   
Too Small a Dose? Make Your ADD Meds Last Longer
Q:
"My eight-year-old takes 10 mg. of Focalin three times a day, but metabolizes it quickly, so he's not covered all day. The doctor won’t up the dose as he’s already over the FDA limit of 20 mg. Help!" 
A:
The FDA's recommended daily limit refers to the maximum dose of medication in the body at one time, not to the total taken in a day. Your son is taking 10 mg. at a time, not 30 mg. a day. Also, FDA guidelines are just that—guidelines, not absolute limits. When my patients metabolize a stimulant quickly, I first try to supplement it with a non-stimulant. I might prescribe one of the tricyclic antidepressants, such as imipramine or nortriptyline (these slow down the rate at which the neurotransmitter norepinephrine is absorbed). Next, I would keep careful records and “fill the gaps.” If a four-hour tablet lasts three hours, your son might need one of these tablets every three hours. I would keep observing each unit of the day, and try to have an adequate dose in place for each. Note: These are only suggestions. I’m not recommending a specific treatment plan for your son. That should be determined only by his physician.
Larry Silver, M.D., is the author of Dr. Larry Silver's Advice to Parents on AD/HD and The Misunderstood Child: Understanding and Coping with Your Child's Learning Disabilities. He is also a clinical professor of psychiatry at Georgetown Medical Center in Washington, D.C.
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