ADHD Stimulants: Preparations, Initiation, and Titration

00:00 So let's talk about the preparations that are available.

00:02 Right. You have the short acting, the intermediate or long acting, and the combination of a short and long acting, which that's really cool.

00:10 That gives us some different options and some flexibility to treat the symptoms.

00:14 So the short acting is the 3 to 6 hours right now.

00:17 This will be the initial treatment you should try, particularly for any age.

00:21 For those who haven't had stimulants before, think about starting your plan with a short acting stimulant.

00:27 Now, the initial treatments you've got that started for them, someone who's naive to it, but you also may use it to determine the optimal daily dose before you switch to an intermediate or a longer acting preparation.

00:39 So if this client is brand new to stimulants, this is what you want to start with a short acting that will be the 3 to 6 hour.

00:46 Now when would you use an intermediate? That's the 6 to 8 hours or a long acting.

00:50 That's 8 to 12 hours.

00:52 Well, the benefit of these medications, it's more convenient with a short acting.

00:56 They have to keep repeating doses till you get everything figured out.

00:59 But this might be able to get away with one dose a day, so it's more convenient and you know that convenience equals compliance or adherence.

01:09 It's also less stigmatizing if the person doesn't have to take medications around others, and this type of medication is less likely to be misused or diverted.

01:18 The biggest value with the diversion is usually the shorter acting one, so people get that bang right away.

01:24 Now, the third category you're considering, when you're looking at how you're going to prescribe this for your clients, is a combination of the short and long acting.

01:32 These are really cool because these can provide adequate coverage for your clients, and they can get their homework done in the evening or complete other tasks that they want to do at the same time.

01:42 Remember, we use these medications for children who are focusing on homework and school, but it's also used for adults who are wanting to improve their performance at work. So think of an example of a use case would be like a long acting at home before they go to school, and then you can take a short acting booster after school.

02:00 So when we say combination of short and long acting, that means both of those medications.

02:05 You take the take the long acting before they go to school.

02:07 They don't have to take the medication around anyone else or go see the nurse.

02:11 And then when they get home after school, you give a short acting one to help them make it through their homework and hopefully not interfere with their sleep.

02:20 So when you're starting and titrating medication, your goal as a provider is to find a dose that achieves symptom improvement with the minimal adverse effects.

02:29 Well, pretty much that's the goal for any medication treatment right now.

02:33 It might take you several months.

02:35 And remember you're going to need to monitor them weekly.

02:38 So as you advance the dose remember that the maximum dosing will vary based on the medication and the formulation that you're giving.

02:45 So this is not a medication that you just prescribe and move on.

02:49 This is really where you get to use your school your skills and develop that relationship with your client.

02:56 So it's going to take a long time.

02:58 Help your client understand that.

03:00 Know that you're going to have conversations with how they're doing each week.

03:03 You may not talk to them each week, but you want them to record their experience over that week and know that it's going to be different for every client, different for every medication and formulation.

03:15 This is a long game, but the result is worth it.

03:19 So how do you help your client get to that treatment goal? How do you find this magic dose? Well, there's some generic frameworks that you want to consider.

03:28 First, you start at the lowest dose.

03:30 And remember you're starting with that short acting first to kind of get an idea so you can get it dialed in.

03:35 Once you start at the lowest dose, then you go to the next increment in two weeks.

03:40 So the initial dose give it two weeks to see if you have some improvement or what you need to change. And then at the end of two weeks, either continue to monitor the patient and return to a lower dose if you've got some adverse effects that outweigh the benefits.

03:55 So this will be the framework that you will continually repeat with the client.

03:59 So make sure they're very clear.

04:01 People think if they have an infection they take an antibiotic.

04:04 The infection resolves.

04:05 That's not how this works with stimulants.

04:07 You need that give and take and all that information to make sure you get the appropriate dose so you find the dose that achieves the symptom improvement, but it's the minimal adverse effects that can still be effective.

04:20 You've likely heard of the concept of drug holidays with stimulants.

04:23 This isn't routinely recommended, but it may help some children specifically in certain cases, particularly if the child is getting behind in growth and development.

04:32 So you want to think about are there times on a case by case basis when they may not necessarily need the medication? Now if the child's progressing fine there's no problems.

04:43 You don't have to do a drug holiday with stimulants.

04:45 But if on a case by case basis, you and the family or the client decide that they do need the holidays, it would benefit them, then you can schedule it based on when they would need the medications the least.

04:57 For example, a kid may not get the medication on the weekend because they don't have any problems on the weekend.

05:02 That would be an example of a drug holiday.

05:05 But remember, this isn't usually necessary unless the child is having issues with growth.