Last October, Adderall (amphetamine/dextroamphetamine) and its generics entered shortage status. As prescribers scrambled to find alternatives for their adult and pediatric patients with ADHD, many other central nervous system stimulants have seen intermittent shortages as well. Though drugmaker Teva Pharmaceuticals said production of fast-acting, brand-name Adderall tablets is now up to speed, the residual effects of the shortage continue to be felt across brand and generic ADHD medications in all classes and formulations. Some drugmakers expect their shortages to persist through the spring of 2023.
“It’s not just Adderall. At some point, with all stimulants, we’ve seen that patients have been unable to get them at the pharmacy,” said Sterling Ransone, MD, a family physician in Deltaville, VA, and board chair of the American Academy of Family Physicians.
Until the supply is once again able to meet demand, patients, prescribers, and pharmacists must work together to find solutions. Here are some strategies they have tried.
Going cold turkey
Some adults are making the decision to go off their ADHD medication until it becomes available again.
When pharmacists discuss this decision with patients, they might mention that “for those [who] have been taking these medications consistently for a long period of time and at a higher dosage, they may see some fatigue and depressed mood with an abrupt discontinuation of therapy,” said Brigid Groves, PharmD, vice president of pharmacy practice at APhA. “Those symptoms usually dissipate within a week or two.”
Parents are less willing to drop their child’s medications due to concerns about the impact on the child’s behavior and ability to concentrate at school. Even adults feel a negative impact when they discontinue their ADHD medications.
“One patient who took that strategy came back to my office and said, ‘We have to do something about this because I’m having problems at work and I need some help,’ ” Ransone said.
Different doses, formulations, or fewer pills
When the desired drug is available in some form, pharmacists might have to request that prescribers rewrite prescriptions to allow the pharmacist to dispense the drug in different doses. “If the patient is on 25 mg and the pharmacist has a 10 [mg] and 15 [mg pill], we’ll have to rewrite the prescription accordingly,” Ransone said.
Patients are also finding that their pharmacy doesn’t have a full month’s supply of their ADHD medication, in which case they ask their prescriber to call in another prescription for 15 pills.
“In that case, because these medications do have the potential for abuse—and there have been instances when parents have taken their children’s medication—we always like to verify that with the pharmacy or check the [prescription drug monitoring program] or both,” Ransone said.
Pharmacists may also try to fill these prescriptions with chewable tablets or liquid formulations. When those options are not available, pharmacists might ask prescribers about switching from extended-release to short-acting or immediate release Adderall, but that’s not ideal due to added adverse effects and the need to take more than one pill per day.
“In our schoolchildren, having to leave at lunchtime to take your medicine can be stigmatizing, and we want to avoid that for patients if we can,” Ransone said.
Different drug class
While it’s not preferable, when supply dictates, sometimes Ransone switches patients from a prodrug to another type of drug.
“Pharmacists should counsel patients or parents on how the medication might kick in faster or that it might not last as long,” Ransone said.
Changing drugs altogether, however, can be costly, though prescribers might not realize it, Groves said. “Vyvanse is more closely related to Adderall than Ritalin is, but it’s expensive and insurers might not cover it,” she said.
Advice for pharmacists
It’s likely that pharmacy inventory, patients’ needs, prescribers’ preferences, and insurance benefits don’t align. This can add up to multiple phone calls back and forth between pharmacists and prescribers.
“It would be great if pharmacists could list what they have in stock in the patient’s [electronic health record] so that the physician could see what was available and make the best choice,” Ransone said. But, until that day comes, he said, “My preference would be that the pharmacist leaves a message that says ‘We don’t have Vyvanse. These are the alternatives. Do you have a preference?’ ” ■