JustNuts

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  1. Finally had time to finish reviewing them. All but clomipramine were disqualified, and clomipramine was added as "low". I'll have to add Mydayis to the list when it launches this fall, but I'll hold off until the commercial launch to do that (it'll require a separate entry from Adderall due to the markedly different age limits on use).
  2. Lol yeah but Fetzima is basically just a NRI that happens to also have significant SSRI action (2:1 ratio compared to 1:1 with Savella, 1:10 with Cymbalta, and 1:30 with Effexor).
  3. Lol, so now the outright bizarre mixture of literally four different amphetamine salts with an overall 3:1 d-amp/l-amp ratio is "cleaner" than the pure d-amp, riiiiigh. Makes total sense /s. No neurotoxicity with d-amp or l-amp. Both have similar (small) potential risks of neurotoxicity at truly absurd doses (ones only seen with very major abuse). Only methamphetamine is neurotoxic irregardless of dose. d-amp hits fewer receptor subtypes than l-amp IIRC due to the greater DA effects and lesser NE effects, although it's been quite a while since I reviewed the fine details of amphetamine's pharmacology so perhaps I'm wrong, but I'm pretty confident that I'm right about this. If you try comparing it to a different stim like MPH or to something else entirely then yeah it gets complicated fast since other stuff hits different areas of the brain in different ways, but d-amp and l-amp have much more minor differences in localization. Docs pulling the clinical experience/professional training card as an unjustified cop-out when they don't want to justify/explain their questionable actions, POV, etc and/or won't listen to any input (or even questions!) from you because "you're the patient, not the doctor" always piss me off massively. My current pdoc is really great about all that stuff (not to mention very enthusiastic and knowledgeable), but I've had too many run-ins with bad pdocs in the past and am not optimistic at all about my chances of finding another pdoc as good as this one when we eventually move.
  4. Vyvanse is very popular though and that's the same drug (just as a prodrug). Personally d-amp did not agree with me, even as just a bit of IR augmenting the MAS XR towards the end of the day - it consistently made me feel worse when it kicked in (depressed, miserable, even suicidal). It seems that I need the norepinephrine component for usable effects.
  5. I haven't tried getting a specific generic brand again since the last attempt. The only pharmacy I use is Walgreens. I'd try to get the QL override approved, but at this point I'd have to have my pdoc send in another fricking PA, wait for that to get denied, then appeal it, which takes forever and is a PITA, and I don't even know if we'll still have the same insurer next year, so I'm not sure that it's worth the effort at all. If I knew we were definitely going to have the same insurer next year than I'd have appealed it already since it's such a huge headache. Yep, it's the 20 mg Barr MAS IR generic. Absolutely disgusting taste. If the sleep doc has experience treating narcolepsy than they'd be used to prescribing higher doses of d-amp and shouldn't have an issue with it, but otherwise IDK if they'd be willing.
  6. Protriptyline failed the inclusion test. I will check later to see if any research exists on any of the others you've mentioned. The absolute minimum benchmark for inclusion on the enwiki list I linked is one positive case report and a theoretically viable MOA, so that rules out a good chunk of "theoretically this could work" stuff that hasn't actually been tried (or if it has, hasn't been published at all).
  7. Cash cost, post-insurance cost (copay/coins), or what the insurer actually pays? To give you an example, the cash cost for 90x 20mg Adderall IR is $124.49, my post-insurance cost (copay) is $10, and the insurer actually pays a further $36.42, making the actual total cost of the medication $46.42. CVS is literally the worst pharmacy chain though, you can't really expect much out of them. The one time I ever asked about a specific generic (it was for bupropion SR, they had just switched manufacturers from Sandoz to Solco and I started seeing bizarrely glaring negative changes in the medication's effects -- I severely doubted that the manufacturer switch would affect things, but after ruling out all reasonable alternate explanations as best as I could with no improvements, I was forced to assume that perhaps Solco's release mechanism was not quite up to snuff for whatever reason). Anyways, I asked about switching back (but not directly to the store - probably a mistake), and was told that it would be no problem to do that and that next time I filled they would use the old generic...of course next time when I filled they hadn't followed through with that, and by the time I realized this (well after leaving the pharmacy) I just gave up and decided it really wasn't worth the effort. In retrospect, I think I should have pushed harder, but the likelihood of a legitimate issue with a generic switch is so low that I didn't trust that was actually the issue, and I was too miserable to care. (I have thought about asking to switch Adderall IR generics a number of times because the generic they use rapidly dissolves at a far too fast rate and is nauseatingly sweet, which has led to me gagging or even nearly vomiting on more than one occasion, but I don't really want to deal with trying to get that changed, even more so than with any other drug because it's a CII and my pharmacist is already doing me a big favor by partial filling it and running it through my insurer as a 30 day RX to partially bypass the QL) I think I worded things a bit too harshly w.r.t. your pdoc -- sorry about that. It sounds like she's a great doctor outside of this one issue.
  8. Checked pubmed - selegiline could be added, but it lacks case reports and has somewhat poor research overall (would be rated "low"), but see below for the major caveat. As for the other MAOIs, evidence for them appears substantially more limited, although I didn't check each one separately like I did for selegiline. The list has lacked MAOIs for so long because of several reasons, but the most major one is because they aren't really that viable a treatment option for most people due to the whole dietary restriction issue (and yes Stahl brushes it off, but that's in the context of treatment-resistant depression, not ADHD). Selegiline is the only irreversible one without a dietary restriction (with the Emsam patch), and that's still only for lower doses of it too - higher doses still require dietary restrictions, and so do all other irreversible MAOIs. The single reversible MAOI on the list doesn't have dietary restrictions at all. But an argument can be made for including at least selegiline... hmm... After some more research I finally decided to add selegiline in the end, so it's in there now. I suppose it's past time for another round of general updates, but there's a major network meta analysis that the EAGG is working on right now that I think I should probably wait on, so I did some minor partial ones instead. Are there any other major candidates that were overlooked (outside of the irreversible MAOIs)?
  9. Neither 5-HTP nor L-tryptophan are safe to take in combination with antidepressants - both of them have a non-trivial risk of causing serotonin syndrome when used with other serotonergic drugs (e.g. most antidepressants), which you do not want to experience. An additional concern is eosinophilia–myalgia syndrome (EMS), which is strongly associated with L-tryptophan consumption, and current consensus is that L-tryptophan consumption is the primary causitive factor in EMS. Due to this alone, I strongly recommend avoiding L-tryptophan altogether - it is nowhere near safe.
  10. See table: https://en.wikipedia.org/wiki/Attention_deficit_hyperactivity_disorder_management#Comparative_efficacy.2C_tolerability_and_regulatory_status
  11. They thought it was Desoxyn? Haha! AXR I can understand, that would be easy to confuse if you haven't encountered the d-amp spansules before, but Desoxyn? Then again if they were working off of the name alone maybe they just got Dexedrine and Desoxyn mixed up, but that doesn't explain mixing up Dexedrine with Adderall... I'm surprised that they stocked the Desoxyn but not the d-amp. Maybe you encountered a (statistically improbable?) pharmacy with more than one patient on Desoxyn? Even then, from what I've heard Desoxyn is not cheap (from the pharmacy/insurer perspective), I certainly know it's not cheaper than d-amp IR, I doubt the spansules are much more than IR in the US if CA prices are any indication (which they should be for a generic), and no sane pharmacist would be more comfortable with Desoxyn in their CII rack than with d-amp in it... Hmm. My pharmacy never started stocking my Fetzima even though I've been on the same dose for close to six months now, but then again that's costing my insurer something like $380 and they get it in 30-count bottles, so I guess the lack of counting required and high cost explain that. I don't care too much about waiting a day or two for it so whatever. They didn't have d-amp IR in stock when I was on that either and they didn't keep it in stock either, so Walgreens is by no means universally good about carrying d-amp (and I remember it taking them like a week to get it delivered too - odd, considering that the Fetzima is always delivered quickly). Why the hell did the Walmart pharmacist ask you to leave like that? That's horribly unprofessional and unjustified. Independent pharmacies are notoriously good about customer service and accommodating special requests, but they are more price sensitive because they cannot afford to loose as much money on RXs, generally have different contract terms than the big chains do with the major PBMs, and likely have higher acquisition costs than the big chains do even if they use the same suppliers, which can put them at a significant disadvantage in some cases. For example discount cards like GoodRX are a major issue for many independent pharmacies since that often leads to them loosing money or making next to nothing on the RX, but the big chains will usually eat that cost to attract more customers (although attitudes towards this are shifting and some chains have started locking out certain discount cards). What really sucks about discount cards for chains and independents alike is that not accepting them can sometimes violate their contracts with PBMs that have both discount cards and regular health insurers as clients - which puts the pharmacy in a very bad position where they can't refuse to accept the cards without breaching their contract, and to make matters worse, discount card companies are fully aware of this and basically resolve consumer issues with getting a discount card accepted by calling the pharmacy to "helpfully" inform them that they are in breach of the pharmacy's contract with whatever PBM the discount card uses and essentially threaten everyone into submission (if the pharmacist ignores them, corporate gets called next). It's all very nasty stuff. Bluntly put, your pdoc is an idiot. There is nothing magical about pure d-amp or d-amp spansules that makes it worse for the heart than much higher doses of d-amp combined with a fricking PNS stimulant (levoamphetamine). If anything the d-amp is arguably better for the heart than the MAS due to it essentially being a purely CNS stimulant... And given that we have firm evidence on there being no association between treatment with ADHD medication and several different types of major cardiac events for both children and adults, the only argument possible is that "supratherapeutic doses in general may raise the risk", which is possible (although I'd argue that if you lack risk factors and the dose isn't utterly insane there's generally enough precedent in the literature to justify using these doses even if we assume they do actually increase CV risk), but she's already prescribing a supratherepeutic dose of Adderall, so she can't use that argument at all and clearly already considers supratherapeutic doses to be an acceptable risk. The real reasons of course are likely the combination of misremembered details about cardiovascular risks of ADHD medications, lack of familiarity with prescribing d-amp, much more familiarity with prescribing MAS, and unfortunately all too typical levels of ignorance about psychopharmacology among the people who are supposed to have effectively/essentially specialized in practicing psychopharmacology...
  12. It sounds like you're in a crisis situation - the ER will likely admit you, but at least you'll be safe there and can get this sorted out. Edit: Posted just as you updated, so I missed the update. See how you feel tomorrow and definitely look into what hospitals are covered even if you decide you don't need to go -- having that information on hand is always handy for the future just in case it's ever necessary.
  13. Benzodiazepines have a significant risk of worsening depression. I don't think I've ever heard of someone proposing to treat depression with them before. While benzos can in some cases help depression indirectly by alleviating anxiety that is interfering with your ability to handle your depression, they don't really have any direct antidepressant effects unless they're abused for the euphoric effects that they can sometimes cause when misused (not a good idea at all as benzodiazepines are both psychologically and physically addictive).
  14. Yes, lithium did that for me. It was also utterly useless for its intended effect so it was eventually ditched. Lamotrigine did something similar along with ruining the efficacy of my benzos (and not really working), while I did not get along too well with Depakote either (it was briefly somewhat effective but had nasty hormonal side effects that led to me ditching it abruptly), although I don't think Depakote messed with the stimulants as much as the other two did. Note that the bexpiprazole could also be the cause (or even the quetiapine - is that stable or did it change recently?). Some people get good results when combining dopamine partial agonists and stimulants, and others get poor ones, so the brexpiprazole could really go either way.
  15. Eh, I'm not that surprised, it's equal to 40 mg MPH TID or 120 mg daily, that's pretty high. 60 mg MPH TID, 180 mg MPH per day. Wow. IDK how people can tolerate such high per-dose levels of IR, I doubt I could handle serum levels going that high. I mean my old Concerta+Ritalin combo was maybe equivalent to 40 mg IR at absolute peak, but normally more like 32.5 mg, and peak levels were more than adequate anyways on that combo - definitely wouldn't want them to have gone higher than that (the dropoff from the Concerta was another matter entirely though). Yours is certainly the highest d-MPH dose I've ever heard of someone being on -- I think 80 mg was the highest dosage of d-MPH I'd heard of someone taking before this, and I think that person was taking 40 mg d-MPH XR BID, which is a bit different from pure IR. My insurer asks for a PA anywhere past 40 mg d-MPH XR // 20 mg d-MPH IR daily. Their MDL on racemic MPH is 60 mg for IR and roughly the same for all extended release formulations (72 mg for Concerta though). However their Adderall MDL is really quite annoying - 60 mg per day, and despite calling the pharmacy twice on two different occasions to ask about their requirements for overriding the MDL ("just send in a PA request and it'll get approved, no problem"), when I asked my pdoc to send in a PA for overriding that (which took a little while due to the insurer repeatedly managing to forget to fax the required form to my pdoc's office when asked to do so) the insurer just denied it, citing their MDL as the reason for denying it. Circular reasoning much? And after telling me it'll be no issue at all to be approved and all we need to do is send in a simple PA request not once but twice (and from different reps)! We never bothered appealing the decision since I can just refill at the 75% mark (every 22.5 days) and have my pharmacist submit the RX as a partial modified fill for 60 mg daily over a 30 day period each time to get the full 80 mg covered by insurance anyways, but that leaves no room for flexibility and half the time I end up missing a half or full day when refilling. They'll cover outright stupid combinations of multiple different doses of XR, or mixing XR and IR, at higher total doses and/or greater expense to them - but those combos have poorer therapeutic effects for me so it's not helpful for those to be covered. But ask them to cover the cheapest amphetamine med at 80 mg daily instead of 60 mg daily, even though you could take more than that with numerous other combos and they'd be completely fine with it - all of a sudden that's a huge issue. Insurers. Bah.