David Baxter PhD
Late Founder
Pharmacy Is Out of My Medication! ADHD Treatment Disruption
by By Andrew Adesman, MD, and Anna Krevskaya, MD, ADDitudeMag.com
Retrieved April 30, 2018
Your pharmacy has stopped carrying your prescription. Or your insurance won’t cover the extended release formulation you want. Or your child can’t swallow his pills. ADHD medication disruptions like these are frustrating and potentially catastrophic to care. Here, two ADHD doctors offer solutions for vaulting pharmaceutical hurdles.
In late 2017, a manufacturing problem disrupted the production and distribution of two popular ADHD medications, Quillivant XR and QuilliChew ER, across the United States. Before the problem’s resolution some three months later, families across America found themselves scrambling for treatment solutions. Some drove hundreds of miles to chase down prescriptions. Others cut back treatment on weekends and holidays to stretch out their prescriptions as long as possible. And still others began trying alternative medications — with mixed results.
“I was informed about the shortage Monday” and given a replacement prescription, said parent Melissa Teem at the time of the Quillivant shortage. “[On] Tuesday, my daughter took her new medicine — she came home with a full lunchbox and complained of a headache. Today, the same — she had two bites to eat, and I had to pick her up early because her head hurt so bad. This sucks.”
Whether impacted by the recent Pfizer disruption or not, most parents would agree with Teem’s sentiment: Being unable to find or fill your child’s ADHD prescription is an incredibly stressful and possibly unhealthy problem for parents and children alike. Here, pediatric specialists Andrew Adesman, MD, and Anna Krevskaya, MD, both of Cohen’s Children Medical Center in New York, offer practical advice for families in medication distress.
Problem: Your Pharmacy Doesn’t Carry Your Preferred Medication
Problem: Your Preferred Medication Is No Longer Available or Affordable
You may think that one medication is clearly best, however the reality is that there are likely several medications that, used alone or in combination, can make a big difference with minimal side effects. We advise our patients to remain flexible when considering all feasible treatment approaches and adjusting the following attributes:
Keep in mind that many insurance companies limit or restrict the ADHD medications included within their formulary of options. Before speaking with your healthcare provider about medication options, check to see which ADHD medications are covered under your specific insurance plan. Also be aware that different covered medications come with varying levels of coverage; some specific medications have minimal co-pays while others have substantial ones.
In addition, some medications may carry a “prior authorization” requirement; this typically means your healthcare provider must provide a justification for this medication. These are most likely to be approved if you have tried using one or more medications on the insurance formulary without benefit or with major side effects.
Problem: Your Medication Expenses Are Rising Too Fast
Above all, when responding to a medication disruption or other treatment challenge:
Stimulant Medications for Treatment of ADHD
G: Generic formulation available
O-L: “Off-label” (likely safe and effective, but not FDA approved for administration in this manner)
This Chart was created by Drs. Andrew Adesman and Anna Krevskaya of Northwell Health, Inc. Questions or comments: ADHDMedGuide@northwell.edu. Northwell Health is not affiliated with the owner of any of the brands referenced in this Chart. This Chart should not be used as an exclusive basis for decision-making. Use of this Chart is strictly voluntary and at the user’s sole risk. Copyright 2018 by Northwell Health, Inc, Great Neck, NY. All rights reserved. Sale of this Chart is strictly forbidden. Send inquiries to Office of Legal Affairs, Northwell Health, Inc, 2000 Marcus Avenue, Lake Success, NY 11042.
For a downloadable version of this chart, click HERE.
Other Helpful Resources
by By Andrew Adesman, MD, and Anna Krevskaya, MD, ADDitudeMag.com
Retrieved April 30, 2018
Your pharmacy has stopped carrying your prescription. Or your insurance won’t cover the extended release formulation you want. Or your child can’t swallow his pills. ADHD medication disruptions like these are frustrating and potentially catastrophic to care. Here, two ADHD doctors offer solutions for vaulting pharmaceutical hurdles.
In late 2017, a manufacturing problem disrupted the production and distribution of two popular ADHD medications, Quillivant XR and QuilliChew ER, across the United States. Before the problem’s resolution some three months later, families across America found themselves scrambling for treatment solutions. Some drove hundreds of miles to chase down prescriptions. Others cut back treatment on weekends and holidays to stretch out their prescriptions as long as possible. And still others began trying alternative medications — with mixed results.
“I was informed about the shortage Monday” and given a replacement prescription, said parent Melissa Teem at the time of the Quillivant shortage. “[On] Tuesday, my daughter took her new medicine — she came home with a full lunchbox and complained of a headache. Today, the same — she had two bites to eat, and I had to pick her up early because her head hurt so bad. This sucks.”
Whether impacted by the recent Pfizer disruption or not, most parents would agree with Teem’s sentiment: Being unable to find or fill your child’s ADHD prescription is an incredibly stressful and possibly unhealthy problem for parents and children alike. Here, pediatric specialists Andrew Adesman, MD, and Anna Krevskaya, MD, both of Cohen’s Children Medical Center in New York, offer practical advice for families in medication distress.
Problem: Your Pharmacy Doesn’t Carry Your Preferred Medication
- Many chain pharmacies can search their computer system to find the medication you need at another location; in some cases, you may need to request this service in person at the pharmacy
- If the chain pharmacies near you don’t have the medication you need, try calling the independently owned pharmacies nearby
- Most manufacturers of brand-name (non-generic) medications maintain websites that often help patients find that medication at nearby pharmacies
Problem: Your Preferred Medication Is No Longer Available or Affordable
You may think that one medication is clearly best, however the reality is that there are likely several medications that, used alone or in combination, can make a big difference with minimal side effects. We advise our patients to remain flexible when considering all feasible treatment approaches and adjusting the following attributes:
- Duration: Although once-daily dosing is often ideal, taking a long-acting medication before school and then a short-acting medication in the afternoon can provide equitable benefits.
- Active ingredient: Sometimes you need to adjust the type of stimulant medication used. If you can’t find a long-lasting liquid methylphenidate, consider one of several long-lasting liquid amphetamine formulations. In some cases, these may work even better!
- Alternate “delivery system:” If your child is unable to swallow pills, you may assume your only choice is a liquid medication. In reality, many different “delivery systems” for ADHD medications exist — including “sprinkles,” dissolving tablets, chewables, skin patches, and liquids.
- Similar products are also different: Don’t assume that you can’t achieve success with a medication if a very similar medication failed. For example, several methylphenidate medications can be given as sprinkles, yet each of these beaded formulations is different, and one sometimes works much better than another.
- Sometimes two medications are better than one: Occasionally, combining the use of a stimulant medication with a non-stimulant medication can produce better results than using either medication alone.
Keep in mind that many insurance companies limit or restrict the ADHD medications included within their formulary of options. Before speaking with your healthcare provider about medication options, check to see which ADHD medications are covered under your specific insurance plan. Also be aware that different covered medications come with varying levels of coverage; some specific medications have minimal co-pays while others have substantial ones.
In addition, some medications may carry a “prior authorization” requirement; this typically means your healthcare provider must provide a justification for this medication. These are most likely to be approved if you have tried using one or more medications on the insurance formulary without benefit or with major side effects.
Problem: Your Medication Expenses Are Rising Too Fast
- Generic brand name: Generic formulations are often less expensive, but this is not always the case.
- Shop around: Different pharmacies may price the same medication quite differently. Discount retailers like Costco and Sam’s Club often sell prescription medications at lower prices than do other pharmacies.
- Take advantage of “Savings Programs” offered by the medication’s manufacturer. For brand name products, go to the manufacturer’s website for that product and look for discount offerings.
Above all, when responding to a medication disruption or other treatment challenge:
- Keep an open mind. Several different medication regimens can very likely meet your needs.
- Discuss with your healthcare provider all possible options; express your openness to trying either a different delivery system or active ingredient.
- If a patient can swallow a pill or capsule, this allows for more treatment options. Most people — including grade school children — can easily learn to swallow a pill with minimal instruction. The key is to not rush the process: Start by practicing with very small candy pieces and then gradually increase the size of the “pill.” The website PillSwallowing.com can provide many helpful tips and tricks.
- “Happy accidents” are not uncommon: a new medication is sometimes even better than the older “preferred” prescription.
Stimulant Medications for Treatment of ADHD
| Short-Acting Preparations | Long-Acting Preparations | |||
|---|---|---|---|---|
| Methylphenidate | Amphetamine | Methylphenidate | Amphetamine | |
| Liquids | ● Methylin Solution G | ● ProCentra G | ● Quillivant XR | ● Dyanavel XR ● Adzenys ER ● Vyvanse (when dissolved in water) |
| Advantages: easy to swallow, easy to make small dose adjustments, especially when first starting treatment, different flavors Disadvantages: long-acting preparations are available as brand only | ||||
| Chewable | ● Methylin Chewable G | —— | ● QuilliChew ER | ● Vyvanse Chewable |
| Advantages: different flavors Disadvantages: long-acting preparations are available as brand only | ||||
| Oral Disintegrating Tablets | —— | —— | ● Cotempla XR-ODT | ● Adzenys XR-ODT |
| Advantages: dissolves quickly, no liquid is needed to take the tablet, does not need to be swallowed whole Disadvantages: some patients may not want to place medicine under their tongue | ||||
| Sprinkles | —— | —— | ● Focalin XR G ● Metadate CD G ● Ritalin LA G ● Aptensio XR | ● Adderall XR G ● Vyvanse O-L ● Dexedrine Spansule G, O-L ● Mydayis |
| Advantages: capsules can be opened and medication “sprinkled” on food, most are available as a generic Disadvantages: some patients have oral texture sensitivity to the “micro beads” (note: Vyvanse is a powder, not beads) | ||||
| Transdermal Patch | —— | —— | ● Daytrana O-L | —— |
| Advantages: applied directly to skin, patch can be cut to optimize dose (off label); patch can be kept on beyond 9 hours (off label) Disadvantages: takes longer to start working, rash is not uncommon | ||||
| Crushable | ● Ritalin Tablets G, O-L ● Focalin Tablets G, O-L | ● Adderall G, O-L ● Evekeo O-L ● Zenzedi G, O-L | —— | —— |
| Advantages: may be “hidden” within food Disadvantages: not flavored; possibly bitter if not “hidden” within food | ||||
| Caplet | —— | —— | ● Concerta G | —— |
| Advantages: available in a wide range of doses, different strengths can be combined to optimize medication dose Disadvantages: must be swallowed whole |
G: Generic formulation available
O-L: “Off-label” (likely safe and effective, but not FDA approved for administration in this manner)
This Chart was created by Drs. Andrew Adesman and Anna Krevskaya of Northwell Health, Inc. Questions or comments: ADHDMedGuide@northwell.edu. Northwell Health is not affiliated with the owner of any of the brands referenced in this Chart. This Chart should not be used as an exclusive basis for decision-making. Use of this Chart is strictly voluntary and at the user’s sole risk. Copyright 2018 by Northwell Health, Inc, Great Neck, NY. All rights reserved. Sale of this Chart is strictly forbidden. Send inquiries to Office of Legal Affairs, Northwell Health, Inc, 2000 Marcus Avenue, Lake Success, NY 11042.
For a downloadable version of this chart, click HERE.
Other Helpful Resources
