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Adderall is in short supply at the moment, which has led to shortage of substitution amphetamines.
What to do?
For a patient taking Adderall, I feel the best approach is, prior to issuing the prescription, asking the patient (or staff) to call their pharmacy to confirm that their dose is available in the quantity needed. Calling around to other pharmacies is not ideal, and some pharmacies are declining to fill Adderall scripts for nonregular customers.
If Adderall is unavailable, they should inquire about availability of possible alternatives:
Generic Adderall in other mg strengths (5, 7.5, 10, 12.5, 15, 20, 30 mg) to combine or split
Generic Adderall XR
Generic Dexedrine immediate release
Generic Dexedrine Spansule (extended release capsules) if Dexedrine IR is unavailable
Vyvanse, which may be available generically within a year. Savings card available for individuals with private insurance
Generic Ritalin (methylphenidate), although for adults it is generally less effective than Adderall
How to convert doses:
Cost | Strengths | Conversion from Adderall 20 mg | Duration of action | Appetite suppression | |
Adderall (mixed amphetamine salts) | $10+ | 5, 7.5, 10, 12.5, 15, 20, 30 mg | Usually BID | 5 hr | Yes |
Adderall XR | $25+ | 5, 10, 15, 20, 25, 30 mg | Same Adderall dose combined to QD | 10 hr | Yes |
Dexedrine | $20+ | 5, 10 mg | 20 mg Adderall = 15 mg Dexedrine (may need to divide TID) | 4 hr | More than Adderall |
Dexedrine Spansule (ER) | $35+ | 5, 10, 15 mg | As above, combined to QD | 8 hr | More than Adderall |
Vyvanse (lisdexamfetamine) | $400+ | 10, 20, 30, 40, 50, 60, 70 mg | 20 mg Adderall = 50* mg Vyvanse, combined to QD | 10-14 hr | More than Adderall |
Ritalin (methylphenidate) | $20+ | 5, 10, 20 mg | 20 mg Adderall = 40 mg Ritalin (often divided TID) | 4 hr | Less than Adderall |
*If converting to Vyvanse, advise taking it as early as possible in the morning to avoid insomnia, and also because onset of benefit is delayed up to 90 minutes as the prodrug (lisdexamfetamine) is cleaved to dextroamphetamine in red blood cells. Although 20 mg of Adderall is equivalent to 50 mg of Vyvanse, some individuals respond differently so round down on the conversion. Consider only doubling the Adderall mg dose to arrive at the starting Vyvanse dose.
The Shortage
Why?
Demand
More people taking Adderall due to relaxed online prescribing laws during the pandemic, when stimulant prescriptions increased by 16%.
Supply
Teva pharmaceuticals, the main manufacturer of generic Adderall, is having difficulty keeping up.
How long?
The shortage is expected to continue at least until March 2023.
What should you tell patients looking to buy Adderall on the street?
Many street versions of Adderall are laced with fentanyl.
Comparing dextroamphetamine to levoamphetamine
Dextroamphetamine (D-amp) and levoamphetamine (L-amp) are similar drugs but not exactly the same. One may be better for hyperactivity, the other better for inattention although it is unclear which is which (Sagvolden and Xu, 2008; Arnold et al, 1972).
Amphetamine preparations contain either
Only D-amp (Dexedrine, Vyvanse as a prodrug)
More D- than L-amp (Adderall)
Racemic: 50% D- and 50% L-amp (Evekeo, formerly Benzedrine)
No formulation has more levoamphetamine than dextroamphetamine.
Why is pure L-amphetamine not produced?
Peripheral effects (elevated blood pressure and heart rate) would be excessive at the dose of pure levoamphetamine necessary to treat ADHD.
Comparing Adderall to Dexedrine
How is Adderall (75% D-amphetamine) different from Dexedrine (100% D-amphetamine)?
The main advantage of generic Adderall ($10+) over Dexedrine ($20+) is cost. Adderall is better if less appetite suppression is desired.
Advantages of Adderall (75% D-amp) over Dexedrine (100% D-amp)
Price ($10+ vs $20+)
Slightly longer duration of action (5 hours vs 4 hours)
More available mg strength tablets
Less appetite suppression
Advantages of 100% D-amp over Adderall
More appetite suppression
Potentially less elevation of heart rate and blood pressure
Best abuse-deterrent option (Vyvanse, which is 100% prodrug of D-amp)
Transdermal option (Xelstrym)
Visual Mnemonics
There are over 20 preparations of stimulant medication for ADHD. If a patient inquires about "Mydayis", prescribers may struggle to recall anything about it-- maybe that it is a long-acting ADHD med--but is it an amphetamine or a methylphenidate?
Cafer's Psychopharmacology: Visualize to Memorize 270 Medication Mascots PDF download has visual mnemonics for all of the variations. The main feature of stimulant mascots is that amphetamine pictures include an amplifier, while methylphenidates include a Scantron sheet--"Write a line" (for Ritalin) on "math final date" for methylphenidate.
Comparison tables
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