Adderall didn't raise my heart rate sense I have add ? Any thoughts ?

[Davycrocket]

Any thoughts on this subject ?

[notloki]

You get used to some side effects. I sure did to the fast heart rate/blood pressure. Yesterday I took 60 mg IR dextroamphetamine and an hour later at the docs office had a pulse of 78 and a pressure of 110/82. It is true the propranolol slows the heart rate but at 60 mg/day dose not affect blood pressure.

Edited February 23, 2017 by notloki

[jt07]

A little background information and more information in general would be nice.

[JustNuts]

1 hour ago, notloki said:

You get used to some side effects. I sure did to the fast heart rate/blood pressure. Yesterday I took 60 mg IR dextroamphetamine and an hour later at the docs office had a pulse of 78 and a pressure of 110/82. It is true the propranolol slows the heart rate but at 60 mg/day dose not affect blood pressure.

60 mg of IR d-amp in a single dose? How the hell do you tolerate a rise to such incredibly high serum levels?

[notloki]

4 hours ago, JustNuts said:

60 mg of IR d-amp in a single dose? How the hell do you tolerate a rise to such incredibly high serum levels?

And I take 30 mg in the afternoon. The evidence is I metabolize amphetamine very quickly. I've always needed a decent dose of it to be effective. Too little amphetamine and I get sleepy or fall asleep. At the job we mostly do all the work in the morning, very intense, and afternoons are more relaxed. After trying many combinations I have found I get the most bang for my buck, ie get things done, if I take the biggest dose in the AM.

I am given considerable freedom to take my daily 90 mg as I see fit. Sometimes afternoons are more busy so I don't take as much in the AM and spread the remaining 60 mg into 2 doses of 30 mg. I don't like to take a whole 60 mg as one dose in the PM, I get side effects I don't get if I take 60 mg in the AM. I cut off taking amphetamine at 3 PM so I don't have sleep problems. I can nap by 6 PM and sleep by 9 PM.

As my pdoc says "You are not psychotic, losing weight, manic, have great labs, and generally seem to be doing very well so we will go with what works."

A few people on my ADHD list take 100+ mg/day.

 

Edited February 24, 2017 by notloki

[JustNuts]

1 hour ago, notloki said:

And I take 30 mg in the afternoon. The evidence is I metabolize amphetamine very quickly. I've always needed a decent dose of it to be effective. Too little amphetamine and I get sleepy or fall asleep. At the job we mostly do all the work in the morning, very intense, and afternoons are more relaxed. After trying many combinations I have found I get the most bang for my buck, ie get things done, if I take the biggest dose in the AM.

I am given considerable freedom to take my daily 90 mg as I see fit. Sometimes afternoons are more busy so I don't take as much in the AM and spread the remaining 60 mg into 2 doses of 30 mg. I don't like to take a whole 60 mg as one dose in the PM, I get side effects I don't get if I take 60 mg in the AM. I cut off taking amphetamine at 3 PM so I don't have sleep problems. I can nap by 6 PM and sleep by 9 PM.

As my pdoc says "You are not psychotic, losing weight, manic, have great labs, and generally seem to be doing very well so we will go with what works."

A few people on my ADHD list take 100+ mg/day.

 

You must be a CYP2D6 ultrarapid metabolizer, I've never heard of anyone taking such a high per-dose quantity of dextroamphetamine. It so vastly exceeds typical dosages (and my range of "typical" is much broader than most) that I'm really shocked you can tolerate it. Keep in mind that I am looking at this from a per-dose approach, not an overall-daily-dose approach - there are a decent number of people taking overall daily doses this high (although they are definitely a minority), but someone taking single doses equivalent to 60mg of IR? That's virtually unheard of, at least for medical uses of amphetamines. Methylphenidate would be a little bit different but that dose is still "holy shit" level. It's good to know that it works for you.

[notloki]

10 hours ago, JustNuts said:

You must be a CYP2D6 ultrarapid metabolizer, I've never heard of anyone taking such a high per-dose quantity of dextroamphetamine. It so vastly exceeds typical dosages (and my range of "typical" is much broader than most) that I'm really shocked you can tolerate it. Keep in mind that I am looking at this from a per-dose approach, not an overall-daily-dose approach - there are a decent number of people taking overall daily doses this high (although they are definitely a minority), but someone taking single doses equivalent to 60mg of IR? That's virtually unheard of, at least for medical uses of amphetamines. Methylphenidate would be a little bit different but that dose is still "holy shit" level. It's good to know that it works for you.

So CYP2D6 is the major player in d-amp's metabolism, that's good to know. While I have not gotten push back from insurance on my dosing I would like to have genetic testing so I have some hard proof of a reason for needing this high a dose. I realize 60 mg at one time is pushing a tweaker dose but I don't experience normal tweaker behavior on this dose. Blood pressure and pulse are normal, I'm not talking a mile a minute unable to stay on one topic, and I still get hungry although portions are smaller and it takes less to make me feel full. That's a good thing as I always can stand to lose a few pounds as I am overweight (diabetic) at 190-200 lbs.  Off amphetamine I am in the 210's range of weight, which classifies me as obese.

It helps that I am seeing the psychiatrist who, in this area, is regarded as being the one to treat the difficult cases. So he is more comfortable with off label prescribing and unusual doses. 

Thanks for the info, very helpful.

 

Edited February 24, 2017 by notloki

[JustNuts]

11 hours ago, notloki said:

So CYP2D6 is the major player in d-amp's metabolism, that's good to know. While I have not gotten push back from insurance on my dosing I would like to have genetic testing so I have some hard proof of a reason for needing this high a dose. I realize 60 mg at one time is pushing a tweaker dose but I don't experience normal tweaker behavior on this dose. Blood pressure and pulse are normal, I'm not talking a mile a minute unable to stay on one topic, and I still get hungry although portions are smaller and it takes less to make me feel full. That's a good thing as I always can stand to lose a few pounds as I am overweight (diabetic) at 190-200 lbs.  Off amphetamine I am in the 210's range of weight, which classifies me as obese.

It helps that I am seeing the psychiatrist who, in this area, is regarded as being the one to treat the difficult cases. So he is more comfortable with off label prescribing and unusual doses. 

Thanks for the info, very helpful.

 

Insurance doesn't care about individual doses, they only care about daily doses. My insurer's MDL on IR d-amp is equivalent to 60mg/day.

Interestingly enough, generic IR dextroamphetamine appears to be substantially more expensive than generic IR mixed amphetamine salts (Adderall) at similar doses. 90 tablets of 20mg MAS = $49 ($47 for 90 15mg tablets), yet 90 tablets of 5mg d-amp = $124 ($83 for 60 5mg tablets, which is linear price scaling and shows consistency, so we know there wasn't a brief spike in price (which occasionally happens to some of my meds)). MAS is significantly more challenging to produce than d-amp from a synthesis standpoint, so it definitely cannot be a synthesis issue, and as identical tablet quantities were compared, it cannot be a cost-per-unit issue. Maybe it's just because IR d-amp is (apparently) relatively rarely prescribed? Yet economies of scale would dictate that even though MAS is likely produced at a higher rate, the simple limitation of d-amp to no more than 10mg tablet sizes means that d-amp tablets should be relatively price competitive due to less manufacturing costs from producing so many different dosage forms. The issue is likely not from a lack of competition either, as there are a significant number of companies still manufacturing d-amp, although quite a few companies that used to manufacture it no longer manufacture it, likely due to the shrunken market size. However there appear to be more companies currently manufacturing MAS than they are companies manufacturing d-amp, so perhaps there was strong enough competition to drive down prices further? IDK. Price data is from my insurer, which provides me with detailed data on my pharmacy claims that includes their actual cost of acquiring the drug, something that cannot generally be obtained publicly.

Back on topic. If you ever have PGx testing done, it is crucial to ensure with absolute certainty that the testing service you use will assess CYP2D6 CNVs (copy number variations). Simple SNP-only PGx testing cannot detect CNVs, and CYP2D6 ultrarapid metabolism is caused pretty much exclusively by CNVs. Given that you are on the maximum dose of bupropion (stimulant + strong CYP2D6 inhibitor) and this dose of d-amp, I am pretty confident that you're an ultrarapid metabolizer.

The one good case report in existence on a patient who required truly ultra-high doses of psychostimulants for proper symptom treatment (in this case methylphenidate, at a endpoint dose level that's actually arguably worse than yours on a serum-level basis while also lasting longer) described pretty similar effects at the endpoint if I'm remembering things correctly. It's very good that you're seeing such manageable side effects, and you are really lucky to have such a good psych.

[Iceberg]

I've had a doc try and put me on a really high focalin dose once well above the max...so it definitely happens. But for me it just didn't work

[notloki]

After the shortage that affected amphetamine products about 2-3 years ago prices short up once supply normalized. Sometimes I end up paying cash when there are problems with PA's. I was surprised how much 10 mg d-amp tabs cost. Even the pharmacist was and took me aside and apologized and said after I filled with him the last time it was time for he to restock. Even he was surprised at the new prices. 

I don't like Adderall, l-amphetamine gives me side effects like fast heart rate and sweating, side effects I don't get from just plain d-amphetamine.

Edited February 25, 2017 by notloki
correctness

[JustNuts]

On 2/25/2017 at 2:23 AM, Iceberg said:

I've had a doc try and put me on a really high focalin dose once well above the max...so it definitely happens. But for me it just didn't work

In my experience doctors tend to put patients on higher doses of dexmethylphenidate than they would for methylphenidate due to ignorance of the fact that dexmethylphenidate is twice as potent as methylphenidate by weight. This is likely responsible for a substantial portion of the (perceived) benefits of dexmethylphenidate (which do not exist in randomized trials).

On 2/25/2017 at 6:35 AM, notloki said:

After the shortage that affected amphetamine products about 2-3 years ago prices short up once supply normalized. Sometimes I end up paying cash when there are problems with PA's. I was surprised how much 10 mg d-amp tabs cost. Even the pharmacist was and took me aside and apologized and said after I filled with him the last time it was time for he to restock. Even he was surprised at the new prices. 

I don't like Adderall, l-amphetamine gives me side effects like fast heart rate and sweating, side effects I don't get from just plain d-amphetamine.

Ah, these are the insurer's prices, not the cash prices. The cash prices are:

• 90 tablets of 20 mg MAS IR - $49 insurer, $125 cash
• 90 tablets of 15mg MAS IR - $47 insurer, $125 cash
• 90 tablets of 5mg d-amp IR - $124 insurer, $198 cash
• 60 tablets of 5mg d-amp IR - $83 insurer, (unknown - did not record this receipt in my spreadsheet) cash

You can read my (fairly extensive) writeup on how drug pricing actually operates in the United States at my blog entry below:

I seem to benefit quite a bit from norepinephrine stimulation, given my good reaction to (high) doses of methylphenidate/MAS, my good reaction to Fetzima (which is an absurdly strong NRI), and my extremely poor reaction to d-amp (it was intolerable - I felt more miserable, depressed, suicidal, etc during our relatively short trial of augmenting my XR with it (and did not experience much of an improvement relative to without it)). I think it's just a matter of different people better tolerating and responding to either CNS or PNS effects (although it's actually CNS + mild PNS vs CNS + strong PNS, not CNS vs PNS).

[ldo]

JustNuts:

The one time I took methylphenidate, my pulse went up to 150 or something a few hours later. This didn't happen with dexmethylphenidate. On the other hand, I'd been on MAS or dextroamphetamine just previously, and maybe the adaptation to that reduced my reaction to methylphenidate.