlooked. The onset in the morning must be in the 1/2 hr range. If kids have school breakfasts they often can’t get the medication correctly dosed because IR causes, without question, more stomach irritation and more weight loss. It’s often best to give AM meds even after the shool breakfast at school if it means not taking the medication at all. The daily [noon] doses should be given after lunch not before to preclude this irritation. The PM Dose has an unpredictably odd pattern of lasting longer than expected the closer one doses to 6 PM. The late PM dose most often is best given in the 3-4 PM range even if it slightly overlaps the DOE from the noon dose. Special watches can help with alarms as can cell phones, – all of these machinations are profoundly difficult for those with attentional problems.
- Don’t Force the IR Dose to Push for Longer DOE: The meds cannot be forced to work longer by excessive increase of dosage. When the problem with the ‘sides of the window’ [see the reference in another article here], is addressed by regularly increasing the dosage the patient becomes toxic, even during that portion of the day. For example: A person given 20 mg of Adderall IR when 15 mg covers for 5-6 hrs will inevitably become less able to concentrate during those hours by being forced out the top of the window – and the fall in the PM is exaggerated, often with angry storms of affect.
- Misidentification of Any Toxicity Creates a New Incorrect Diagnosis: As noted in 4, an excess in the AM may look to some like bottom, like it isn’t working well. Subsequent to that incorrect assessment more is often given to take the patient to the ‘correct dosage’ creating an even greater toxicity, more abundant thinking, more impulsivity, more irritation and anger. Shortly after all of this predictable, often catastrophic, deterioration the patient is labeled with a new diagnosis: Bipolar Disorder. This problem occurs throughout the country, with great regularity.
- Compliance Deteriorates At the Noon Dose: Based upon the abundant public ignorance and inappropriate stigma given to those with ADD, anonymity with an ADD diagnosis should be encouraged at the outset of every new evaluation. ADD should remain a private affair. To solve this problem of anonymity at school and at work many forego the appropriate dose at noon of the IR medications. This non-compliance is understandable, and must be addressed in some way at the outset to cover the early afternoon. Naturally, we have no recourse but to give the medication at school to cover those with ADD who can’t afford extended release. While I don’t suggest that we miss doses to cover privacy issues, I do feel that privacy and the noon dosing with IR medications presents a much more significant problem with compliance than some recognize.
- Missing the Late PM Dose Creates Family Difficulties: Skipping the PM dose, or giving an inadequate dose for the late PM, is one of the most commonly seen problems with my second opinions. Even if patients are taking the extended release stimulants, thereby covering about 8 hrs in the day, the PM dose keeps a significant last place regarding attention to the details. Interestingly, the home, the family, and the evening responsibilities suffer, between spouses, or with children and adolescents. Arguably the most important part of the day is overlooked in the context of all the attention required to the multiple problems addressed during the previous 8 hrs
These IR challenges must continue to be more adequately addressed, even if the new extended release medications do reveal the IR stimulants as even more inadequate. We must not drop our attention to these details even though other options exist, as the DOE remains the unavoidable common denominator, the Silver Thread of Understanding, that weaves its way through all stimulant medication adjustment.