ADHD medication and avoiding tolerance

Not the social kind of tolerance, the medical/pharmaceutical kind.

One of the things we noticed about our son is that the dose of Vyvance he’s been on for about three years seems to wear off sooner: before it was good until after school (we used to call dinnertime the Arsenic Hour), and now we’re getting reports that he becomes his unmedicated self while at school in the afternoon. The temptation is to ask for an increased dosage, but tolerance is a known side effect for some people taking methilphenidate drugs. (There’s also an interesting thing that a doctor on some podcast mentioned, which is that changed life circumstances can affect how much you need. That doesn’t apply in this case, but I figured I’d mention it to lay the groundwork for pointless theorizing in some future post.)

Anyway. What my son’s pediatrician prescribed is alternating Concerta and Vyvance. The boy was on Concerta before, and for reasons related to anxiety, we switched to Vyvance, which has been good for several years.

As he explained it to me, a moderately-educated layman (I have a rusty B.Sc.Hons. in biology) is that the tolerance is in how well the liver processes the drug. Essentially, and I know I’m anthropomorphising here, the liver “knows” the stuff from familiarity and has become really good at eliminating it from the bloodstream.

So, just like switching up your exercise program when you plateau, what he’s doing is switching up medications. The liver isn’t as familiar with the form of the Concerta, it switches, and it “forgets” the shape of the Vyvance molecules. In our case, we’re alternating every two weeks. The pediatrician said he’s kept patients on this regime for as long as 11 years and has seen no increase in tolerance from either. (Given that he’s a pediatrician, he might only see a patient for 18 years, so 11 years is the longer end of testing regimes.)

I didn’t ask whether this has been tried only with Vyvance and Concerta, or whether it’s a general strategy for all of the slow-release methylphenidates. And I trust the man (I send my son to him, after all) but the most I can recommend is that, if you or someone in your household is experiencing tolerance problems, you should talk to your health care provider and see if it’s a strategy that would work for you.

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