Archive for the ‘Medication: Best Meds’ Category

Pristiq vs Effexor

Question: Now that Pristiq has been out for awhile, what has been the clinical response with your patients compared with the Effexor XR formulation? Rumors have said it is more tolerable and less sexual side effects, although I have tried some samples, and it doesn’t seem to be as calming as Effexor, and I am unsure what the Pristiq 50mg dose is compare to a similar Effexor XR dosage?

Also what SSRI/SNRI tends to have the fewest sexual side effects?

Thanks


Answer:

Pristiq and Cymbalta seem to have less sexual side-effects than Effexor
and if Pristiq at 50mg is an adequate dose it should have the least
sexual effects. 90% of the first 570,000 treated with Pristiq have
stayed with a 50mg dose. This dose has the same efficacy in control
studies as 75-150 of Effexor with better tolerability. The drop out
rate due to side-effects is essentially the same as placebo.

When most people (normal metabolizers) take Effexor – 70% of the benefit
comes from Effexor being metabolized so the effects are very similar.
Pristiq does have a slightly higher ratio of norepinephrine effect
relative to serotonin than Effexor and this could account for your
impression that it’s not as calming – that is most likely a temporary
effect.

Because Pristiq doesn’t require the same liver metabolism as Effexor
there are less issues with drug drug interactions and tolerability for
those people (7-10% of Caucasians) who are poor metabolizers. Poor
metabolizers don’t usually do as well on Effexor and don’t usually
tolerate doses above 75mg. Some people do better on 100mg of Pristiq.

Pristiq is also more cost-effective, especially at 100mg dose – since
there is a 100mg tablet – whereas Effexor frequently requires 225mg or
more necessitating multiple capsules.

Wyeth is also getting ready to launch a program where they will pay 1/2
of your cost (copay or cash) as long as you take it on a continual
basis for life if necessary.

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Best Medications Revisited

In December 2006 I participated in a survey of psychiatrists by a pharmaceutical company.  They asked me if I could have only five medications to prescribe which ones would I choose?  Since I have a cash only practice I have to go with the most effective medications long term.

Most medication studies are to meet FDA requirements, which means short studies (6-8 weeks), and they only have to show 50% improvement in symptoms and be statistically better than placebo (that may be associated with only 30-40% improvement).  These studies do not represent real world treatment – patients can’t be given any counseling and can only be on one medication. 

It is only through extensive clinical experience that we can learn which medications are best.

I think of the best medications as the ones that patients come back and say are great….that they have changed their life – side effects are minimal, and the highest standard is that they are still saying it after 6 months, 1 year, 5 years, etc.  If the medication starts working on day one that is a bonus. 

Great medications help you feel better, function better, be less stressed and help protect your overall health.  Great medications also enable you to focus on your life – career, relationships, hobbies, and not be constantly preoccupied by symptoms and survival.  You think – I wish I had this medication a long time ago. 

The main problem with the best meds is cost – especially if you don’t have good insurance – but usually there’s a way to get the medications you need or at least to find generics that are close to the best branded meds.

In my experience stimulants as a group have the highest batting average (the highest percent of the time a particular med works great).  I have patients that have taken them for over three decades.  I haven’t seen any long term problems from taking them.

I was initially trained in the 60’s.  One of the most helpful things I was taught – “if what you are doing isn’t working, do something else.  Even if it is wrong it will get you unstuck.”  This led me to trial and error and eventually to appreciate the value and relative safety of stimulants.

Amphetamines have been available for over 70 years and methylphenidate over 50 years so we have more experience with them than any other medication that we currently use in psychiatry.  Ironically, stimulants aren’t included in the top 10 most often prescribed meds by psychiatrists in the first quarter of 2008.  Despite the fact we have much safer delivery systems the FDA still regulates all the stimulants at a higher level – requiring a written prescription and maintaining a record of each prescription. This creates practical problems, inconvenience, etc.,  not to mention a certain intimidation is felt by doctors.  By contrast, the most abused prescription medications – pain meds – such as Hydrocodone – are much less regulated.

My top 5 list has changed some since 12/06 and hopefully will keep changing as we get even better medications.  For now it consists of the following:

#1     Stimulants – Vyvanse (preferred by 3/4’s of my patients who prefer amphetamines) and Adderall XR (preferred by 1/4 of my patients who prefer amphetamines).  15% of patients prefer one of the methylphenidates such as Concerta, Focalin XR, or Daytrana.

#2     Benzodiazepines – Alprazolam (Xanax and Niravam are my first choice).  Clonazepam, especially Klonopin wafers are a  close second.  

Alprazolam, in a recent study was the #1 med prescribed for stress symptoms by primary care physicians.  Psychiatrists in 2008 used Clonazepam #1, then Seroquel #2, and Alprazolam #3 for stress symptoms.   

#3     Sleeping medication – Ambien CR/Lunesta (I rated Ambien CR first in 06 only because 15-20% of patients have a bad taste the next day from Lunesta – but using a mouthwash with whitener morning and night usually prevents significant taste problems).  Both of these meds work great for most people.  They are both approved for long term use and provide normal sleep.  Short acting Ambien is still preferred by some patients and some take it because it is in generic and they can’t afford CR or Lunesta.  Short acting may not keep you asleep more than 5 hours and has some risk of side effect issues.

No sleep medications were in the top 10 meds prescribed by doctors in 2008.

#4     Antidepressants – Pristiq/Effexor XR – I don’t have enough experience with Pristiq (son of Effexor) to be confident that the majority of patients will end up preferring it to Effexor XR, but in theory it’s better, safer to use, easier to dose, easier to combine with other meds, especially Wellbutrin.  Wellbutrin is the only antidepressant that almost never has weight gain or sexual side effect issues (except for infrequent uses of MAOI’s like Emsam patch).  But Wellbutrin doesn’t have efficacy for the whole range of anxiety and depression symptoms so it would not be the preferred med if you could only use one antidepressant.

Cymbalta is the other antidepressant in this category.  It has more FDA approved uses including fibromyalgia, and generalized anxiety disorder and is very similar to Pristiq in its ratio of effect on serotonin and norepinephrine.  I rank Pristiq first because it has much lower protein binding and therefore gets into the brain faster and works faster.  Prestiq has essentially no drug drug interactions whereas Cymbalta inhibits metabolism of certain medications that can either result in unexpected side-effects or interfere with the activation of pain medications like codeine or hydrocodone. 

#5     Mood stabilizers – Abilify/Seroquel.  There is no perfect choice in this category.  I use these two the most but I also use a lot of Lamictal, Zyprexa (Symbyax) and Lithium.

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My brother is 16 and he has ADHD. What is the right starting dose for medication?

It is usually better to start low and increase until no additional benefits or side-effects.

Weight can be used to determine maximum dose, 2mg/kg for methylphenidate and 1.5mg/kg for amphetamines.  The following chart was published by Biederman and Wilens at the Harvard department of psychiatry.

More people prefer amphetamines.  Only 16% prefer methyphenidate.  This fits my clinical experience over the past 40 years.  The following chart shows a meta-analysis study that was done that confirms this.

So, if your brother weighs 150 pounds (or 70kg) he may need doses of methyphenidate up to 140mg, or Concerta 54mg 3x per day, or 1-2 Daytrana patches, or 90-150mg Adderall, or Vyvanse 70mg 3x per day for optimal effect.

Over the past several weeks I have tried Vyvanse in over 300 patients, many of whom were previously on Adderall.  The majority of patients prefer Vyvanse – they report that it is smoother, has less side-effects, less rebound in the afternoon, and more efficacy throughout the day.  Vyvanse has less risk to blood pressure or the cardiovascular system and has a mode of action that prevents using it to get high.  There are still some patients that prefer and do better on Adderall.  The lowest dose of Vyvanse is 30mg, which is equal to 10mg of Dexedrine or 20mg of Ritalin (methylphenidate).

How much medication should your brother take?

Enough, not too much.   It takes time and trial and error to find the best dose for each individual.

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How can I prevent recurrence of depression and what do I do if the depression does come back?

Depression runs in my family and I’ve been on the same medicine for a while with no episodes of depression.  About two weeks ago I woke up feeling not myself and contributed it to getting my period on top of coming down with a respiratory infection.  Still not feeling well after two weeks I think it might be depression because I feel tired, confused thinking, can’t focus, etc.  I’ve called my doctor and he told me to up my medicine 100mgs.  My question:  

Since I have not had an episode of depression in quite some time could it have been brought on by me not feeling well?

 


 

Dr. Jones’ reply:

I’m not sure what antidepressant you are on – but it was possibly Zoloft or Luvox since they can be increased by 100mg increments, but not SNRI’s (Effexor, Cymbalta) or other SSRI’s (Prozac, Celexa, Lexapro, Paxil).

Women with a family history and or prior history of depression who respond to an SSRI or SNRI can have return of symptoms if their serotonin level is reduced (as it is premenstrually, post partum, or during perimenopause).  Being ill can also contribute to relapse by disrupting sleep or normal thyroid function.

Previous studies have shown that:  "the dose that gets you well keeps you well", but even then the relapse rates are:  20% of patients have recurrence within 3 years,  50% relapse if the dose is lowered, or 80% relapse if medication is stopped.

Recurrent depression not only causes distress and possible short term impairment, it can also increase your vulnerability to future episodes and decrease your responsiveness to treatment.

There are several things that can help prevent recurrence:

  1. Good sleep – 7-8 hours every night (Lunesta, Ambien provide normal sleep)
  2. Physical activity – daily vigorous activity for at least 30 minutes (a 2 mile walk or equivalent)
  3. Omega 3 fatty acids – take twice daily.  (I trust Cooper brand the most)
  4. Bright light daily 
  5. Thyroid – make sure thyroid levels are good  test.askdrjones.com/ 
  6. Cognitive behavioral therapy – if needed
  7. Other medications – other medications may help such as alprazolam, atypicals, stimulants
  8.  L Methylfolate – (Deplin,  Cerefolin, or Cerefolin NAC)  – these contain a form of folic acid that gets into the brain cells.  Deplin was recently approved by the FDA as an add-on treatment for depression.  Cerefolin also contains B12 and Cerefolin NAC has a third ingredient that increases glutathione (a powerful brain cell antioxidant).  These medications not only can improve mood, but improve cognition and energy.  Caution:  taking Deplin if your B12 level is low can be harmful.  It is safer to either check your B12 levels or take Cerefolin. 
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My 15 year old daughter has been put on Risperdal to "glue" her thoughts. She is severely depressed and worries constantly. Her doctor added Lexapro to the Risperdal. How do we know if the Lexapro is working or just helping the side-effects of Risperdal?

I don’t use Risperdal because of the increased risk of neurological side-effects, and increased prolactin interfering with hormones, including estrogen.  Lexapro is good for anxiety, obsessiveness, and depression, especially sadness, but if your daughter is manic depressed/bipolar the Lexapro can make her more emotionally unstable.  Effexor XR is a broader spectrum medication with potential advantages but would also destabilize if she is bipolar.

How thorough was her examination?  What family history is there for anxiety, depression, or bipolar?

If your daughter needs a mood stabilizer or something to "glue" her thoughts I have had the best luck with Abilify or Seroquel. test.askdrjones.com/2005/02/14/ranking-the-mood-stabilizers/

Age fifteen is such a critical time developmentally so you need an experienced clinician and you need to be seeing some improvement.

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Vyvanse: New Treatment for ADHD

 Vyvanse, the new ADHD medicine, has a unique prodrug delivery system developed to prevent abuse.  In addition to marked reduced abuse and misuse, studies have shown other major advantages over Adderall XR – the most prescribed medication for ADHD.  Vyvanse has been found to be more consistent in its effect, more effective, especially for attention, longer acting and to have less rebound symptoms in the afternoon.    

 How is Vyvanse different from Adderall?

  • Adderall is 75% dextroamphetamine (dexedrine) + 25% levoamphetamine (mostly effects norepinephrine) 
  • Vyvanse is 100% dextroamphetamine as the active ingredient but it is bound to an amino acid, L lysine.  Because the amino acid has to be removed by a protease enzyme located  primarily in the intestine before it works, it is designated as a "prodrug".

Note:  The additional norepinephrine effect of Adderall may help alertness and distractibility but it is also responsible for most of the risks and side effects of Adderall.  Many patients taking Adderall do better taking it with Tenex. test.askdrjones.com/  Men on Adderall XR are more likely to have erectile dysfunction and need Viagra type medication.  Some people, especially older men have trouble urinating when taking Adderall XR and may need Flomax.  Patients switching to Vyvanse have been less likely to have these side-effects. 

  Other side-effects related to norepinephrine include:

  • dry mouth
  • muscle tightness
  • nervousness
  • stomach aches
  • cardiovascular effect (so less risk of increasing blood pressure)

Vyvanse is much more consistent than Adderall XR from day to day and patient to patient.  Vyvanse consistently reaches peak blood levels in 3 1/2 to 5 hours at a concentration of 100-175 ng/ml for a 70mg capsule.  Adderall XR has 400% variability – it peaks anywhere from 3 to 12 hours at levels of 70-300 ng/ml for a 30mg capsule.

Acidity levels in the stomach and small intestine and levels of gastrointestinal motility significantly impact absorption of XR but not Vyvanse.  Food, especially fat in the stomach or intestine can delay Adderall XR up to 2 1/2 hours but maximum delay of Vyvanse absorption is less than an hour.  Since it takes 3 hours to digest a fatty meal, forgetting to take XR before eating can result in significant stretches of time with reduced focus and productivity.

Vyvanse may be more likely to increase insomnia, decrease appetite, and increase weight loss – probably because it has a longer duration of action.

In a study where patients took alternately Adderall XR and Vyvanse almost 75% did much better.  However, twice as many patients on Vyvanse did very much better.

"Effect size" is a statistical measure of efficacy when comparing different studies.  The effect size for Vyvanse was significantly higher than any other medication ever studied for ADHD.  Also, when tested in known stimulant abusers it was significantly less likable than oral or IV dexedrine which means it is less abuse prone.

I have tried Vyvanse in approximately 200 patients – these were mostly patients taking Adderall.  Almost everyone that switched prefers Vyvanse.  One woman said that Adderall made her nervous and jittery which caused her to smoke more.  On Vyvanse she’s not smoking.  I still have a few patients that prefer Adderall.  Some probably prefer the increased mood or likability effect.  Some probably need the norepinephrine effect.

My prediction:  Vyvanse will rapidly become the number one medication for ADHD.

 Related ADHD article: test.askdrjones.com/2007/09/06/only-13-of-adhd-kids-are-being-consistently-treated-why-are-we-not-taking-better-care-of-our-greatest-resource/

 

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Say Goodbye To The Pill Ladies

I am now completely against birth control pills. I’m also against hormone replacement with oral estradiol. Estradiol (in every birth control pill) taken by mouth goes through the liver and causes problems with thyroid, testosterone, and the most effective form of estrogen.

In anyone with a history of depression and/or stress reactivity, this can be a major contributing factor to their functioning and quality of life.

For premenopausal women the NuvaRing seems to be the best option. This is because the hormone blood levels are about 1/3 of what they are with the weakest birth control pill.

Controversy continues regarding hormone replacement in postmenopausal women. However, for most women, the benefits outweigh the risks – especially for brain function (mood & memory). Using the right types of hormones and the right dose is essential. The best options are Premarin or Cenestin tablets and/or estradiol by patch or gel.

Remember, estrogen x thyroid x brain transmitters = mood in women.

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Does Xanax work for sleep?

I am not crazy about long term use of Xanax (or any other benzodiazepine) for treatment of chronic insomnia because they don’t produce all the normal sleep states (esp. stage 4 deep sleep).  Whether this is the case in everyone and whether this effect persists indefinately has not been adequately studied.  My main concern is that lack of stage 4 sleep can be associated with less secretion of growth hormone and other restorative processes that occur during the deepest sleep states – e.g., maintaining the immune system.  There may also be some reduction of REM sleep – that might impair long term memory.  None of this is adequately studied.

 
Xanax is a great medication for anxiety and can be used long term – but I prefer that it not be the primary medication for insomnia.  Ambien CR, Lunesta, Sonata, or regular Ambien provide normal sleep.  Tenex (Guanfacine) or Clonidine help induce deep sleep.  Trazodone and Seroquel in low dose seem to provide relatively normal sleep although they are stronger meds and have other potential side effect issues.
 
Rozerem, a prescription med that stimulates specific Melatonin receptors associated with sleep problems (mainly with circadian rhythm problems) is also a possible solution.
 
Before considering any sleep meds, sleep habits (See Do’s and Don’ts of Sleep on my website) need to be addressed.  One of the biggest causes of sleep problems is inadequate am bright light, and too much bright light at night (especially TV and computer screens).
 

 

 

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How can I live like a normal person when I have ADHD?

Most of my ADHD patients do well and many if not most like being ADHD.  There are some who haven’t found the "right medication(s)", but there are frequently new medications that become available.  Within 4-8 weeks we will have Vyvanse, a new form of Dexedrine that has research benefit higher than currently available medications.

Sometimes it takes a combination of meds like Adderall XR or Methylphenidate + Tenex (Guanfacine).  Sometimes it takes a different form of medication (like the Daytrana patch) which is a form of Methylphenidate that avoids first pass metabolism in the gut and liver.  This is a plus for patients that are rapid metabolizers and don’t get enough of the tablet forms into their brain.  There are also people that don’t tolerate any of the stimulants except Desoxyn.

test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

 

Another possibility is that you are not just ADHD.  At least 85% of people with ADHD have other conditions that have to be addressed.  You are 3 times more likely than the general population to have a mood disorder, an anxiety disorder, substance abuse issues, or impulse control disorder.

We already know 11 different gene variants that are more common in people who are ADHD.  All these possible complexities need to be addressed as well as basic health habits (especially sleep) to enable you to have the quality of life you want and deserve.  

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Vitamins & Supplements: Are they really worth it?

  We have heard it since we were kids, but do we really need to take our vitamins? 

The answer is yes. 
Most Americans don’t get the nutrition they need simply from the foods they eat, and supplements insure that our body meets its nutrient “quota” enabling our body to function optimally at the cellular level.  However, the vitamin and supplement industry is not regulated by the FDA, so there is no guarantee that products bought from grocery and health food stores are effective or contain the stated ingredients.    
Cooper Complete Vitamins are backed by Science.
That is one reason we decided to make them available to our patients. Reputable physician Kenneth Cooper created the Cooper Institute, a non-profit organization that manufactures, researches and publishes studies on Cooper Complete vitamins. He ensures regular testing to measure efficacy, potency and absorption of Cooper supplements.  Not only does Dr. Jones promote these vitamins, but he takes them himself and he furnishes them to his staff at no charge to promote wellness among staff members.  To encourage patients to take these supplements over other store bought brands, Dr. Jones decided to make these supplements available to his patients at a discounted price, so we offer the Cooper Complete© line of products for less than you can get them at most grocery stores and even less than the price from ordering them directly from his website. 
If you are interested in ordering supplements or would like more information about the supplements, please feel free to contact our office or e-mail us your request to info@askdrjones.com.  


Studies published in the American College of Nutrition and
the American Journal of Medicine found Cooper Complete multi-vitamin lowered: 
· Oxidation rates of LDL Cholesterol by 14%

· Homocysteine levels by 17%

· C-reactive Protein Levels by 32%

High levels of these values are all associated with increased cardiovascular disease risk.


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