Concerta and Ritalin: Can they be Combined?
ByI recently posted a blog post about Ritalin. Although it often ‘gets a bad rap’, it’s a medication which can still be very helpful for ADD/ADHD. Of course, the newer medicines (which are long acting) seem to be better for a good treatment response, though Ritalin can still play a role.
In that article, I mentioned the concept of taking Ritalin with Concerta – i.e. together. When someone commented on that post, I realized that I should share more specifics and details about how this can be done safely and effectively.
For background information, you can reference these previous blog posts about Ritalin and Concerta:
- The article on Ritalin can be found here
- An article on Concerta can be found here
- My popular article on how to dose Concerta effectively can be found here
The Concept Behind Concerta’s Formulation:
Concerta, as the first long acting ADHD medication, was developed using a fascinating approach. The scientists put kids with ADHD into an ‘analogue classroom’ – meaning a research environment which simulates a school classroom. So, children were given tasks which would occur in a regular school day, and they were monitored by experts in ADHD. These kids were given an IV line, which allowed for the researchers to draw blood HOURLY, so they could establish the blood levels of the medication throughout the day – and they could correlate the blood levels of the medication to the behavior (and ADHD symptoms) observed throughout the day.
The researchers tried different approaches with the medication. The children were given short acting Methylphenidate (i.e. the medicine in Ritalin). By giving different amounts of medicine on a very frequent basis, they were able to create different levels of blood concentration through the day.This was called a ‘sipping study’. They were giving little bits of Ritalin throughout the day, very frequently – like you would ‘sip’ a soda. By monitoring the blood levels, they created different ‘profiles’ of blood concentration.
The first concentration approach was: FLAT. This meant that the medicine was given to reach a ‘plateau’ level of blood concentration, and the rest of the doses throughout the day were set up to maintain that level of concentration in the blood.
The second concentration approach was: ASCENDING. This meant that the doses were set up to increase the blood concentration slightly, hour by hour throughout the day.
The third concentration approach was: DESCENDING. This meant that the doses were given to create an initial spike up, and then the blood concentration would drop through the course of the day.
Guess which concentration approach was proven to be most helpful in controlling symptoms of ADHD through the course of the day?
ASCENDING worked best.
Thus, Concerta was developed to create an ascending profile of blood concentration throughout the day. This means that when the 22% of immediate release methylphenidate is absorbed, it creates a spike in blood concentration in the first hour, and then the Concerta is formulated to increase the concentration of methylphenidate in the blood, so that hour by hour, there is more medicine in the system. The concentration level increases for the first approximately 8 hours of the day, and then it begins its drop. It thus gives approximately 12 hours of symptom control.
Why does an ascending profile seem to work well?
The researchers suggested that there is ‘acute tachyphylaxis’, or ‘acute tolerance’. They suggest that if the blood level of the medication is the same at 11 am as it was at 10 am, the brain is becoming tolerant to that level of medicine that quickly, and it is less effective at 11 am as it was at 10 am. Concerta was formulated to overcome this, by having slightly higher concentrations of medicine throughout the day. Under the theory of acute tachyphylaxis, the system of ‘tolerance’ to the medication would reset itself each night, as the medicine wears out of the system.
Back to combining Concerta with Ritalin:
Explaining the science of Concerta was important to explain the rationale for what I’ll say next about combining Ritalin (or short acting Methylphenidate) with Concerta.
It is important, because if the ‘ascending profile’ theory is correct – then adding Ritalin to Concerta first thing in the morning will ruin the unique formulation of Concerta, and essentially ruin the ascending profile of concentration.
In other words – if Concerta is formulated so that a certain amount of it is immediate release (i.e. 22%), then the rest of the pill supports that to create the ascending profile. If one takes a short acting Ritalin with the Concerta in the morning – then the ascending concentration profile in the blood becomes a descending profile, because the initial spike will be so big, that it would throw off the concentration profile for the rest of the day.
So, the ‘Concerta purists’ (if you could call them that) would say that you should never add regular Ritalin to Concerta first thing in the morning. If someone isn’t getting a strong enough response first thing in the morning, then they need a higher dose of Concerta.
These ‘Concerta purists’ would be fine with adding regular Ritalin to Concerta at the end of the day – if a little ‘bump’ is needed to make the medicine last longer. For example – if the Concerta lasts for 12 hours, but on certain nights, night school classes are taken, adding a 10 mg Ritalin tablet at the end of the day on those nights would be completely reasonable.
So Why Do Some Doctors Add Ritalin To Concerta In the Morning?
Despite what the researchers may say, and what studies may show in those circumstances, each person is an individual, and people have different responses to medication.
In my years of clinical experience, do I believe the ‘ascending profile’ story of Concerta to be 100% true and accurate for everyone? No – I don’t. I have seen people for whom Concerta was a miracle medicine, and I have seen people for whom Concerta didn’t work at all. I have certainly (and regularly) seen people who add Ritalin to Concerta at the end of the day.
Concerta and Ritalin together in the morning? Not generally my practice, though I have colleagues who have done this with reported success.
The most important point for YOU:
Your treatment needs to be individualized.
I hope that you can discuss with your doctor the strategies which may help you to optimize your medication treatment for ADHD. Heck – if you’re going to take medication for ADHD, you want it to work the best it can, right?
Combining Ritalin and Concerta may just be an ‘advanced strategy’ for managing your medications that will help you and your doctor to find the right treatment.
A final point about safety: When combining Concerta and Ritalin, remember that these are the same medication, and that higher doses of methylphenidate can cause more side effects, particularly cardiovascular ones – i.e. increase blood pressure, or increase heart rate. Be sure to talk to your doctor about the ‘total daily dose’ to make sure that it is safe for you.
Please share your experiences and thoughts below.
All the best,
Dr. Kenny
p.s. I have just put together a new video on how to use ADHD Medications both safely and effectively. You can get access to that video by visiting here.
Thanks so much for the interesting information. I have found Concerta to have a bad effect on my son. I have now tried him on Ritalin LA (40mg) and the teachers raved about how much he improved in class. However, for the first few weeks he had a radical “drop” at about 6.25 hours after taking the meds. He literally went wild for 30 minutes and then settled down again. The teachers and I decided I would fetch him half an hour earlier from school so that the drop off could be dealt with calmly at home. This drop off was pretty bad in the evening too. But after a few weeks his body adjusted and this has been the most effective medicine he has tried. I have found that when he has sports practice late evening (6-7:30pm) I have to give him half a Ritalin Sr 20mg at about 4pm to tide him over the drop off and extend the concentration of meds past when the LA would have worn off. This has been essention for him and his sports team to survive practice!!
Two other parents I have spoken to have also noticed this steep drop off twice a day with Ritalin LA.
Hi i live in Glasgow Scotland and im looking for advice on where i can purchase Concerta or Ritalin safely & securely on a regular basis , I have a family member who suffers greatly from Narcolepsy , Their doctor has taken them off Ritalin & put them on MODAFINIL 200 mg , This is really changed their lifes & existance with this bad change , get back to me asap please on peterjamie @ fastmail.fm
David – I would think you need to talk to the doctor to get a new prescription and get it filled at the pharmacy. Any other option would likely lead you to much great problems…
Dr. Kenny
Dr. Handelman — the acute tolerance principle is very interesting, and makes intuitive sense, but I’m wondering if it applies to amphetamines as well. For example, Vyvanse seems to have a very flat profile, where it slowly goes up to a peak around 4 hours, and then slowly descends the rest of the day. Wouldn’t the theory of acute tolerance mean Vyvanse (and Adderall XR, etc…) wouldn’t work as well as medications like Concerta? Vyvanse is said to last 12-14 hours, so I’m wondering how Vyvanse overcomes this.
Joey – that is a very intelligent question.
One answer is – I don’t know.
The other answer is that although the study with concerta is very interesting and instructive – it hasn’t been replicated with concerta and certainly hasn’t been replicated with other medicines.
Dr. Kenny
I give my son ritalin la 20mgs. at 7am school day. At around 5pm, he becomes real hungry and irritable. He cannot concentrate to study or do homework. What can I do?
Dinorah,
You can consider adding short acting methylphenidate at the end of the day. Ask your doctor if this can work for you.
Dr. Kenny
Hi, I have just read your article about combining the two drugs. This has been the ONLY thing that has worked for my son. Initially he was on just Ritalin, 10 mg, but we found the “drop off” time to be about 2 1/2 hours, requiring at least 3-4 doses just to get through the day. Then, our doctor switched him to Concerta, 18 mg, which didn’t work at all. It didn’t seem to “get into his system” rapidly enough so that the first 2-3 hours of school were miserable. Then, we decided to try both. So, now he gets a 10 mg Ritalin and a 36 mg Concerta about one hour before he goes to school. I believe the Ritalin “kicks in” right away and then the Concerta acts as a “safety net” throughout the rest of the school day. It’s really difficult to get the medications “just right,” and sometimes takes a lot of trials and errors to reach success.
My son the have ADHD and ODD was taking concerta 27mg in the Morning and retalin 5mg at 4pm and the meds they did not work for hem he was getting more agresive in one whole week he did not did good at school was hitting his teacher and bite her and the kids from his class totaly out of cantrole cause the meds were not working how its sopose to work on him now he is on other the i hope they work on him talk to yyou son doctor to see if they come with a good plan with you son and the best for hem good luck
My doctor started me on concerta 36, 2 months ago. It worked well to reduce hyper activity, frustration and impulse, but not so well for concentration or focus. I am now switched to concerta 54, and it works to greatly reduce frustration and how I handle problems, but does not work well for anything else. Does this mean I need to go back to concerta 36 or up to concerta 72?
My diagnoses = Severe ADD + hyper activity syndrome.
Wait times for appointments in Canada can be over 2 weeks so I thought I’d ask you.
I’m 17 and an honour student at my high school, so I’d like to get the doesage corrent before college.
Dr. Handelman – “Concerta is formulated to increase the concentration of methylphenidate in the blood, so that hour by hour, there is more medicine in the system” how much more medicine releases per hour during the ~7 hours that fallow the first hour?
Also – “if the blood level of the medication is the same at 11 am as it was at 10 am, the brain is becoming tolerant to that level of medicine that quickly, and it is less effective at 11 am as it was at 10 am” how this concept (per hour) fit with the last 4 hours of the day?, were the concerta is at DESCENDING profile?
Can you pleas add reference links to the research articles if it is passable.
Thx, your web is vary vary helpful to me (and to my doctor)
HAG PASCH SAMEAH, FOCUSED AND KASHER TO ALL
Oz
Hi,
Here’s a reference to the study which worked on the ‘ascending profile’ of drug delivery to improve response: http://www.jaacap.com/article/S0890-8567%2809%2960635-3/abstract
When it comes to the end of the day – when the profile is ‘descending’, this theory doesn’t really apply – though even though that happens around the 8th hour of medicine, most people get a ful 12 hours of medication response.
I am 41 and have been taking stimulant medication since I was 25yrs old. At that time I had to do my own research into everything because doctors thought that adults grew out of ADHD or ADD.
Now I take 81mg of Concerta and I find after the 8-9 hrs I require Ritalin. I take the Concerta at 7am and the Ritalin at 4pm, 6pm, 8pm, 10pm at 10mg per dose. I run my own business with my office at home. My two children both have ADD/HD. I’ve tried different dosages and spreading it out more and encountered instances where I can say, “woah, now why did I do that without thinking”. That is an indication that the medication has lost it’s effectiveness. (I will also not that I try to exercise 3x/week and don’t smoke or drink coffee).
Why do I spread the Ritalin out? So that I don’t have high’s and low’s. If you were to graph it out it wouldn’t look like a rough sea with many up’s and down’s but a smooth curve.
I have Propranolol on hand, short and long acting, depending on my day ahead. I plan ahead for the amount of stress I am going to encounter and use the long acting Propranolol accordingly. The short acting is for those days where an influx of stimulation in the form of unexpected tasks or deadlines emerge or I know I’ve taken an appropriate amount of stimulant medication but I find it a challenge to sit and do the menial tasks that need to be done.
To simplify the use of the Beta-Blockers (Propranolol is one medication from this family) they are to control the effects that the stimulant medication has on the body. An example would be, I’ve found that I need a certain amount of stimulant medication but sometimes I find that I have no appetite. I won’t cut back the stimulant medication because than it won’t be doing it’s job, I add the Beta-
Blocker. Now I can concentrate and I don’t have the loss of appetite. This is only an example, for each individual the case may be different.
In my experience you have to do your own research and don’t rely upon your Doctor to lead you by the hand. When I say research, I mean verifiable 3rd party information.
I have found Dr. Kenny to be one of those sources of information. This isn’t enough for most Psychiatrists though. That is why I also appreciate when Dr. Kenny includes the references of where he received his information.
My final thoughts: Don’t leave your health just in your doctors hands. Before you start taking stimulants get your heart tested, ECG, get a blood test and know your blood pressure. To alleviate any unnecessary stress about taking stimulant medication get a home blood pressure monitor and a heart rate monitor, the kind worn around the chest.
I am a 33 year old and have been diagnosed with ADD years ago and, more recently, with Bipolar II Disorder. That being said, there are several medications that I need to take daily to treat both disorders’ symptoms as well as to balance the effectiveness of the medications required for both disorders. Of note, I’m a married mother of 2 boys and my husband and boys have ADHD as well.
My Bipolar medications are: Lamotrigine 75mg in the AM and 100mg in the PM daily, Citalopram 20mg daily, and Olanzapine (Zyprexa) 5mg daily or up to 15mg as required if I’m rapid-cycling.
My ADD medications are: 81mg (1-54mg & 1-27mg) of Concerta daily at 7 AM, and 10mg of Ritalin taken at 3pm, 5pm and 7pm (30mg total) .
I know my ADD meds dosages may seem high, but I am often groggy, tired and unfocused due to the Olanzapine. So much so, that I often feel the Concerta dropping off and by 1pm I feel out of it, unmotivated, and irritable and anxious because I feel the Concerta wearing off and I am so unfocused. I have been speaking to my family doctor and my psychiatrist to impress upon them that I really feel that my Bipolar meds are reducing the effectiveness of my ADD meds, and that I think that I may need an additional 10mg of Ritalin at 1pm. They are of course reluctant because of the high dosage and they have both said that they fear that it may induce hypomania.
I have tried the extra 10mg dose on my own for about 2 weeks and found that it help helped my concentration and mood a great deal and it didn’t bring on mania. I have told my doctors about my experiment, and so far they are still reluctant. I know that the textbook answer is to be cautious about too much methylphenidate, especially with Bipolar, but I know that as an individual both my Bipolar and ADD meds ought to be tailored to my needs. Of note, I don’t feel a racing heart, speediness or agitation, and I frequently check my blood pressure – it is always on the low side.
Am I missing something, or completely off the charts in my expectations with what I feel I need in terms of meds? Any thoughts or advice is appreciated.
My question: I have an 8 year old client with ADHD. The doctor he is seeing now, has him on 36mg of Concerta, and 10mg Ritalin after school. This child still has extreme hyperactivity, He was put on the medication dosage on 1/25/11. Been a month with this dosage and is ‘some’ better. Example of behavior: He hits the floor early, even if he is up late, cannot stay still, runs everywhere, and fidgets with his fingers and is up and down constantly while waiting for his breakfast. Does the dosage he is on, need to be increased or decreased, or what? Thank you for your expertise.
Delcia – if the dose of medicine helps a little, but not enough, probably a dose increase will help (as long as side effects aren’t a concern). Talk to the doctor about this.
Dr. Handelman, thank you for this Blog. I am 46 yo male that hit a “wall” about 18 months ago and started feeling NO energy and falling asleep anywhere at anytime, which was NOT something I had been experiencing in my previous 45 years.
After starting with Dexedrine and having to continue to increase(as my body got used to the dosage) to 3x15mg of Dexedrine per day, I sought psychotherapy, started Lexapro. Still, taking Provigil, Dexedrine & Wellbutrin was NOT getting me back to my LIFE of being able to stay awake and also focus/concentrate.
One Blog in here is correct. It’s not that simple to just sit back and let your doctor figure things out for you. I have been on Concerta 27 x2 per day for about a little over a week. I have been able to completely stop the Dexedrine & Wellbutrin, yes, through my doctors.
For the 1st time in almost 2 years, I stay awake all day, nap like anyone else might(full belly, warm Saturday afternoon, etc. etc.), and can focus/concentrate. I will learn soon if my downward spiral has cost me my job and if it has, that is quite sad. But to know that I may have my LIFE back because now I can stay awake, focus/concentrate, get things done around the house(wife is very happy), is an AMAZING feeling.
I guess one of the points to this comment is, I was prescribed 10mg x1 per day of Ritalin while also taking the Concerta 27. I have only taken the Rital once(just before I went on a run) and am concerned that the Ritalin will be like the Dexedrine where I will have to keep uping the dosage and times per day taking it, so I am trying NOT to take the Ritalin. But the Concerta 27 is working and I thank you for your Blog about the 2 together and for your work in Medicine.
I grew up not taking ANY type of medicine for anything(couldn’t afford it plus just convinced myself medicine was for wimps). After a career in US Military(USMC), with taking little to NO meds, I am now faced with the reality that I need them and finding that Concerta 27 works and that it’s okay to use Ritalin later in the day “when needed” is a blessing. Thanks again Dr. Handelman, keep up the GREAT work!
I was diagnosed with ADD in my twenties. Now, that I am 38 years old, I am trying some of medications with my psychiatrist that would work best for maintaining my attention, and focus during morning school. The medication prescribed to me first were: Dexedrine Spansules 5mg [for ADD one capsule in the morning at 8:00 a.m], Wellbutrin 150 mg [for depression, one tablet in the morning at 9:00 am] and Clonazepam 1 mg (for anxiety, one tablet three times a day).
The very next day, at 8:00 am, I was quite eager take one capsule of 5 mg of Dexedrine Spansule and to my amazement it kicked in immediately within 45 minutes and I felt bliss! I never tried Dexedrine Spansules before, or any other ADD medications prior to today. There was a great sense of clarity, calmness in front of my brain! The medication also heighten my attention span to help me focus on topics at present in classes and around the kitchen table at home with my family. The whole pill lasted the whole day. I couldn’t fall alsleep immediately for my bed time at 11:00 pm, so I took Clonazepam to helped me gradually sleep.
Now, on the second day, at 8:00 a.m I took one tablet of Dexedrine Spansule 5mg with one tablet of Wellbrutin 150 mg. An hour and half has past and I am not responding to the Dexedrine Spansule medication of a rapid effect that I experience yesterday! The bliss gone! Two hours, has past, it’s now 10:00 a.m and still nothing! From 12:00 pm on to the end of my day, at 6:00 pm, no effect took place at all. I did not feel any calmness, or sharp attention span. The answer completely eludes me.
I continued to use Dexedrine Spansule 5mg for the rest of the month in February as prescribed by my psychiatrist (however, I stopped the added combination of Wellbutrin to it). I didn’t think the Wellbutrin is a contributing factor here. The treatment effect of Dexedrine Spansules 5mg just completely stopped. When I visited my psychiatrist – he said, “no”, Wellbutrin is not the culprit or the clonzapam. Most likely, my brain quickly, grew tolerance to dexedrine spansules just in one day on a low dose. My psychiatrist increased the dose of dexedrine spansule 15 mg one tablet a day. Unfortuntantly, after 30 days of March ended, I returned to my psychiatrist, delivered bad news, that my brain had the power of endured or resisted the action of a drug. A higher dose of 15 mg did not improve my concentration and focus. The treatment was a failure for me.
Another ADD medication, Concerta 18 mg of Methylphenidate HCL was the next treatment option. So, I take three tablets by mouth once daily, in the morning, after I eat breakfast. For one month, I followed the prescription, finished the bottle – still there was no effect! My attention and concentration are not being treated and my grades are at all time low. This was shit, completely useless.
The psychiatrist advised that I try the new ADD medication, Biphentin 10 mg – a low dose for starters. For 30 days, I took one tablet by mouth daily in the morning, and I did not any effects in my head. Back to visit the psychiatrist again, the doctor increased the dose to 30 mg one tablet daily. I went home, another 30 days had gone by, and I was not feeling anything from the increased dose of 30 mg of Biphentin. The psychiatrist, wrote a prescription for another increase in the dose to 60 mg one tablet daily of Biphentin. Again after 30 days ended, I had no positive results, none, nil, zip!
So I think my brain need a mixed of amphetamine salts e.g) Adderrall XR or Vyvanse. What do you think?
Can you suggest newer augmentation options speed up ADD medications or Anti-depressants?
I am at my worst end trying figure which drug is the best fit to get my concentration and focus back. What would you recommend? Provigil?
Oh by the way, I tried Strattera – it made me drowsy and it didn’t work.
Jenna
Approximately 10 years ago I was diagnosed with severe ADD. This was discovered when I tried to go to law school. I couldn’t focused to save my life & eventually it cost me my job. I was prescibed 40 mg. of ritalin & my doctor would not increase it bc other medications I’m taking. I changed doctors & the new doctor put me on Concerta 36mg twice a day (no Ritalin). I have to say that nothing happens. I try to read & I have to struggle to keep my eyelids open. I really, really want to read my favorite author (A.C. Doyle) but it is just impossible. I’ve been thinking that combining Ritalin (20mg) once a day might work but I think that I’m going to face a lot of reluctance. I lost my job & I can keep my mind from wondering around to the point that I can’t even balance my checkbook (I have to pay somebody to make heads & tails of my bills). I feel embarrassed & stupid bc I can’t keep up with other people’s conversations. I’m permanently in la, la land that it isn’t even funny. Despite the fact that I’m taking (Symbyax 12/50 mg) and Effexor ER 150 mg twice a day, I sleep like a baby 14 hours a day. At this point, I don’t feel depressed and I make list of things to do, my mind just wonders, & I go from one project to another & my mind is permanently in the clouds. What do you all, think? Any advice? Please reply at doc.karch@gmail.com thank you. P.S. It took me 4 hours and a lot of editing to write this brief posting.
Amy – if you have been diagnosed with ADHD, and you are having problems with focus – check with the doctor about getting specific treatment for ADHD. You are already taking antidepressants/anti-anxiety medicines – so your doctor will have to work with you on an overall treatment plan.
Dr. Can you give me feedback on giving stimulant medicine to a recovering opiate addict? My husband is in recovery from opiates (2 years) and also had ADD. He had been taking Adderal for many years and stopped it when he went into recovery. He never abused his ADD medicine but his doctor said that addicts can’t take medicine like adderal. He really needs this to maintain his ADD and other drugs have not helped. I’m afraid his frustration now may cause him a relapse from the opiates! What are the general guidelines for addicts in recovery who have ADD?
Hi,
People can be put on the newer longer acting medications, or the non-stimulants.
So – vyvanse is the least abusable stimulant, and strattera and intuniv are non-stimulants, so they are not abusable.
Ask the doctor about those.
My son has ADHD he was taking concerta in the morning and retalin at 4pm but he was not getting any improment he was getting more agersive so i talk to his doctor and he change the meds to.and now he is taking intuniv1mg in the morning and focalin xr 15mg in the morning do you think is good two mix this two medication for him in the morning
Ana – combining intuniv with focalin is a good combination – though it depends how your son responds…
I have a 7 year old who has been taking concerts 18 mg for the past two weeks. The major downside has been not being able to go to sleep and when he starts to come off the medicine he is irritable, irrational and emotional. The doctor wants to add 5 mg of Ritalin at 3pm. What should I expect? I am nervous about adding another medicine but he can tell the concerts helps him at school. I just don’t know if he or I can handle these mood swings. Will the Ritalin help or possible hinder? So confused and worried about doing what is right!
I have a 8 year old taking Methylin chewable tablets 10 mg twice a day, in the morning and at noon. This is working well, but we would prefer to just dose him once a day. We would like to try Concerta but when I looked at your articles you spoke of three-times-a-day dosing with fast-acting Ritalin preps in your conversion ratio information so I don’t know how to figure his Concerta dose. I know the doctor has to do it but she doesn’t always seem savvy to what is available in Ritalin doses even though she thinks she is, so I would like to be able to discuss the Concerta dose with her at our appointment, rather than just be left at home with an acting-out kid when she guesses wrong. How do I calculate his possible Concerta dose using our present dosage schedule? Thanks!
Annie – just forget about the third dose at the end of the day – for example – if he is taking 5 mg AM and 5 mg noon, consider it 5 mg 3 x per day and convert the concerta dose appropriately (because Concerta lasts longer than then twice daily dose). If it lasts too long, consider a shorter acting MPH preparation – i.e. Metadate, Ritalin LA or Biphentin (Canada).