Category: Medications

Choosing the Best ADHD Medication for Your Child

There are a lot of options when it comes to treating kids with ADHD.

In addition to behavioral therapy, there are a number of different stimulant and non-stimulant medications.

How do you choose the best ADHD medication for your child?

Is there a best ADHD medication for your child?

What Types of ADHD Medication Are Available?

When DSM-II was published, in 1968, Ritalin had already been studied and was being used to treat hyperkinetic children with minimal brain dysfunction syndrome.
When DSM-II was published, in 1968, Ritalin and Adderall had already been studied and were being used to treat hyperkinetic children with minimal brain dysfunction syndrome.

Whether your child’s ADHD symptoms include problems with inattention, hyperactivity and impulsivity, or both, the treatments are the same:

  • Stimulants – Adderall/Amphetamine vs Ritalin based
  • Non-Stimulants – Intuniv (extended release guanfacine), Kapvay (extended release clonidine), Strattera

Remember, that although often underused, it is recommended that behavior therapy be the first treatment for younger, preschool children with ADHD. Both medication and behavior therapy are typically recommended for older children with ADHD.

Other off-label medications for ADHD that are also sometimes used include bupropion (Wellbutrin), tricyclic antidepressants such as desipramine (Norpramin), and imipramine (Tofranil), and modafinil (Provigil or Nuvigil).

Yes, we have come a long way from Dr. Charles Bradley’s first studies of benzedrine (racemic amphetamine) in 1937.

How to Choose ADHD Medication for Your Child

Once you start looking at medication options, the first thing to keep in mind is that there is no one single ADHD medication that is better than others for all kids.

The best ADHD medication is going to be the one that your child will take and which controls your child’s symptoms without side effects (or with minimal side effects) for as long as you need it to, without costing an arm and a leg.

So, do you want an ADHD medication that comes as a chewable pill, a pill or capsule that your child can swallow, a capsule that can be opened and sprinkled on food, a dissolvable tablet (ODT), a liquid, or a patch?

How long do you want it to last? 4, 6, 8, 10, 12 hours?

Is your child going to take it every day or just on school days?

What ADHD medicines has your child already tried?

Answering those questions will help to narrow down which ADHD medicine might be best for your child.

ADHD Medications

Again, there is really no one best ADHD medicine.

“…stimulant medications are highly effective for most children in reducing core symptoms of ADHD.”

American Academy of Pediatrics ADHD Clinical Practice Guideline

And you don’t even have as many options as you think you do.

While it may seem like there are dozens of medications available to treat ADHD now, most are really just different variations of the same few active ingredients.

And if you don’t have insurance or if you have have a high deductible, you will want to know that those that aren’t yet generic (in bold) are going to be much more expensive than the others:

  • Short Acting Stimulants (4 to 6 hours) – Adderall, Evekeo, Focalin, Methylin (chewable), ProCentra (liquid), Ritalin, and Zenzedi (often taken twice a day)
  • Intermediate Acting Stimulants (6 to 8 hours) – Dexedrine, Ritalin SR, Methylin ER
  • Intermediate to Long Acting Stimulants (8 to 10 hours) – Focalin XR, Metadate CD, Metadate ER, and Ritalin LA
  • Long Acting Stimulants (10 to 12 hours) – Adderall XR, Adzenys XR-ODT, Aptensio XR, Concerta (Methylphenidate ER), Cotempla XR-ODT, Daytrana (patch), Mydayis, Quillichew ER (chewable), Quillivant XR (liquid), and Vyvanse (capsule and chewable)
  • Non-Stimulants – Intuniv, Kapvay, Strattera

In general, stimulants are thought to work better than non-stimulants, but again, there isn’t one stimulant that is consistently better than another.

And there isn’t one medication that targets specific symptoms better than another, so you don’t need to look for a specific medication just because your child has the inattentive type of ADHD vs another who is also hyperactive and impulsive.

Deciding Which Medication Is Best for Your Child

Which ever medicine you choose, you typically want to start at a low dose and slowly adjust the dose up or down as necessary based on how well it is working and whether or not your child is having any side effects.

“…more than 70% of children and youth with ADHD respond to one of the stimulant medications at an optimal dose when a systematic trial is used.”

American Academy of Pediatrics ADHD Clinical Practice Guideline

Keep in mind that:

  • generic, short acting Ritalin (methylphenidate) is often going to be your least expensive option
  • coupons are often available for newer medications to lower or eliminate your copay, but that doesn’t help you if you don’t have insurance, have a high deductible, or if a medication isn’t covered by your insurance
  • it often takes a few days for kids to adjust to being on an ADHD medication, so don’t judge them too quickly
  • it doesn’t take weeks or months for an ADHD medication to work, so don’t wait too long to make adjustments
  • if your child is having major side effects, don’t just switch medications, be sure to switch the active ingredient too. For example, if a low dose of Metadate CD made your child very irritable and caused trouble sleeping, then switching to Ritalin LA doesn’t make much sense, as they are both time release versions of methylphenidate. Other ADHD that contain methylphenidate as an active ingredient include , Aptensio, Concerta, Cotempla XR-ODT, Daytrana, Methylin, QuilliChew ER, and Quillivant XR.
  • many of the newest medications, including Evekeo, Zenzedi, and Mydayis, are really just different forms of Dexedrine, one of the first ADHD medicines.
  • you can open and sprinkle the contents of Adderall XR, Aptensio XR, Focalin XR, Metadate CD, Ritalin LA, and Vyvanse on applesauce if your child can’t swallow these capsules. The contents of Vyvanse is a powder and will easily dissolve in a small amount of water! These are often less expensive options than a newer chewable, liquid, or dissolvable tablets.
  • you can not open Concerta and Metadate CD or you will ruin the time release delivery system. They must be swallowed whole.
  • while there is an authorized generic for Concerta, there are some generic versions that do not have the same therapeutic effect because they do not have the same extended delivery system. Make sure you are getting an authorized Concerta generic.
  • some extended release ADHD medications simply mimic taking the medication twice a day, giving 50% of the dose in the morning and another 50% later in the day, like Adderall XR, Focalin XR, Metadate ER, Ritalin LA, and Vyvanse
  • other extended release ADHD medications have different time release schedules. For example, Concerta gives 22% of the dose immediately and then slowly time releases the rest throughout the day. Similarly, Metadate CD releases 30% of the dose immediately and the rest later. Aptensio XR uses a 40/60 delivery system. And Daytrana, the patch, slowly time releases the dose throughout the day.
  • although some people start the day with an intermediate or long acting medication to get their child through school and then a short acting medication after school, before doing this, consider increasing the dose of the intermediate or long acting medication to see if it will last longer
  • non-stimulants are pills that must be swallowed and they typically must be given to your child every day for them to work properly
  • genetic tests to try and see which medications will work best for your child have not been tested on kids
  • even if you are only going to be giving your child medication on school days, be sure to give it every single day at first, even weekends, so that you can more easily see what side effects it might be causing. Otherwise, since it could wear off by the time you see your child after school, you might miss uncommon side effects, like if it made him too calm or more irritable.
  • being able to concentrate and do your work and not getting distracted and talking with your friends all of the time is not a side effect – it is the desirable effect.

Most importantly, know that you can take out a lot of what might seem like guess work if you have a good understanding of how these medications work.

What To Know About Choosing an ADHD Medication

For the great majority of kids with ADHD, one of the many available medications will help to control their symptoms of inattention, hyperactivity, and impulsiveness. Learn how to choose the best one for your child.

What To Know About Choosing an ADHD Medication

Avoiding Confusion During an Allergy Attack – Adrenaclick vs EpiPen Directions

Whether you have an EpiPen or Adrenacick injector, make sure everyone around your child with allergies knows how to use it.
The FARE Food Allergy & Anaphylaxis Emergency Care Plan provides detailed instructions for all available epinephrine injectors.

The price of EpiPens has been in the news a lot recently.

Most people know that they went Mylan’s EpiPen 2-Pak went from costing about $100 in 2006 to over $600 today and that there has been little or no competition.

One competing device, Auvi-Q was recalled in 2015, but it was fairly expensive too.

Good News and Bad News About EpiPens

Things have gotten better recently.

First, a generic EpiPen 2-Pak is now available. It costs $339.99. While still expensive, it does lower co-pays for many people with good insurance.

The latest news? A generic Adrenaclick injector for $109.99 at CVS pharmacies.

Even better, coupons are available that can make the injectors free for many people.

So what’s the bad news?

The directions for using the EpiPen 2-Pak and the Adrenaclick are not the same. That can cause some confusion. Do you want someone to grab one and not be sure how to use it when your child is having a life-threatening allergic reaction?

That makes it important for everyone to be familiar with both types of epinephrine injectors.

Adrenaclick vs EpiPen 2-Pak Directions

The fact that the Adrenaclick has two caps that you need to remove before use, while the EpiPen only has one, can lead to confusion. Also, the Adrenaclick injector, despite its name, doesn’t actually ‘click’ after you use it, like the EpiPen does.

EpiPen 2-Pak auto-injector directions:

  1. Remove the EpiPen Auto-Injector from the clear carrier tube to find an EpiPen Jr (green label) or EpiPen (yellow label).
  2. Remove the blue safety release by pulling straight up without bending or twisting it.
  3. Swing and firmly push orange tip against mid-outer thigh until it ‘clicks’.
  4. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
  5. Remove auto-injector from the thigh and massage the injection area for 10 seconds.

Remember that the orange end is the needle end! And you know that your child got your dose if you heard the click sound.

Adrenaclick epinephrine auto-injector directions:

  1. Remove the outer case.
  2. Remove grey caps labeled “1” and “2”.
  3. Place red rounded tip against mid-outer thigh.
  4. Press down hard until needle enters thigh.
  5. Hold in place for 10 seconds. Remove from thigh.

With the Adrenaclick injector, the red tip end is the needle end! Do not touch this end or you could unintentionally inject your self. After use, the needle should be visible.

Avoiding Confusion About Your Epinephrine Injector

All of the epinephrine injectors are easy to use. At least on paper.

In the heat of the moment though, when a child is having a life-threatening allergic reaction, it may not seem so easy though.

It will likely be even more difficult if the epinephrine injector you grab is not what you are expecting. Make sure you know how to use your epinephrine injector, both when your pediatrician prescribes it and when your pharmacist dispenses it to you (in case you get a different one, which is allowed in some states).

  1. Read the instructions.
  2. Watch a video.
  3. Use a trainer device.
  4. Be prepared!

It is also important that anyone that watches your child, whether it is a family member or the school nurse, knows how to use your child’s epinephrine injector.

“Individuals and caregivers are often reluctant to use self-injectable epinephrine in anaphylaxis despite instruction to do so.”

Pediatrics March 2007

Other things that can lead to confusion about epinephrine injectors include that you:

  • use an EpiPen or Adrenaclick training pen instead of the real injector with active medication when your child is having an anaphalytic reaction
  • use the real injector when you meant to use the training pen
  • don’t carry your child’s epinephrine injector with you at all times, which is why it is important to get more than one injector each time, allowing you to keep one at school, one at home, and one and travels with your child, etc., eventually allowing your child to carry his or own epinephrine injector at an age-appropriate time
  • forget to move to a higher dose of epinephrine as you child grows, keeping in mind that the Jr (0.15mg) dosing is only for kids under 66 pounds
  • aren’t sure when to use your EpiPen or Adrenaclick injector or are afraid to use it, which can lead to an unnecessary delay in your child getting a lifesaving treatment
  • don’t get a refill if your epinephrine injectors have expired or you actually needed to use one
  • understand that you still need to call 911 after you have used your epinephrine injector, even if your child begins to immediately feel better. Symptoms can return, which is why you are given two doses (2-Pack) of epinephrine.

A good Food Allergy & Anaphylaxis Emergency Care Plan can help avoid much of this confusion. In addition to easy to read instructions on when to give epinephrine, this type of plan should include directions for your child’s epinephrine injector.

When in doubt – you should usually give epinephrine if you have any concerns that your child is having an anaphylactic reaction. It is a safe medicine.

More Information About Epinephrine Injectors

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Are Drug Coupons Behind the Jump in the Cost of an EpiPen?

The high price of Mylan’s EpiPens is getting a lot of attention lately.

In a way that’s good. Not just so that something will finally be done about high drug prices, but because more people need to know about food allergies and about the importance of having and using EpiPens. That is one thing Mylan got right. Their education and awareness campaigns not only encouraged parents to get EpiPens for their kids, but they strongly encouraged them to use them.

Just a ploy to sell more EpiPens? Not when you realize that many people are afraid to use their EpiPens, even when they are having a severe allergic reaction.

Still, they certainly got greedy with the continued price hikes.

Although we are getting used to hearing about high drug prices, they typically aren’t for drugs that your pediatrician prescribes everyday.

You were likely outraged when Martin Shkreli raised the price of Darapim to $750 a pill, but you probably still have no idea what it is used for. On the other hand, you may have or almost certainly know someone with an EpiPen.

An epinephrine autoinjector is traditionally the only treatment for people having anaphylactic reactions to peanuts, insect bites and stings, or other serious allergic reactions.

Why fuss about the cost of a life-saving drug or device? A product that can save your child’s life in a manner of seconds would be priceless to most people.

Much of the issue is that they went from costing about $100 in 2006 to over $600 today. Even last year, a set of two EpiPens (one dose) cost up to $450. So it would be nice to have that option to save lives and save money. Afterall, the very same EpiPens are much cheaper in most other countries.

Surprisingly, it has been the media and not parents or patients who are doing most of the complaining about the high cost of EpiPens. Most of us have insurance and can use a coupon to waive their copay and effectively get their EpiPens free. Those without insurance may not be able to see a doctor to get a prescription, but if they can, may be eligible for Mylan’s patient assistance program.

So who is paying full price?

Mostly people with high deductible insurance plans, at least until they realize that they might save money going with a more costly insurance plan without a deductible, especially if family members have other medical problems, like asthma.

Why asthma?

Have you priced an asthma inhaler lately? Those that you use to prevent asthma can easily cost $300 to $400 each month. A rescue inhaler can cost another $100.

Competition hasn’t helped us get less expensive asthma inhalers. You will need a coupon for that.

Drug coupon use by patients could “come at the cost of higher long-term expenses for themselves and society.” That was a warning in the New England Journal of Medicine editorial “Prescription-Drug Coupons — No Such Thing as a Free Lunch.”

Unfortunately, instead of heeding the warning back in 2013, some companies adopted it as a business model.

Martin Shkreli didn’t do anything original when he bought the rights to the antiparasitic drug pyrimethamine and rebranded it as Darapim, raising the price 5,000%.

For example, although Lupin Pharmaceuticals makes many generic medications, they chose to license Suprax, an expensive antibiotic with a coupon, as a branded generic. So while a similar generic antibiotic, such as cefdinir, might cost about $50, Suprax costs about $250 to $400 for a 10 day course. It will also likely be on the highest and most expensive tier of your insurance, which is why they offer a coupon.

Impax Laboratories, another big maker of generic drugs, takes the cake though. They are selling Emverm for $596 a pill. A chewable pill that is used to treat pinworms, with two doses over two weeks, that means one treatment to stop your child’s butt from itching can cost almost $1200 – unless you use their coupon. An inexpensive generic version of the very same medicine, Vermox, was discontinued in 2011.

It was discontinued by Teva Pharmaceuticals, who then sold the rights to the drug to Amedra Pharmaceuticals, which was then acquired by Impax.

An off-patent, generic drug, Vermox should have been getting cheaper, not having its price soar. The fact that they offer consumers free coupons, meaning they won’t actually pay for the drug, likely explains how they get away with it.

Of course, we all end up paying. There is no free lunch, except maybe when the drug reps for these companies drop off those coupons at your doctor’s office.