Archive for the ‘Medication: Best Meds’ Category

If you only had 5 medications to work with …

Recently, one of my pharmaceutical reps asked me a question she’d been asking other doctors.  "If you only had 5 medications to work with, which ones would you choose?"  For me it was easy.

1. Adderall XR

Has the best batting average.  Batting average = how often patients say, "This med is great.  It changed my life and has no significant side effects."  And they’re still saying it after a year.

2. Alprazolam (Xanax or Niravam)

Helps people take back control of their lives.  Was the most prescribed med for stress last year.

3. Ambien CR

Safe sleep medication which gives you normal sleep.  Normal sleep = foundation for health.

4. Effexor XR

Has the most flexibility (SSRI at low doses, dual agent at higher doses), works the fastest, and has no significant drug/drug interactions.

5. Abilify

Best mood stabilizer.  Was the 1st of the new generation of atypicals.

I no longer take insurance.  To be successful I have to use the meds that work the best.  My goal for each patient is to find "the right medication at the right dose."  All of these "Top 5" have alternatives that I often use.  The bottom line is that with these meds I have seen the best long term results.

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Determining the Best Stimulants

Click here to see how Dr. Jones determines "Best Meds"

Stimulants are without a doubt my most successful medications.  All except Provigil require a triplicate prescription, which is ironic because stimulants are seldom abused when properly prescribed. Approximately 10% of adults will abuse prescription medication but what they abuse is primarily pain medications, especially Hydrocodone (4 to 1 over stimulants and tranquilizers 2 to 1 over stimulants). Ironically, pain medications and tranquilizers are much less regulated and can be called in with refills whereas stimulant prescriptions have to be written each time. In what way does this possibly make sense? To paraphrase an old Bullwinkle cartoon, “are you familiar with government intelligence?” “It sounds like a contradiction in terms to me sir.”

The single most important thing for all ADHD patients on stimulants is ALL DAY coverage.


Adderall XR primarily and Adderall tablets to a somewhat lesser extent rank #1 in my practice. Adderall is a type of amphetamine. Amphetamines have been studied in patients since 1936. The fact that we have more years of scientific study and clinical experience with this type of medication than any other we use in psychiatry is reassuring to me and many of my patients. There is no evidence of long term problems with Adderall or other amphetamines.

These medications help with staying calm and focused on what one chooses, not just what’s interesting. Adderall also tends to improve mood. It doesn’t usually decrease appetite but helps control weight because eating impulsively due to being bored or stressed is reduced. It is usually the best long term treatment for Bulimia-sometimes combined with an SSRI. The primary indication for Adderall XR and Adderall tablets is Attention Deficit Hyperactivity Disorder (ADHD).  Adderall was the first stimulant approved by the FDA to treat adult ADHD.

Adderall helps people to think about one thing at a time and to single out the important from the unimportant. The XR formula usually allows for once a day dosing although some people, especially those that want 16 hours of calm/focus and productivity, may take it twice a day. It has a low abuse potential because it takes 6 hours to reach maximum blood level, (3 hours for Adderall tabs). Abuse potential correlates highly with rate of onset of action.

Dexedrine is similar to Adderall and may be as effective for boredom or low motivation, but isn’t as calming.

Desoxyn (see below)


Methylphenidate may be better than amphetamines for hyperfocusing. Moodiness may be a side effect, but it is less likely to affect blood pressure or erectile functioning. We have over 50 years of scientific study and clinical experience with methylphenidate and have no evidence of long term problems or loss of efficacy.

Daytrana patch is the most flexible and potentially longest lasting stimulant – up to 15 hours if removed at 12 hours or if left on for up to 24 hours.  It has a smooth onset of action and wears off 3 hours after it’s removed.

Concerta usually lasts 12 hours.   For patients who would do best on a methylphenidate product but who don’t like or can’t tolerate patches, Concerta is the best choice. 

Other forms of methylphenidate:

Ritalin and Methylin last 3-4 hours and rebound can be a problem. Methylin comes in chewable and liquid forms for children and adults that have trouble swallowing pills.

Focalin is the primary active ingredient in methylphenidate and may be better tolerated by a few patients.  It lasts 4-6 hours.

Focalin XR lasts approximately 8 hours and was the second stimulant approved by the FDA to treat adult ADHD.

Metadate CD is 30% release initially and 70% in 4 hours.  Ritalin LA is 50% immediately and 50% in 4 hours.  Both last around 8 hours.  Some people have a preference for one or the other.


Some people prefer methylphenidate and some prefer amphetamine products. In one study that compared methylphenidate to amphetamines, about 40% said either worked fine, 15% preferred methylphenidate, and 30% preferred amphetamine.  If the percentages are the same as the study and with no other factors to guide the decision, I feel patients are better off starting with Adderall XR. It will work well in at least 70% of people. If Adderall does not work, I would next try Daytrana.  This will get the success rate to 85%.

Pediatricians usually start with a methylphenidate product because they’re milder.  This is probably true.

There are a few patients that don’t tolerate Adderall, Dexedrine, Concerta, or other methylphenidate type stimulants. The most common side effects they complain of are nervousness and irritability. For these people Desoxyn (methamphetamine) usually works well. I have 15-20 patients who can’t tolerate other stimulants but who lead normal lives on this medication. Unfortunately, it is now only available in short acting tablets. It lasts 4-6 hours and is very expensive. Because it is the most likely of the stimulants to be abused it has to be monitored more closely. We have 60 years of clinical experience with this medication and there is no evidence of long term problems or loss of efficacy.

Provigil is a different type of stimulant. It does not require written triplicate prescriptions and basically has no abuse risk. Provigil was originally marketed for excessive daytime sleepiness associated with narcolepsy and has since added formal approval for daytime sleepiness associated with shift-work and sleep apnea.

Provigil primarily increases alertness but may also improve cognitive functioning and learning. In a study in mice, Provigil enabled old mice (equivalent to 70 year old humans) to learn a maze as fast as young mice. Without Provigil the old mice took twice as long to learn the maze.

Provigil is very well tolerated but occasionally causes headaches or dizziness when first starting. Dose reduction usually solves this problem. It doesn’t work on boredom or low motivation. There are studies showing benefit for ADHD in some patients but it’s not on the order of magnitude of benefit we see with Adderall XR or methylphenidate. It is sometimes added to other stimulants or to antidepressants. It is also useful for chronic fatigue from physical causes such as fibromyalgia. It is pricey and insurance companies frequently try not to cover it. But it is very safe and effective, and many patients find it useful. Although it has only been on the market for a few years, we have no evidence of any long term problems.

Click the link below for latest info on new drugs:

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How To Take Tenex (Guanfacine)

Tenex (Guanfacine) is usually taken once or twice daily.  It can be taken 3-4 times/day but it has a 16 hour half life so frequent dosing is not necessary.  If taken regularly total blood levels will gradually increase over the first three days and then will level off.

Tenex comes in 1 and 2 mg tablets that are easily broken in half.  If taken primarily for help with sleep or if an individual is very sensitive to side effects it can be taken in the evening.  For irritability, muscle spasms, anxiety, increased blood pressure or any symptoms associated with high levels of norepinephrine it is usually taken in the am or am and evening.

As with most medications, start with a low dose – ½ of 1mg and gradually increase as needed until the right dose is found.  Extra doses can be taken for acute symptoms like agitation associated with increased or unusual stress.

Side-effects are usually mild and transient – especially sluggishness or dizziness.  If any side effects are bothersome decrease the dose and take at bedtime only.

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Tenex (generic Guanfacine) is a medication that has been used for years as a mild antihypertensive.  In the body and in the lower brain centers it reduces the release of norepinephrine (sometimes called noradrenalin).  In the prefrontal cortex in the front of the brain it decreases sensitivity to distracting stimuli and therefore helps with focus (on target stimulus).  A slow release form of Tenex will likely be FDA approved for ADHD within the next year or two. There are good controlled studies showing that Tenex benefits many ADHD symptoms although it doesn’t help with boredom or enhance ability to focus on things the ADHD individual has low interest in.  Only stimulants help the full range of ADHD symptoms and that’s why stimulants are considered the first line treatment.

Stimulants increase norepinephrine throughout the brain and sometimes in the body.  In the prefrontal cortex this helps decrease distractibility but in other areas of the brain it sometimes causes nervousness, insomnia, decreased appetite, or irritability and in the body can cause muscle twitches, stomach ache, or increased blood pressure.  In the lower brain centers in children it has sometimes been found to delay growth.

All of these negative effects can be reduced or eliminated by Tenex (Guanfacine) plus distractibility is further improved.  If taken in too high a dose it can cause sluggishness or dizziness and occasionally can cause swelling.  It is one of my top 10 most frequently prescribed medications – usually with stimulants or sometimes antidepressants.  It can be taken once or twice daily (See how to take) because it has a half life of 16 hours – it can be effective if taken just once a day.

Tenex is related to Clonidine.  But Tenex is 10 times stronger in the prefrontal cortex than in lower brain centers where Clonidine has the same potency in all brain areas and is therefore much more sedating – sometimes causing morning drowsiness when taken at night.  But some people need the higher sedation at night and it has a stronger enhancement of growth hormone – in fact Clonidine is sometimes abused by body builders to increase muscle building.

Many of my patients have found Tenex to be helpful for social anxiety.  It reduces symptoms like sweating, and dry mouth but it also decreases distractibility.  People with social anxiety are distracted by negative or “what if” thoughts.  They are also distracted by physical symptoms and they are distracted by any negative cues in their environment, e.g., if giving a presentation and one person yawns the immediate thought is, “I must be boring”.  It’s very hard to do a good presentation when your mind is jumping all over the place.  Stimulants also help social anxiety by increasing control of what you focus on.  The combination of stimulants (such as Adderall XR, Daytrana) and Tenex is especially helpful in lowering public speaking anxiety symptoms so that with adequate opportunities to practice, public anxiety response will gradually desensitize.

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Best ADHD Medications

Question: What are the best medications for ADHD?

Answer: Surgeons are practical. “A difference that makes no difference is no difference”. Recognizing ADHD and finding the right treatment makes a dramatic difference in someone’s life.  ADHD is relatively easy to diagnose. There are more studies showing the effectiveness and safety of medication in treated ADHD than in any other mental health disorder and most general medical disorders.

Stimulants are almost twice as effective as other types of medication (like Strattera, Provigil, and Wellbutrin XL, Tenex). Long acting stimulants are usually safer (especially less rebound) and more effective. Sometimes short acting medications can be used to supplement the long acting stimulants. Some people do better on amphetamines and some do better on methylphenidate type of stimulants. Some do okay on either.

More people do better on amphetamines according to one study.  In another study amphetamines were more likely than methylphenidate to allow ADHD patients to function at the highest level.

In general, amphetamines are more effective for the majority of ADHD patients because they have a broader spectrum of action relative to both subtypes of ADHD symptoms.  Because amphetamines have been shown to be very effective for a higher percentage of patients than methylphenidate, I start most patients on Adderall. Because long acting medications are safer and generally more effective I start with the XR form. It generally has at least an 8 hour duration of good effect. Some people take it twice a day to get 16 hours of calm focus.

I use the new Daytrana patch if Adderall does not work well, or when the advantage of the patch lasting up to 15 hours is the most important clinical consideration.

Some patients prefer Adderall because of the help with weight control – not usually decreased appetite but they stop eating out of boredom or stress. They also are more physically active and more likely to be able to motivate themselves to exercise. In fact, stimulants in general enable an ADHD person to choose what they want to do or focus on instead of being at the mercy of only doing things they have a high interest in.

To me, the ultimate test of medication is how it does in the long term.  I tell patients I’m not interested in them coming back and saying, “I think it’s helping a little bit doctor”.  I’m looking for, “This medication is great. It has helped me change my life and I don’t have any significant side effects”, and they are still saying it 1 year, 5 years, etc. We have almost 70 years of research showing the effectiveness and safety of amphetamines and 55 years with methylphenidate. I have patients who have done well on stimulants for over 30 years. I don’t see any long term problems. I can’t say that for any other type of medication that I prescribe.

I frequently add Tenex (Guanfacine) to stimulants to enhance efficacy and to further minimize side-effects.

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How To Use The Daytrana (methylphenidate) Patch

Daytrana (methylphenidate)

Daytrana is an adhesive patch formulation of methylphenidate (such as Concerta, Ritalin, Focalin). It is the first patch to be approved by the FDA for treatment of ADHD. Although the formal indication is for use in children 6-12 years of age it can be used in all age groups.

The approved wear time is for up to 9 hours, providing 12 hours of effective control of symptoms. Wearing time for the patch can be individualized so that it is removed 3 hours before you want it to wear off. This allows for up to 15 hours of effectiveness, i.e., 12 hours wearing time. Many patients leave the patch on for 24 hours. The effect wears off in 15 hours and sometimes sleep is better when leaving it on.


The studies for approval were done by applying the patch to the side of the upper leg, just below the waistline of the underwear. It probably works just as well on the abdomen (in women) or on the side of the arm.

It is essential that it is applied properly.  Half the backing is removed and that side of patch applied to the body. The skin must be clean, dry, and have no hair. Then the other half is removed and pressure is applied by the palm of the hand for 30 seconds.

The combination of heat and pressure will keep the patch firmly attached. Most people begin to notice an effect in one hour, but for some it takes 1 ½ to 2 hours. To speed up the rate of onset it may help to keep firm pressure on the patch for a full minute.


The patch is 10, 15, 20, & 30mg in strength. This refers to the amount of medication released during a 9 hour wearing time. If left on longer than 9 hours additional medication is released.  After 4-5 weeks of regular wear, absorption improves and up to twice as much medication is released.

This may result in better efficacy or may cause side-effects. In the event of side-effects the dose just needs to be reduced. Total dose should not exceed the maximum published dosing limits of 2mg per kg of body weight.

This translates to:

100kg = 220 pounds

50kg = 110 pounds

1 kg = 2.2 pounds

The medication is equally distributed throughout the patch. Although it’s not part of the formal FDA approval some patients report that cutting the patch in half and wearing on separate days works well.

Patients may wear 2 patches at one time when requiring a higher dose. It is recommended they both be put on the same side. The patch should be alternated between the left side and the right side. If any redness remains don’t put the patch on the red area but move it down or further back on the hip.

Each patch has 2 ¾ the total medication on the label.  This means that:

10mg has 27.5mg

15mg has 41.3mg

20mg has 55mg

30mg has 82.5mg

A unique feature of Daytrana is that after 4-5 weeks of regular use the absorption of medication improves and close to twice as much medication is released into the system.

If switching from Concerta 36mg, Daytrana 30mg was found to be equivalent.  After 4-5 weeks the dose of Daytrana may need to be reduced. 72mg of Concerta (2 x 36mg) may require 2 patches of 20-30mg initially but after 4-5 weeks one patch will be sufficient.

The patch sizes are:

1 ½ x 3 ½ inches(30mg)

1 ½ x 2 ½ inches(20mg)

1 3/8 x 1 7/8 inches(15mg)

1 3/8 x 1 3/8 inches(10mg)


Side-effects are the same as for all methylphenidate products except for possible skin irritation. In a large clinical trial only 7% discontinued due to side-effects and about ½ of those were due to skin irritation.

Other side-effects include:

  • Decreased appetite
  • Sleeplessness
  • Sadness/crying
  • Muscle twitches
  • Weight loss
  • Nausea

Most of the significant side-effects like muscle twitches, insomnia, irritability, and possibly even decreased appetite and stomach ache can be improved by reducing the dose. But if side-effects persist at the effective dose then Tenex (Guanfacine) ½ to 2mg once or twice daily can be very effective plus it also improves distractibility.

Most patients do not have any skin reaction or have mild redness that goes away quickly once the patch is removed. A small percent of people will have more marked redness that may persist for a few hours and a very few may develop a more significant localized skin allergic rash.


Remember that after 5 weeks the amount of medication released is almost double the dose on the label if worn for 9 hours and even higher if worn longer.

Because the patch provides up to 15 hours of effective symptom control and can be flexibly dosed to wear off within 3 hours when removed, it should be considered the first line form of methylphenidate in clinical practice. No other stimulant on the market provides more than 12 hours with single dosing and in ADHD it is hard to remember to take second and third doses of medication.

Note: If there are concerns about the possibility of growth delay – especially in children in the bottom quartile, Tenex can be given at bedtime. Clonidine is even stronger but is frequently too sedating. Tenex is also effective for the occasional person that has increased blood pressure from stimulants.

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Getting Worse on SSRI or SNRI

Question: I am a 24 year old who has suffered anxiety and depression since the age 15. Nothing has worked. I have mostly taken Zoloft. Recently I have switched to Cymbalta. I am in my second week of Cymbalta and feel very keyed up, irritable, anxious, and feel as if I could loose my mind. My quality of life gets worse from day to day. I am pretty much begging someone to help me! I have tried therapy, psychologist, psychiatrist and a few other medicines. Could you please lend me some advice??
Answer: Without doing an evaluation or having a doctor patient relationship with you, I can’t give you specific medical advice. I can only discuss general principles.
First, make only one medication change at a time. When you stop one and start another at the same time you can’t be sure if you have problems due to side effects of the new medication or discontinuation of the original one.
When starting an SSRI (like Zoloft) or and SNRI (like Cymbalta) they can make anxiety symptoms worse for the first 2-3 weeks or longer.

In general it works better to use a benzodiazepine with them at least for the first 3-4 weeks (e.g., Alprazolam, Clonazepam, Lorazepam) See Best Meds for Anxiety
There are patients who don’t seem to tolerate any norepinephrine enhancing medication. They usually do better on Lexapro or Celexa, the most purely serotonin modulating antidepressants now available.

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Taking Wellbutrin and Effexor Together

Question: A friend has been on Effexor XR for a few years now, but the doctor wants her to get on Welbutrin to help her stop smoking. Can she take both Welbutrin and Effexor XR together if she cuts the Effexor XR to 75 from 150, and will this give her the desired effect of both?

— Jeremy W.
Answer: Effexor XR and Wellbutrin XL or SR are usually tolerated well taken together. She may not need to decrease her dose of Effexor XR.
It is better to take Wellbutrin in the am and Effexor at suppertime or 6pm to avoid both peaking at the same time. She might want to at least monitor her BP, especially if she takes both in the am.

This combination is especially good for managing sexual side effects, delayed/absent orgasm and/or libido.
Wellbutrin may also help with possible weight gain on Effexor XR (or any SSRI/SNRI). For decreased craving for cigarettes, she will probably need 300 mg Wellbutrin and possibly 450 mg/day. The XL form is safer and better tolerated, but the SR form is in generic, and therefore, sometimes necessitated by cost issues.

This article originally appeared in the Q&A section 04/01/2005. Revised 01/22/2006.

FAQs: Comparing Meds

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Zyprexa and Cymbalta OR Another Combination

Question: I take Zyprexa and Cymbalta for depression. I would like to get off the Zyprexa*. Is there another combo that will work just as well, such as Cymbalta-Effexor, or Cymbalta-Wellbutrin? Thanks for the help – I enjoy your website.

— Max
*Max clarified this was due to “side-effects mostly. I have to have blood test to make sure it’s not affecting my liver and sugar. Cost is a consideration.”
Answer: Current clinical research evidence for effective treatment of depression not responding to antidepressant alone (*see note) is strongest for the “atypicals,” including Zyprexa. There are secondary differences with each of the others. Risk of metabolic side effects and weight gain vary within the group. (Note: Assuming adequate dose and duration and preferably including a broad-spectrum antidepressant like Cymbalta or Effexor, which modulate both serotonin and norepinephrine.)
My 1st choice in this group, considering side effects and efficacy, is Abilify. (more on Abilify) Changing to Cymbalta and Abilify would be the simplest alternative. However, due to genetics and other complexities, sometimes one specific combination works better than anything else.
There’s no current solution to cost concerns (unless limited income, then see because no generic substitution exists for your 2 meds (2 generic drugs could be combined to somewhat duplicate the main effects of Cymbalta and another 2 for Zyprexa – but this gets tricky.).
This doesn’t mean you wouldn’t do well on Wellbutrin (available in generic), but Wellbutrin’s effects are totally different and changing would be a gamble.
Good luck!
Dr. Jones

FAQs: Comparing Meds

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"Xanax, Niravam or Klonopin?"

Question: I have mitral valve prolapse syndrome(dysautonomia) and very infrequently get panic attacks from a food, smell, etc. For a one shot attack which is better at stopping it quicker, Xanax, Niravam or Klonopin?

— R.F.

Answer: When you say “mitral valve prolapse syndrome (dysautonomia),” I assume you are referring to the functional mitral valve prolapse associated with excessive adrenaline/noradrenaline that is assocaiated with panic attacks and anxiety caused by panic attacks. This type of M.V.P. usually goes away when panic attacks are adequately treated.
Your report of panic attacks brought on by a food smell is unusual. Through classical (pavlovian) conditioning, any stimulus, external or internal, can induce a physiological response (e.g. panic attack). Klonopin wafers dissolved sublingually (under the tongue) and Niravam, which is dissolved immediately on the tongue, are both reported to work faster. This is also true for Xanax (brand is better) but it’s very bitter and brand Ativan.
Some people do better with one, some do better with another. Because we have samples/coupons for Niravam and Klonopin wafers, those are the ones I now give patients to compare. Most people do well with at least one of these. Some do well with either. I don’t think there’s any way to predict which will be better for any individual. I usually start with Klonopin if there are also racing thoughts or obsessing. I start with Niravam if there are problems with depression.
Niravam (or Xanax) is out of the system much quicker (mostly by 6-8 hrs.), whereas Klonopin takes much longer to clear (up to 24 hours or more). Some people prefer the shorter duration, others like the longer duration. Of course, nothing is simple – there are people who prefer one under certain conditions and the other one under different conditions.
Finally, you have to take “enough, not too much” (i.e., the right dose).
Good luck!
Dr. Jones

FAQs: Comparing Meds

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