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Dr. Bob is Robert Hsiung, MD,
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Posted by BekkaH on January 23, 2003, at 19:39:15
In reply to Re: Strattera Allergic Reaction, posted by golfergman on January 23, 2003, at 10:26:10
Hi. Did you know that Strattera is also available in 10mg capsules? Perhaps your doctor could prescribe those instead and increase the dose very, very slowly over many days. Also, don't take it too close to bedtime. This medication is not technically a stimulant. It is more like the antidepressants, and you probably won't feel better for quite a while. That's the way most psychotropic medicines are. Except for the stimulants (amphetamines and ritalin) and a few other meds, most take at least a few weeks at a sufficient dosage to have a positive effect.
Posted by not exactly on January 24, 2003, at 6:57:13
In reply to Re: Strattera Allergic Reaction, posted by golfergman on January 23, 2003, at 10:26:10
> Yesterday I took my first dose of straterra 18mgs. Im 47 year old male and I know this is a very small dose. My first day I would have to say Im rather down about the whole ADD thing. I definetly felt an affect. I felt high as a kite and didnt like it at all. My Dr. wants to start out with small doses for 4 days. My feeling is I dont know if I can handle this. Im not taking it today because it made me edgy, uptight, couldnt sleep at night. In other words I didnt feel good about it. The same thing happened when I tried Ritalin. Does anyone have some insight or similar experiences. I feel rather down about the whole thing. I guess I'll just have to live with this the rest of my life.
I can sympathize with your reaction. You might be hypersensitive to certain kinds of drugs. I know I am - if I start taking almost any psychoactive drug at a "normal" dosage level, it will send me up the wall. I haven't tried Strattera (not yet, anyway, but I may soon - that's why I'm reading the Strattera posts), but I'm definitely hypersensitive to Ritalin. If I took 10 mg of Ritalin 3 times day (a typical adult dosage), I'd be "wired", irritable, unable to sleep, and convinced it was a "bad" drug. But if I take only 1.25 to 2.5 mg (1/4 to 1/2 of the lowest dose "kiddie" pill) twice a day, I have found it to be very beneficial.
One possibility is that you are a "poor metabolizer" of Strattera. According to the prescribing info:
"A fraction of the population (about 7% of Caucasians and 2% of African Americans) are poor metabolizers (PMs) of CYP2D6 metabolized drugs. These individuals have reduced activity in this pathway resulting in 10-fold higher AUCs, 5-fold higher peak plasma concentrations, and slower elimination (plasma half-life of about 24 hours) of atomoxetine compared with people with normal activity [extensive metabolizers (EMs)]."
The 10-times greater AUC ("Area Under Curve" of the graph of level vs. time, a measure of total drug exposure) is an extreme case of "Your Mileage May Vary"! Oddly enough, they don't give any dosing guidelines if this condition is present (or suspected). I would think that you'd need to take 1/5 of the usual amount half as often in order to get the same level of drug activity that "normal" (EM) folks experience. This translates to 8 mg (10 is the smallest cap they make, probably close enough) once a day as the TARGET dosage; a conservative approach would be to start with half that amount and slowly ramp up! So even though your 18 mg is "a very small dose" it could still be way too much FOR YOU.
Given your reaction, skipping the next day's dose was the right move. Have the negative effects worn off yet? If you're feeling OK in a day or 2, here's what I would do:
Open an 18 mg cap and take only 1/4 of the contents (4.5 mg). If the side effects are tolerable (e.g. sleep is possible), continue taking this amount once a day for a few days. Then slowly increase the dose, a tiny bit more every few days, until either you notice a benefit or the side effects are too much.
[Disclaimer: I'm a chemist, not a doctor. I can't guarantee this will help, or even be completely safe. Don't follow this advice if you're not comfortable with it. Talk to your doctor first.]
Remember that the full beneficial effect might take a week or 2 to kick in, while the side effects (especially those resulting from taking too much too soon) will be evident almost immediately and should diminish over time as your body adjusts. But there's always the possibility that this is simply the wrong drug for you - too many side effects for too little benefit, even with a very cautious dosing schedule. Significant side effects that don't improve with time and worsen dramatically with every small dosage increment indicate an allergic reaction or other incompatibility, and the drug should be discontinued.
BTW, I'm concerned by your closing comments: "I feel rather down about the whole thing. I guess I'll just have to live with this the rest of my life." Of course, this sort of pessimism can result from repeated treatment failures. Have you tried numerous ADD medications with no benefit?
But you might also be suffering from depression along with your ADD. I know what this is like - I have both of these problems (plus others). Sometimes depression can diminish concentration & motivation, and hence be mis-diagnosed as ADD. Have you tried any antidepressants? You might find one of the mildly-stimulating antidepressants, such as Wellbutrin or desipramine, to be helpful. Given your reactions to Ritalin & Strattera, I'd recommend that you start with no more than 1/2 the usual dosage.
Good luck, and let us know how you're doing.
- Bob
Posted by golfergman on January 24, 2003, at 13:18:02
In reply to hypersensitivity, depression » golfergman, posted by not exactly on January 24, 2003, at 6:57:13
Thanks for all the responses to my post. I'm very touched by the support and info you all give. Let me let you in on the latest. Ok, first of all let me start by saying , up until now I never say myself as depressed. I have always keep busy with positive things to do , like workingout, and golf, and meditating . After taking the Straterra Ive felt kind of down and have had negitive feelings . Nothing extreme, but not my normal self. But on retrospect , I see that maybe I might have a depression problem. You see I have been living with a depressed person for about 10 years(wife) , and I have always felt responsible to bring her up out of her depression. Maybe this is wearing on me , and what I feel is normal is really not. I have noticed I have started drinking somewhat more than I think is good for me , not extreme , but more than I feel is healthy for me and I have quit meditating. Its funny but thats when I started back considering medications for ADD . I talked to my Dr. and she wants me to try Wellbutrin, 100mgs twice a day. That was yesterday I recieved the Wellbutrin , but Im so apprehensive about it I just look at the pills and am afraid to take them. I just now read some post on Wellbutrin , and I will try it. I just havent been able to get the nerve up to take the plunge , after the straterra experience. You see I've never taken anything before now except the one time I took ritalin that affects the mind. I sorry if all this sounds selfabsorbed, I just thought my history sheds light on my medication experience and results. God Bless.
Posted by not exactly on January 24, 2003, at 14:30:34
In reply to Re: hypersensitivity, depression, posted by golfergman on January 24, 2003, at 13:18:02
I will comment more on some of what you've said later when I have time. For now, a bit of warning re the Wellbutrin. It's a good med, helped me a lot, and could well be right for you. But it can be very stimulating for the first few days. This will wear off, and the real AD effect takes a week or so. Be patient, but also be cautious. I recommend you don't take more than 100 mg total the first day until you see how it affects you. Increase the dose only when you feel comfortable that you can handle the "speedy" effect. It _will_ get better over time. Good luck.
Posted by disney4 on January 24, 2003, at 14:54:28
In reply to Re: hypersensitivity, depression » golfergman, posted by not exactly on January 24, 2003, at 14:30:34
I tried Wellbutrin Sr twice before, and couldn't tolerate the shakiness and anxiety. I took it for about a week, and I was still shaky. Do you know if this effect always wear off? I might try it again.
Posted by mom2mbcb on January 25, 2003, at 6:35:44
In reply to Re: hypersensitivity, depression » not exactly, posted by disney4 on January 24, 2003, at 14:54:28
Hi, Has anyone found straterra works with memory problems, depression , anxiety,? I was recently diagnosied with adult adhd and am having some improvement on depression with Wellbutrin, Adderral worked eal well for my memory and focus as i bounce all o9ver the place when i get going...did straterra help SLOW you down, and help depression?
Deb
Posted by BekkaH on January 25, 2003, at 16:24:28
In reply to hypersensitivity, depression » golfergman, posted by not exactly on January 24, 2003, at 6:57:13
Hello "not exactly":
In your post, you suggested that the previous poster open a capsule of Strattera and take a fraction of the capsule's contents. According to the Strattera website, the capsule should not be broken or sprinkled on food. You said you are a chemist, so perhaps you know more about this than I do, but I thought it was significant that Lilly specifically advised against opening the capsule. There are some drugs in capsule form that can be broken, but apparently this is not one of them.
Bekka
Posted by BekkaH on January 25, 2003, at 17:12:13
In reply to Re: hypersensitivity, depression - not exactly, posted by BekkaH on January 25, 2003, at 16:24:28
This is the continuation of that long Strattera thread, just in case some newcomers can't find information on the medication. The older posts are archived each week.
Posted by not exactly on January 25, 2003, at 22:32:08
In reply to Re: hypersensitivity, depression - not exactly, posted by BekkaH on January 25, 2003, at 16:24:28
> Hello "not exactly":
>
> In your post, you suggested that the previous poster open a capsule of Strattera and take a fraction of the capsule's contents. According to the Strattera website, the capsule should not be broken or sprinkled on food. You said you are a chemist, so perhaps you know more about this than I do, but I thought it was significant that Lilly specifically advised against opening the capsule. There are some drugs in capsule form that can be broken, but apparently this is not one of them.
>
> Bekka
Bekka,Thank you for pointing this out. I hadn't seen this warning.
Yes, I'm a chemist, and the study of neurochemistry/psychopharmacology is my hobby (some might call it an obsession). But I'm not omniscient. :-)
I had looked over the Strattera website fairly thoroughly, and carefully read the entire "prescribing info" .pdf document at least twice (as I mentioned, I hope to try Strattera soon, so I've been researching it extensively). But somehow I missed the warning about opening a capsule. A quick Google search with the query "sprinkled site:strattera.com" indeed turned up the following statement: "Strattera capsules should never be broken and sprinkled on food. They must be taken whole." This appears on the "How to Take Strattera" page [http://www.strattera.com/cnt_taking/howtotake.html] and is repeated verbatim on the FAQ page [http://www.strattera.com/cnt_common/faqs.html#5].
Frankly, I am surprised and puzzled by this statement. Such warnings are typical for medications that are time-release, enteric, or incompatible with food. However, none of these apply to the Strattera capsules in particular or their contents (atomoxetine) in general. The two other prescription medications that are in the same chemical family, namely reboxetine [http://biopsychiatry.com/reboxetine/index.html] and fluoxetine (Prozac) [http://biopsychiatry.com/fluoxetine/index.html], do not have this warning.
But most significantly, there is no mention of this anywhere in Lilly's official "prescribing information". This is the thorough and definitive source of information on the product for doctors, pharmacists, and patients, most of whom will never see the website. Such prescribing information documents (also called "product inserts" or "monographs") are carefully prepared by pharmaceutical manufacturers, and rigorously scrutinized by their medical, chemical, and legal experts before publishing to minimize the possibility of any negative effects (including scandals and lawsuits) of using their products. If opening a capsule were truly inadvisable, then surely the warning would appear here. Unless specifically counterindicated, many people would try this, not to subdivide a dose, but because they have difficulty with swallowing capsules.
My theory, and I stress that it is _only_ a theory, is that whoever prepared the text for that portion of the website copied the boilerplate information from some other medication, edited it to say "Strattera", and neglected to delete the part that didn't apply. Such "cut-and-paste" errors are not uncommon on the internet.
In another Strattera thread [http://www.dr-bob.org/babble/20030119/msgs/136572.html], "britwit" refers to taking doses of "12.5 mg" and "37.5 mg", which are certainly not standard sizes. I'm assuming this was done by splitting the 25 mg caps. So we know at least one person on this board is opening capsules, perhaps (hopefully) according to a doctor's recommendation.
In summary:
1) I still believe it is safe and reasonable to open a Strattera capsule and take a portion of the contents - I personally would not hesitate to do so
2) the warning which appears on the website (but _not_ in the prescribing information) is most likely an error
3) again, I AM NOT A DOCTOR - consult the medical professional who prescribed Strattera for you before you attempt any dosing regimen which differs from what they indicated- Bob
Posted by not exactly on January 26, 2003, at 0:15:32
In reply to Re: hypersensitivity, depression » not exactly, posted by disney4 on January 24, 2003, at 14:54:28
> I tried Wellbutrin Sr twice before, and couldn't tolerate the shakiness and anxiety. I took it for about a week, and I was still shaky. Do you know if this effect always wear off? I might try it again.
The official "prescribing information" document [http://us.gsk.com/products/assets/us_wellbutrinSR.pdf] mentions that temporary stimulant side effects are common. Of particular note is the following statement under "Dosage and Administration":
"Gradual escalation in dosage is also important if agitation, motor restlessness, and insomnia, often seen during the initial days of treatment, are to be minimized. If necessary, these effects may be managed by temporary reduction of dose or the short-term administration of an intermediate to long-acting sedative hypnotic. A sedative hypnotic usually is not required beyond the first week of treatment. Insomnia may also be minimized by avoiding bedtime doses. If distressing, untoward effects supervene, dose escalation should be stopped."
Your symptoms of "shakiness and anxiety" sound like extreme cases of this. Did you notice _any_ reduction of these side effects after a week of dosing? It's possible that you didn't wait long enough, but having such severe and unpleasant symptoms persist for this long a period may mean it's not the right drug for you.
If you decide to give it one more try, I'd recommend starting at a lower dose. Use the 100 mg size (I assume you tried the standard 150's) and don't take more than 1 per day until the side effects subside. Something like Klonopin might help you through the adjustment period (I think using a "sedative hypnotic" is overkill unless you have serious insomnia). You should discuss your concerns with your doctor first.
- Bob
Posted by jodie on January 26, 2003, at 0:29:27
In reply to STRATTERA - continued, posted by BekkaH on January 25, 2003, at 17:12:13
> This is the continuation of that long Strattera thread, just in case some newcomers can't find information on the medication. The older posts are archived each week.
Hi, BekkaH
I've been without my cable for a few days, thats why I haven't posted. I use cable instead of phone line for my internet service. I have a new post down there somewhere. Just updating you & everyone else on my supposed allergic reaction to strattera.
Posted by not exactly on January 26, 2003, at 0:46:16
In reply to Re: hypersensitivity, depression, posted by golfergman on January 24, 2003, at 13:18:02
> sorry if all this sounds selfabsorbed
I was recently concerned about the same sort of thing. Why am I spending so much time obsessing about my psychological state when I could be doing something positive? The answer, I decided, was that right now I _need_ to concentrate on these issues so I can improve my ability to cope and my capacity to enjoy life. Until I do, I really _can't_ effectively "do something positive".
If you had the flu, nobody would think you were being "self-absorbed" if you chose to take time off from work and stay in bed for a few days. If you don't take care of yourself, who will?
And don't worry that you're imposing on us by sharing your problems. Your golf buddies might not appreciate it, but we love to wallow in this sort of thing. That's why we're spending our time on Psycho-Babble rather than going out in the "real world" (whatever that is) and having "fun" (ditto).
But seriously, by sharing information and support with each other, we're all better off.
Don't be too hard on yourself...
- Bob
Posted by viridis on January 26, 2003, at 0:56:38
In reply to Re: hypersensitivity, depression - not exactly » BekkaH, posted by not exactly on January 25, 2003, at 22:32:08
The best way to resolve this issue is to call the company directly and ask to speak with "technical support" (or the equivalent). I've had this experience with another med that wasn't supposed to be divided (according to the doctor and website). The answer, from one of the people who actually developed the delivery form of the med, was that they just discourage division because it's hard to achieve accurate dosing, not because there's anything dangerous about it.
I have no idea whether this applies to Strattera -- there could be additional issues such as the med absorbing moisture from the air etc. I'd just call the company directly and ask. They'll know the answer.
Posted by disney4 on January 26, 2003, at 10:03:28
In reply to Re: hypersensitivity, depression » disney4, posted by not exactly on January 26, 2003, at 0:15:32
Thanks for the info Bob. Before asking my Dr. for Wellbutrin again, I am going to try a small daily dosage of Provigil. It has been used experimentally as an AD, and I had some left from a very brief trial. I remember it was much easier to tolerate than Wellbutrin, and I felt better right away. Unfortunately I was scared off of it and on to another med by some well meaning people.
Elsie
Posted by not exactly on January 26, 2003, at 13:42:27
In reply to Re: hypersensitivity, depression » not exactly, posted by disney4 on January 26, 2003, at 10:03:28
Provigil may be a good option for you. I'm on it now, and I find it helps my motivation & focus (I have ADD). It seems to be keeping my mood out of the pits as well (depression has been a chronic problem). It reminds me of how I felt on Wellbutrin, but it's more subtle.
I've been feeling some vague anxiety, but given what's happening in my life now, it may not be caused by the Provigil. Other minor negative effects I've noticed are dulled emotions and diminished capacity for feelings of joy/reward. Wellbutrin did the same thing. Don't think this reaction is common.
At least Provigil won't cause the severe adjustment problems when you start it. Hope it works for you.
- Bob
Posted by BekkaH on January 26, 2003, at 22:09:47
In reply to Re: hypersensitivity, depression - not exactly » BekkaH, posted by not exactly on January 25, 2003, at 22:32:08
Hello not exactly,
That's an interesting screen name. I read through a few of your posts on different topics. Am I correct in understanding that you are on BOTH Provigil and Ritalin? Wow! I don't think I could ever tolerate such a combination, but I've met a few people on this board who've successfully combined Provigil with stimulants. I have to read more about Provigil. I've read some articles about it in the past, and I still don't understand how it works.
Bekka
Posted by not exactly on January 26, 2003, at 23:02:36
In reply to Re: hypersensitivity, depression - not exactly, posted by BekkaH on January 26, 2003, at 22:09:47
Bekka,
> That's an interesting screen name.
It refers to my diagnosis:
Chronic Major Depression? not exactly...
ADHD? not exactly...
OCD? not exactly...
GAD? not exactly...
Asperger's Syndrome? not exactly...> Am I correct in understanding that you are on BOTH Provigil and Ritalin?
Right now, I'm taking only Provigil & Neurontin.
I've tried Ritalin several times in the past, both by itself and in combination with other meds. I'm a "low-dopamine" type of depressive, so Ritalin has been a helpful AD enhancer. It definitely reversed the emotional flattening I experienced with Wellbutrin.
I did try Ritalin along with the Provigil for a few days to see if it would similarly reverse Provigil's emotional flattening. Didn't help (just amplified the anxiety) so I discontinued the Ritalin.
> I don't think I could ever tolerate such a combination
It's funny. I'm very sensitive to stimulants, in the sense that I need only small amounts for optimal effect. But they don't "stimulate" me; they actually calm me down. Dexedrine, for example, makes me quite serene. But then so does very loud very fast dance music. Go figure.
> I have to read more about Provigil.
> I still don't understand how it works.I don't think anyone really understands how Provigil works. I asked my pdoc if it was a norepinephrine agonist. "Not exactly..."
- Bob
Posted by Peter S. on January 27, 2003, at 12:05:01
In reply to Re: hypersensitivity, depression - not exactly » BekkaH, posted by not exactly on January 26, 2003, at 23:02:36
How are people doing on Straterra? I bought a ton of it which cost me an arm an a leg. I realized aftwerwards I should have split up the prescription. After taking 40mg and throwing up, I've been hesitant to try it again. I'm probably going to split up the capsules and try 10mg to start. The warnings to not split up capsules sound silly to me. I would love to hear updates from people about experiences, dosages, side effects, etc.
Thanks!
Peter
Posted by not exactly on January 27, 2003, at 14:35:04
In reply to Straterra Updates?, posted by Peter S. on January 27, 2003, at 12:05:01
> The warnings to not split up capsules sound silly to me.
I agree, and you certainly stated it more succinctly than I did in my long-winded treatise on the subject [http://www.dr-bob.org/babble/20030125/msgs/137561.html]. :-)
Considering the number of bad reactions, plus the fact that many seem to be doing OK on significantly reduced dosages, Lilly's official recommendation that _all_ adults should start at 40mg/day seems unrealistic and almost irresponsible.
- Bob
Posted by Dog Breath on January 27, 2003, at 14:49:10
In reply to Straterra Updates?, posted by Peter S. on January 27, 2003, at 12:05:01
> How are people doing on Straterra? I bought a ton of it which cost me an arm an a leg. I realized aftwerwards I should have split up the prescription. After taking 40mg and throwing up, I've been hesitant to try it again. I'm probably going to split up the capsules and try 10mg to start. The warnings to not split up capsules sound silly to me. I would love to hear updates from people about experiences, dosages, side effects, etc.
>
> Thanks!
>
> PeterI'm on day 5 of Straterra. I did 2 days at 25mg and 3 days since 50mg. I have had no side effects (or really any effects) so far. I also take 20mg Lexapro.
D
Posted by BekkaH on January 27, 2003, at 17:56:35
In reply to Re: Straterra Updates? » Peter S., posted by not exactly on January 27, 2003, at 14:35:04
> Considering the number of bad reactions, plus the fact that many seem to be doing OK on significantly reduced dosages, Lilly's official recommendation that _all_ adults should start at 40mg/day seems unrealistic and almost irresponsible.> - Bob
>
************************************************
Hi Bob,
I agree, and that's true for almost all medicines I've tried over the years. There are some medicines that I can't even consider because the lowest strength available is still too high for me.
Bekka
Posted by BekkaH on January 27, 2003, at 18:38:17
In reply to Re: Straterra Updates?, posted by Dog Breath on January 27, 2003, at 14:49:10
Dog Breath? I'm amazed and amused at the screen names PB members think up. Is Dog Breath better than Cat Breath? A few months ago, someone posted with the screen name "Freudian Garter Belt." That was surely the strangest name I've seen. I asked him/her what it meant, but I got no reply.
Posted by not exactly on January 27, 2003, at 19:30:36
In reply to Dog Breath, posted by BekkaH on January 27, 2003, at 18:38:17
> A few months ago, someone posted with the screen name "Freudian Garter Belt."
> That was surely the strangest name I've seen.
> I asked him/her what it meant, but I got no reply.I assume a Freudian Garter Belt is what would be worn underneath a Freudian Slip. :-)
- Bob
Posted by Phil on January 27, 2003, at 19:33:43
In reply to Re: Dog Breath » BekkaH, posted by not exactly on January 27, 2003, at 19:30:36
Posted by BekkaH on January 27, 2003, at 20:00:19
In reply to Re: Dog Breath » BekkaH, posted by not exactly on January 27, 2003, at 19:30:36
> I assume a Freudian Garter Belt is what would be worn underneath a Freudian Slip. :-) - Bob
************************************************
Good thinking, Bob! Thank you!
>
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