ZakMeister

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I have been a couple patients on both Adderall and Ritalin where the latter is taken in the morning and the other one around noon time.

Frankly I am opposed to this regimen as they both attain similar outcome..esp when they have similar (NOT same) MOA and either has extended release formulations. I was about to refuse filling this combo but did not do it esp coz the patient has been on this regimen for months and apparentlyit is working out well for him. Has anyone seen this?
 
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owlegrad

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Oh and to answer the question yes I've seen that combination and dispensed it personally. In my mind it was pretty much no different than taking either one of them bid.
 
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josh6718

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I would be interested to learn more about how the mechanism of action is not the same. Care to enlighten me?
From what I remember, methylphenidate works by blocking the re-uptake of dopamine at the synapses whereas dextroamphetamine/amphetamine causes the transporter to work in reverse causing the release dopamine into the synapse.
 
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ZakMeister

ZakMeister

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I would be interested to learn more about how the mechanism of action is not the same. Care to enlighten me?
Amphetamines inhibit reuptake of DA and NE, stimulate the release of neurohormones (NE, 5HT, DA) and synthesis of other neuropeptides while Ritalin is just a reuptake inhibitor.
 
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Oh and to answer the question yes I've seen that combination and dispensed it personally. In my mind it was pretty much no different than taking either one of them bid.
I can see how u would view it as taking either one bid, but how would you assess what a safe max dose is, if it’s two different meds that work the same way?
 
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owlegrad

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I can see how u would view it as taking either one bid, but how would you assess what a safe max dose is, if it’s two different meds that work the same way?
That's a really good question. It would depend on the drugs for me. For example, are both drugs being taken at about half (or less) of their maximum safe doses? In that case I would figure that cumulatively they are not exceeding a safe max dose. If one or both drugs were being taken above that limit I might have to rethink my strategy.

Obviously these are highly abused drugs but the principles of determining a safe maximum dose really aren't too different from other drug combinations are they? How do you decide if a few blood pressure medications being taken together are safe? Likely you assume the prescriber is monitoring the patient and if you really do your due diligence you also counsel the patient on signs and symptoms of overdose, how to take properly, etc etc.
 
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Saisri_PharmStdnt

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On the insurance side (for the plan I work for, can't speak for all of them), both Adderall and the Methylphenidates (excluding the Concerta) are each held to the same 60mg per day limit. When have groups of Amphetamines with various mg/day limits, and then the Methylphenidates, Concerta, and Focalin each with their own limit. Most, if not all, of our limits are based on the product inserts.

When we get requests that hit multiple groups, we just make sure they aren't going above the limit for each group. We're aware that each patient is different (adult and child) and that one "ADHD Cocktail" for one patient may not work for another. Many of them are how the original poster said, taking one in the AM and one later in the day.
 
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Feb 11, 2018
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That's a really good question. It would depend on the drugs for me. For example, are both drugs being taken at about half (or less) of their maximum safe doses? In that case I would figure that cumulatively they are not exceeding a safe max dose. If one or both drugs were being taken above that limit I might have to rethink my strategy.

Obviously these are highly abused drugs but the principles of determining a safe maximum dose really aren't too different from other drug combinations are they? How do you decide if a few blood pressure medications being taken together are safe? Likely you assume the prescriber is monitoring the patient and if you really do your due diligence you also counsel the patient on signs and symptoms of overdose, how to take properly, etc etc.
You make great points. Generally speaking, if the prescriber sends an rx for a dose above the max recommended dose, and you confirm that this is the dose the md wants—do you dispense? I feel that maximum recommended dosages were set for a reason, but see many rphs dispensing whatever. Got ambien 10mg bid, pt has been on it and md said it works best. The max is 10 mg though, what do u do?
 

owlegrad

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You make great points. Generally speaking, if the prescriber sends an rx for a dose above the max recommended dose, and you confirm that this is the dose the md wants—do you dispense? I feel that maximum recommended dosages were set for a reason, but see many rphs dispensing whatever. Got ambien 10mg bid, pt has been on it and md said it works best. The max is 10 mg though, what do u do?
I would never dispense ambien BID unless the patient convinced me they need to sleep twice a day.
 

RxVampire

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You make great points. Generally speaking, if the prescriber sends an rx for a dose above the max recommended dose, and you confirm that this is the dose the md wants—do you dispense? I feel that maximum recommended dosages were set for a reason, but see many rphs dispensing whatever. Got ambien 10mg bid, pt has been on it and md said it works best. The max is 10 mg though, what do u do?
Now, if you want some more confusion, look up maximum effective dose vs. plain old max dosing for amphetamine salts.
Why you will witness many RPh under the impression amphetamine salts are VERY over utilized (really worth it?) in the United States at least (I would also agree on this stance). Don't go too crazy/beta over this (only teasing, part of the learning process)
 

TikiTorches

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Now, if you want some more confusion, look up maximum effective dose vs. plain old max dosing for amphetamine salts.
Why you will witness many RPh under the impression amphetamine salts are VERY over utilized (really worth it?) in the United States at least (I would also agree on this stance). Don't go too crazy/beta over this (only teasing, part of the learning process)
They are overprescribed and overutilized. I am very careful with prescribing these. I do not prescribe ritalin and adderall together. I hope the next big thing after this opioid crisis is the stimulant crisis because it is out of hand.
 

VA Hopeful Dr

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Haha, I know. I called md, he’s like “oh I meant two tablets at once.” I still wasn’t sure since its double the max dose
Yeah that's not much better
 
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