Is there any logic to prescribing adderall xr twice a day that im missing?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
A

annoyedpsychiatrist

Full Member
Verified Member
2+ Year Member
Physician
Joined
Sep 3, 2022
Messages
737
Reaction score
1,520
Im getting patients coming in on this and scratching my head as to wtf the logic is. And its from psychiatrists, likely from university of phoenix school of medicine.
Members don't see this ad.
 
Don't be so hasty to judge every use of stimulants like this. The patient could be a surgeon who routinely works anywhere from 8 to 36 hours straight and due to the constant swinging of shifts like this they wouldn't benefit from an ultra long-lasting drug like Mydayis. It's not like the patients taking it twice a day are taking it at 6 AM and 10 PM when they work a 9-5 and sleep from 11 to 6.
 
There is substantial inter-individual variation in how quickly they metabolize these stimulants. Some people really chew through it quickly and have a "wear-off" too soon. Especially in patients who work very early shifts or long/double shifts.

It could also just be bad practice but it isn't completely unheard of.
 
Members don't see this ad :)
TexasPhysician said:
Adderall XR works for about 8 hours. Some here work 7 on/7 off for 12-16 hour days. That’s BID.
Click to expand...
Like you, I was also suspicious of this prescribing pattern. However, for those who wake up very early (~6AM) and work late, it has been very helpful. For some, it helps them sleep. Again, I was skeptical, until a colleague suggested a patient might be "too distracted to sleep." Granted, I do not do this very often, and when doing so, the doses are on the low end (e.g., Vyvanse 30mg bid), never going over FDA max or ~0.5mg/kg of dextropamphetamine.

This is in the context of narcolepsy but UpToDate mentions the following:

Although extended-release formulations are intended to be taken once daily, many patients with narcolepsy find that the clinical effect wears off in four to six hours; such patients may use a second dose of either immediate or extended release in the early afternoon.
 
Last edited:
I can understand those specific examples above but I get this pretty frequently from adults and it has yet to be a doctor or someone working greater than 12 hours. Adderall Xr can work 8-10 hours, I feel like a ir booster or switching to a longer acting stimulant would be sufficient for vast majority of people.

I’m also getting people using first dose of Xr in morning around 8 and second dose at 12 which seems dumb.

I’m seeing a huge uptick in people coming in for adhd evals with questionable sx.
 
annoyedpsychiatrist said:
I can understand those specific examples above but I get this pretty frequently from adults and it has yet to be a doctor or someone working greater than 12 hours. Adderall Xr can work 8-10 hours, I feel like a ir booster or switching to a longer acting stimulant would be sufficient for vast majority of people.

I’m also getting people using first dose of Xr in morning around 8 and second dose at 12 which seems dumb.

I’m seeing a huge uptick in people coming in for adhd evals with questionable sx.
Click to expand...

I did have one patient in residency who needed Adderall XR BID and almost went TID at one point because he said effects would completely wear off after 4-5 hours and IR dosing lasted less than 2 hours. Would take the first dose around 8am and took the second dose around noon. One of the few times Genesight was actually necessary as it turned out the guy was ultra rapid metabolizer at almost all of the relative CYP enzymes (from what I recall he only had 1 enzyme with normal metabolism) and it really was wearing off that fast but insurance wouldn't cover BID dosing of XR until we had that testing.

That said, he was an anomaly. I have had some people who do XR dosing BID and I don't think it's super uncommon, but all of them work long hours (at least 12 hour shifts). I also don't think doing the second dose 4-5 hours later is that dumb, as XR will take a bit longer to kick in and that may be the time to keep the transition smooth. Agree that for most XR in the AM with a lower dose of IR in the early afternoon as a booster is much more common (I've had very poor success with insurance covering the legit long-actings like Mydayis), but BID isn't unheard of. I'd say if that's the standard you're seeing though it's probably just bad prescribing and it's something I see a lot of consults for as well. It's gotten to the point that if it's just a diagnostic question I don't even see them and have our psychologist see them to adminster a DIVA or ACE-Plus.
 
annoyedpsychiatrist said:
I’m also getting people using first dose of Xr in morning around 8 and second dose at 12 which seems dumb.
Click to expand...
I have had that, too. You might be getting people who were misusing what was actually prescribed. I'm pretty strict about this and will sometimes discharge them. This is one of the hardest parts of the job, saying, "No, you can't do that; it's a first sign of stimulant use disorder." Maybe I'm too strict, but red flags go up when patients make the off-hand remark, "Oh, I doubled my dose, and it worked better."
 
annoyedpsychiatrist said:
I can understand those specific examples above but I get this pretty frequently from adults and it has yet to be a doctor or someone working greater than 12 hours. Adderall Xr can work 8-10 hours, I feel like a ir booster or switching to a longer acting stimulant would be sufficient for vast majority of people.

I’m also getting people using first dose of Xr in morning around 8 and second dose at 12 which seems dumb.

I’m seeing a huge uptick in people coming in for adhd evals with questionable sx.
Click to expand...
This is a common non-sense prescription style I see from folks who don't understand psychostimulants well. Outside of those rare outliers discussed above where BID makes sense to have 16 hours of coverage, there are rarely times that 0800 and 1200h of the same dosage of Adderall XR makes sense.

For trainees, say you take Adderall XR 20mg BID at 0800, 1200. This makes an effective dosage of Adderall IR 10mg at 0800, 20mg at 1200, and then 10mg at 1600h. I guess if you have somehow have a day where you need much more focus right after lunch this can be reasonable (some kid where they have 3 back to back to back toughest classes after lunch?). Typically you want to have spikes in psychotimulant dosing like Adderall XR and Focalin XR provide (that is, not having sustained release) but you would want to have those spikes be evenly divided. An ideal psychostimulant AUC should look like 2-3 spikes separated by around 4 hours (like how Concerta works).
 
I've had a few people end up on this kind weird dosing, or came to me.
I get records. And talk with patient and get the why.
I also document the why.

Some times it works. Don't over think it too much.

*but yeah, everyone is coming in these days for adhd evals. And therapists telling patients they think they have adhd, never mind their ongoing Cannabis/Alcohol/untreated OSA...
**I definitely counsel patients on the pubs coming out showing higher CV risk with long term stimulant use; to weight the R/B discussion a bit.
 
I would rather do higher dose of Vyvanse !
 
Members don't see this ad :)
Stagg737 said:
I did have one patient in residency who needed Adderall XR BID and almost went TID at one point because he said effects would completely wear off after 4-5 hours and IR dosing lasted less than 2 hours. Would take the first dose around 8am and took the second dose around noon.
Click to expand...
I had a similar case, although fortunately insurance didn't make a fuss about multiple XR doses so we didn't need to get genetic testing.
 
Merovinge said:
For trainees, say you take Adderall XR 20mg BID at 0800, 1200. This makes an effective dosage of Adderall IR 10mg at 0800, 20mg at 1200, and then 10mg at 1600h. I guess if you have somehow have a day where you need much more focus right after lunch this can be reasonable (some kid where they have 3 back to back to back toughest classes after lunch?). Typically you want to have spikes in psychotimulant dosing like Adderall XR and Focalin XR provide (that is, not having sustained release) but you would want to have those spikes be evenly divided. An ideal psychostimulant AUC should look like 2-3 spikes separated by around 4 hours (like how Concerta works).
Click to expand...
Sure, theoretically this is all correct. And for most patients, this seems to be how things play out. But some patients really do seem to experience the medications on a different timeline. I don't think it unreasonable to think that some patients differ rather significantly in their absorption of, metabolism of, and response to medications.

I never start a patient on Adderall XR BID, but I have worked up to that when their response suggests it (generally in pre-adolescents or young adolescents with obvious behavioral responses).
 
CAP here who also sees adults - BID dosing of XR/ER stimulant isn't common, but it does have its place. I wouldn't be quick to judge without having some background info first. I actually have a number of kids/teens who do this because they are rapid metabolizers (just saw a 7-yo who does best with Focalin XR BID + a third dose as a booster for certain activities - she has not tolerated any other stimulant and we've tried several). It really depends on the individual, so I definitely wouldn't view this as bad practice across the board as it's actually quite useful for certain patients.
 
Not a psychiatrist so take with a grain of salt here:

I will BID Adderall XR with some frequency. Patient takes first dose at 6-7am. Wears off around lunch (so getting around 5-6 hours). A PM dose of short acting only gets them 2-3 hours. XR gets them another 5 hours or so. That takes them to roughly 5pm or a touch later.

Its not that they work a 12 hour work day, its a regular 8-5 job but they take the med earlier than 8 so that its in their system when they show up for work.
 
Am not generally convinced with prescribing long-acting stimulants multiple times a day. If someone requires coverage beyond the standard work day, I am more inclined to recommend a single dose for the day and an immediate release medication which allows for additional flexibility whilst limiting the potential impact on sleep.

What I find in a lot of cases where patients wanting to use long actings more than once a day, is that they often end up using more than what has been prescribed without discussing this - eg. taking it 3, 4 or more times a day, requesting early scripts and revealing addiction issues. Usually the excuse for doing so is that the medication doesn’t work, or runs out very quickly. I will use that as evidence that the medication isn’t working and look at an alternative, but invariably they still keep wanting to use the medication leading to inconsistencies with how, why and what benefits they are supposedly getting.

Part of my skepticism is due to seeing some bizarre stuff like Concerta 54mg QID + Ritalin IR 40mg QID which I think is extremely hard to justify. Most of this seems to be coming from a select few doctors who are so passionate about ADHD that they seem to see it everywhere and tend to start patients on high dosages and titrate them very quickly. On one psychiatrist discussion group someone was talking about a patient who presented with psychotic symptoms on a background of traumatic brain injury, polysubstance dependence, forensic issues and stimulant experimentation seeking an ADHD diagnosis. Most respondents recommended exercising caution, but the high prescriber piped up to say that this was something they saw all the time, they would have no hesitation diagnosis ADHD, using high dose stimulants and that none us understood substance disorders.
 
Liquid8 said:
Am not generally convinced with prescribing long-acting stimulants multiple times a day. If someone requires coverage beyond the standard work day, I am more inclined to recommend a single dose for the day and an immediate release medication which allows for additional flexibility whilst limiting the potential impact on sleep.

What I find in a lot of cases where patients wanting to use long actings more than once a day, is that they often end up using more than what has been prescribed without discussing this - eg. taking it 3, 4 or more times a day, requesting early scripts and revealing addiction issues. Usually the excuse for doing so is that the medication doesn’t work, or runs out very quickly. I will use that as evidence that the medication isn’t working and look at an alternative, but invariably they still keep wanting to use the medication leading to inconsistencies with how, why and what benefits they are supposedly getting.

Part of my skepticism is due to seeing some bizarre stuff like Concerta 54mg QID + Ritalin IR 40mg QID which I think is extremely hard to justify. Most of this seems to be coming from a select few doctors who are so passionate about ADHD that they seem to see it everywhere and tend to start patients on high dosages and titrate them very quickly. On one psychiatrist discussion group someone was talking about a patient who presented with psychotic symptoms on a background of traumatic brain injury, polysubstance dependence, forensic issues and stimulant experimentation seeking an ADHD diagnosis. Most respondents recommended exercising caution, but the high prescriber piped up to say that this was something they saw all the time, they would have no hesitation diagnosis ADHD, using high dose stimulants and that none us understood substance disorders.
Click to expand...
Beyond that wild story about prescribing practices in your area (which are clearly part of the reason for the skepticism around current adult ADHD tx), I echo what you are seeing above. If someone is really wanting peak stimulant effect all day long I think there is a real concern around realistic expectations of the medical intervention. Strikes me as similar to folks wanting opioids when they had any amount of pain. No one on just a psychostimulant without Intuniv/Strattera/Qelbree is going to have 24/7 coverage of symptoms.
 
Merovinge said:
Beyond that wild story about prescribing practices in your area (which are clearly part of the reason for the skepticism around current adult ADHD tx), I echo what you are seeing above. If someone is really wanting peak stimulant effect all day long I think there is a real concern around realistic expectations of the medical intervention. Strikes me as similar to folks wanting opioids when they had any amount of pain. No one on just a psychostimulant without Intuniv/Strattera/Qelbree is going to have 24/7 coverage of symptoms.
Click to expand...

I just recently had a conversation with someone whose work schedule meant for like a month they were getting 4 hours of sleep per night (and were quite sleepy during the day) about whether I thought their Concerta needed to be adjusted. I told him, "imagine you are an SUV and we are trying to get you down the highway. You are planning to put a single gallon of gasoline into an empty tank and we are discussing whether or not you will get better mileage from 87 or 91 grade. It is a conversation that is sort of missing the point."
 
clausewitz2 said:
I just recently had a conversation with someone whose work schedule meant for like a month they were getting 4 hours of sleep per night (and were quite sleepy during the day) about whether I thought their Concerta needed to be adjusted. I told him, "imagine you are an SUV and we are trying to get you down the highway. You are planning to put a single gallon of gasoline into an empty tank and we are discussing whether or not you will get better mileage from 87 or 91 grade. It is a conversation that is sort of missing the point."
Click to expand...
To which the inevitable reply will be... "well doc, how about we try the 100 grade octane? worth a shot"
 
lol.psych said:
Adding on to the long workday rationale:
Why does work get the full benefit of this person’s executive functioning, and the family (who this hypothetical person sees after 5pm) just gets the crash?
Click to expand...
Sometimes this sort of regimen is just for that purpose, although the other part of the issue can be the challenge of getting effect in the late afternoon/early evening without disrupting sleep.
 
FlowRate said:
Sometimes this sort of regimen is just for that purpose, although the other part of the issue can be the challenge of getting effect in the late afternoon/early evening without disrupting sleep.
Click to expand...
And appetite. Pushing cognitive performance on poor PO intake is a 1 step forward, 2 step back game.
 
You must log in or register to reply here.

Similar threads

A
Ativan XR/loreev
Replies
12
Views
935
Merovinge
Merovinge
P
DEA and Telemedicine Prescribing
2
Replies
57
Views
5K
clausewitz2
clausewitz2
N
Any docs unionized out there
Replies
32
Views
2K
Stagg737
Stagg737
milan95
Are there any child psych programs that do therapy training using ear pieces with live guidance?
Replies
12
Views
1K
djo208
D
starbuck2
Any reasonable path to psych?
Replies
12
Views
2K
J ROD
J ROD
Top