OCD with comorbid ADD?

[Sara91Helal]

An adult female has OCD and ADD since childhood. She's been on Escitalopram 10 mg for 3 years, which improved her obsessions. She now wants a medication for her ADD symptoms because she's "starting a new job" and her colleagues noticed her disorganization and inattentiveness. I checked for drug interactions between Escitalopram and Atomoxitine, and it turns out the combination isn't favourable. The question is, what's the best combination to help this patient?

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[wolfvgang22]

Any particular reason you are looking at atomoxitine first instead of starting a low dose stimulant and monitoring closely?

 

[nitemagi]

Most people would say start a stimulant. I would bump the escitalopram towards 30-40mg first. Get a clearer history of the inattentiveness/disorganization - lifelong, situational, avoidant? I see a lot of people with avoidant traits related to effort and anxiety, which stimulants may help a bit, but doesn't necessarily solve.

 

[Sara91Helal]

Any particular reason you are looking at atomoxitine first instead of starting a low dose stimulant and monitoring closely?

No reason, just because atomoxitine is cheaper (patient can barely afford).

 

[Sara91Helal]

Most people would say start a stimulant. I would bump the escitalopram towards 30-40mg first. Get a clearer history of the inattentiveness/disorganization - lifelong, situational, avoidant? I see a lot of people with avoidant traits related to effort and anxiety, which stimulants may help a bit, but doesn't necessarily solve.

The patient has complained of inattentiveness, misplacing stuff, disorganization, and lack of motivation for years (her teachers at school always complained). She has obsessive compulsive traits, but no obvious avoidant traits. She has concerns about Adderall and amphetamine in general (she's very obsessive, also she can't afford).

 

[birchswing]

There is some evidence for omega-3 enriched phosphatidylserine in treating ADD. The prescription version (Vayarin) is expensive. You can buy the supplements separately OTC, or you can eat a diet rich in phosphatidylserine (white beans, for example) along with a fish oil supplement. I personally as a patient found Vayarin slightly stimulating, but it just as likely was a coincidental effect. Probably doesn't come close to the immediate effect of a stimulant.

Out of curiosity, why is generic Adderall so much more expensive than other generics?

Also, as far as the advice (not that it was really intended as advice), I am not a doctor.

 

[Sara91Helal]

There is some evidence for omega-3 enriched phosphatidylserine in treating ADD. The prescription version (Vayarin) is expensive. You can buy the supplements separately OTC, or you can eat a diet rich in phosphatidylserine (white beans, for example) along with a fish oil supplement. I personally as a patient found Vayarin slightly stimulating, but it just as likely was a coincidental effect. Probably doesn't come close to the immediate effect of a stimulant.

Out of curiosity, why is generic Adderall so much more expensive than other generics?

Also, as far as the advice (not that it was really intended as advice), I am not a doctor.

Adderall is imported (not manufactured in Egypt) while there is locally- manufactured Atomoxitine.

 

[birchswing]

Adderall is imported (not manufactured in Egypt) while there is locally- manufactured Atomoxitine.

Ahh, I didn't know you were in Egypt. In the US Adderall is expensive compared to other prescription drugs. I don't take it, but I looked up the price out of curiosity when you said stimulants were more expensive. In the US, generic Aderall appears to be about $50 a month, whereas many generic drugs are $4 a month.

Also interesting that your drug prices are dependent on country of manufacture. In the US the vast majority of prescription drugs are imported, presumably because it's cheaper to import them. About 40% of our drugs come from India alone.

 

[Shikima]

I don't think it's a question of manufacturing origin or if it is generic, rather the fillers they use.

 

[Sara91Helal]

I don't think it's a question of manufacturing origin or if it is generic, rather the fillers they use.

Regardless, how would you help this patient?

 

[strangeglove]

What about dextroamphetamine?

 

[Shikima]

Regardless, how would you help this patient?

Discontinue Lexapro for Wellbutrin to be used in combination with Strattera. Or go with higher dosage of Wellbutrin in combination with Lexapro. Or Strattera alone as it is NE and you have a chance alone to help her mood, anxiety and attention difficulties. Could do a trial of Effexor or Cymbalta with Wellbutrin. Lots of recipes to explore over the next year before jumping right to amphetamines.

 

[MLT2MT2DO]

An adult female has OCD and ADD since childhood. She's been on Escitalopram 10 mg for 3 years, which improved her obsessions. She now wants a medication for her ADD symptoms because she's "starting a new job" and her colleagues noticed her disorganization and inattentiveness. I checked for drug interactions between Escitalopram and Atomoxitine, and it turns out the combination isn't favourable. The question is, what's the best combination to help this patient?

You say her ocd is well controlled but at the same time she has obsessions about stimulants. What else has the patient tried for ocd? I'd make sure that was well controlled first.
Why not clomipramine and Strattera?
Any medical coditions (alcohol?)that makes you overly worried about Lexapro and Strattera?

 

[Shikima]

Zoloft too is gold standard for OCD.

 

[Doctor Bagel]

Awfully low dose of Lexapro for OCD. I am curious about how well it's controlled and if she might benefit from a higher dose. More diagnostic clarity of ADHD would be useful as well, certainly before starting stimulants. Any other substance usage concerns? If so, that would be a big argument against not starting stimulants. About atomoxetine and Lexapro, I'd have to look it up, but I don't think it's a no-go type of combo. I know you need to use lower maximum doses of atomoxetine with some SSRIs, but it's not an absolute contraindication. If you firmly establish an ADHD diagnosis, though, and there's no contraindication to stimulants, it wouldn't be horrible to start there. Atomoxetine is totally OK, too. I think bupropion is third line for ADHD, but it hasn't been that helpful for my patients (of course when you want a stimulant, nothing else is going to help as much, right?).

Your profile says you're a resident. What does your supervisor think?

 

[wolfvgang22]

Yeah, so, make sure the OCD is under control.

Then, first line medication for ADHD is either methylphenidate or amphetamine. I'm a child psychiatrist, and I don't really believe that atomoxetine or bupropion work very well for actual ADHD compared to stimulants, and evidence supports this. That's why stimulants for ADHD are first line. The first stimulant you use will work 85% of the time. I advocate avoiding wasting money on bupropion or strattera that won't work, when you can use a medication that works.

Is methylphenidate expensive in Egypt, too? What about buying it from Canada or somewhere else?
Is it possible to utilize pharmaceutical company patient assistance programs to get some brand name like Vyvanse or Focalin? Try here or here.

 

[whopper]

Adding to the chorus, data suggests that SSRIs don't really do anything at low dosages and OCD usually requires a very high dose SSRI.

 

[shan564]

Push the SSRI. If you're concerned about Lexapro for some reason, just switch to a different SSRI. But as people have said, 10mg of Lexapro is a depression dose, not an OCD dose.

Also, there's no real interaction between Lexapro and atomoxetine. Their might be a weak P450 effect, but not enough to make me think twice unless it's a geriatric patient, in which case I might just monitor a bit more closely. Those drug interaction checkers spit out even the weakest P450 effects, even if there's no clinical significance.