the different ADHD meds & no more Ritalin 😢

Novartis is stopping worldwide production of Ritalin SR. That's great news for medical funding boards ... but bad news for us. Here's what you need to know about this change and all the other meds.

This is pretty big news! Ritalin SR is commonly prescribed since methylphenidate (MPH) is considered a first-line treatment solution for ADHD.

Ritalin SR is Novartis's sustained-release form of methylphenidate and is supposed to last 8 hours. It's also interesting to note that it's the more expensive alternative to Rubifen SR (manufactured by AFT Pharmaceuticals).

I wasn't able to find specific info on why it was discontinued, but it turns out that Novartis actually discontinued Ritalin SR back in October 2014. But it looks like they’re stopping production entirely now though. I suspect Novartis wants to push people towards their newer Ritalin LA formulation (more info at bottom of this article).

Impact on Medical Funding Boards

Most of the readers of this newsletter are from New Zealand and our medical funding board (PHARMAC) must be pretty happy right now. At one point, PHARMAC actually stopped funding Ritalin SR successfully in April 2007.

Their decision was based on studies by Medsafe NZ that found Rubifen SR and Ritalin SR were bioequivalent and Rubifen was much cheaper. That makes sense since they're both methylphenidate formulations, just with a different coating.

What they didn't expect was the dozens of reports from angry parents saying that their kids started experiencing negative side effects. In some cases, children even had to leave school until their parents paid $150/month out-of-pocket for Ritalin.

💬

Dr. Coleman: "Why has Pharmac replaced Ritalin SR with Rubifen SR [...]"

Minister of Health: "Pharmac did so because it can save $1 million per annum [...]"

... ...

Dr. Coleman: "[...] and what would the Minister say in the case of children who are removed from school, who need Ritalin in order to go back, but whose parents cannot afford up to $145 per month to pay for it?"

~ Transcript from NZ Parliament discussing the funding changes of Ritalin SR

PHARMAC ended up re-subsidising Ritalin SR just 5 months later in September 2007 since it was used almost entirely by kids. They thought that the nocebo effect wouldn't be a factor since kids weren't likely to understand the medication.

I swapped from Rubifen SR to Ritalin SR in August last year, and I personally noticed a difference. I felt like my mood had improved and I was less irritable, but it's probable that I just experienced a placebo effect.

A few weeks ago I started a switch from Ritalin SR to dextroamphetamine (perfect timing, right?), I'll report my results when I can.

It looks like Ritalin SR will still be available till December 2020, so you might have a few months to get your refills. If you or your child are on Ritalin SR, then you'll need a medication review soon and your psychiatrist will likely swap you to Rubifen SR.

Common ADHD Medications

Here's what you need to know about Rubifen SR and the other medication options available to you. If I missed your medication just reply to this and I’ll edit it in.

Most people reading this will be taking methylphenidate (MPH). At a very basic level, MPH works by blocking the norepinephrine and dopamine transporters between the synaptic space and presynaptic neurons in our brains. That blocking leads to an increased availability of these neurotransmitters for our prefrontal cortex (linked to ADHD symptoms), this should improve our executive function and concentration.

💊 Methylphenidate Extended-Release (SR/LA)

This is the category Ritalin SR fell into. If you're currently on this then your psychiatrist will probably swap you to Rubifen SR, Ritalin LA, or Concerta.

Rubifen SR: Effectively the same as Ritalin SR, just with a different coating/binding-agent. Supposed to last about 8 hours. Best taken after a high-fat meal and not when you're fasted (more on this in a later post). Initial peak levels reached after 2-3 hours.

Ritalin LA: Ritalin SR can take a couple of hours to reach it's peak effects. LA instead has an immediate release followed by a sustained release over 8 hours. Medsafe recommends this for adults (though it's prescribed to kids too). Can be taken with or without food.

Concerta: Supposed to last about 10-12 hours. Can be taken with or without foods, but should be taken with liquid. This one has an overcoat that dissolves causing initial peak levels to be reached at about 1-2 hours. The pill has two internal drug layers which gradually release MPH over the next few hours. Overall peak levels are reached between 6-8 hours, after which it starts to gradually decrease.

💊 Methylphenidate Short-Acting (IR)

Here you're looking at either Rubifen IR (5mg, 10mg, 20mg) or Ritalin IR (10mg). Both are rapidly and almost completely absorbed into your blood. Can be taken with or without food. Peak levels are reached on average 1-2 hours after taken. Lasts about 3-4 hours.

💊 Atomoxetine

Most commonly known as Strattera, atomoxetine is pretty different from MPH because it's not a stimulant. It's a "selective norepinephrine reuptake inhibitor" and it's believed that it helps increase the availability of norepinephrine in your brain (improving focus and concentration).

Atomoxetine also appears to result in less emotional regulation issues in comparison to MPH. If you have trouble with mood swings then I’d recommend talking to your psychiatrist about this as an option.

It needs to be taken at the same time each day and can be taken with or without food.

It's rapidly absorbed and you'll see peak levels within 1 to 2 hours of taking it.

Supposedly the drug takes two to four weeks to have its maximum effect.

🗒 Note: I found a lot of anecdotal complaints about atomoxetine during my research. Some people love it, but others say that the first few weeks taking it can really be terrible.

💊 Dextroamphetamine

Usually known as Dexedrine (or dexy as my friends like to call it).

This one causes dopamine to be released and is believed to make neurotransmitters last for a longer time in the parts of the brain that control attention and alertness.

Dexedrine comes in a 5mg pill and lasts between 4-6 hours.

I think it's important to be cautious with this one. Amphetamines can be easily abused and can be quite habit-forming (but so are most stimulants).

💊 Mixed Amphetamine Salts

This one is most commonly known as Adderall (we've all heard about it). It's illegal over here in NZ, but it seems to be a common treatment option over in America if MPH doesn't work out.

Adderall comes as a combination of amphetamine salts, dextroamphetamine and levoamphetamine. It contains the active ingredient of Dexedrine, so both Dexedrine and Adderall are pretty similar drugs with the same side effects.

The one you pick mainly seems to be a case of whichever is available and works better for you.

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Find out more about your specific medication from a data sheet repository like this one.

Are you impacted by this change? I'd love to hear your experiences with Ritalin SR and other ADHD medications. (I reply to everyone)

Cheers,
Beat ADHD