Guanfacine 2MG ER + Qelbree Onboarding + Zoloft 50mg

[PrettyGrey]

Hi All,

First post. Just recently joined. Our 7 year-old has ADHD-Combined Type, Generalized Anxiety Disorder, Separation Anxiety Disorder, & Dyspraxia (Developmental Coordination Disorder) + elevated scales for ODD (not high enough for diagnosis).

It's been a wild ride and it still feels insane - being on the medication train alone feels relentless. Looking for insight on your experiences with combination therapy of Guanfacine, Qelbree, and Zoloft (or any other SSRI).

Here's where we are:

Zoloft 50mg - Game change for anxiety. When we aren't tinkering with other meds, his anxiety is in a great place. Practically a non-issue when medicated. FYI - we did a trial under a new Psych Nurse Practitioner (NP) of taking him off the anxiety med thinking maybe the Guanfacine would cover anxiety + ADHD symptoms. Without the Zoloft he was incredibly irritable and quick-tempered.

We tried stimulants over the summer and each one (Focalin, Ritalin, & Adderall) increased irritability, anger, anxiety, aggression, & impulsivity. I should add that NONE of the stimulants were extended release, so I somewhat wonder/suspect if the immediate release formula caused too quick of a spike for him and that's part of the increase.

Completed GeneSight testing (costs $330 out-of-pocket and NP had to order it) in August 2022 - discovered that Intuniv (Guanfacine ER) is the only ADHD med in the "Green" (aka fewer side effects) category. Qelbree, Concerta, Ritalin, & Focalin all in "Yellow" categories (some side effects). Straterra is in the "Red." (Adderall, Dexedrine, Vyvanse did not have enough info for determining any metabolizing issues)

Guanfacine 2mg ER - NP suggested Guanfacine since stims were making anxiety worse. When we started at 1mg ER back in March 2022 we had success with improved compliance, attitude, decreased outbursts, etc., then after about 5-6 weeks, we saw things increasing again, upped dosage to 2mg ER at the end of July 2022.

- We also started to see significant weight gain begin to creep in - 7 year-old went from being underweight due (35th %) to just shy of being overweight (80th%) in the span of 5 months. We're talking 12lbs. The most he had ever gained in a year prior to starting meds was 6lbs. No change in eating habits or activity level.

- In December, we saw gradually escalating impulsivity, hyperactivity, and anger outbursts return. Not the same level as pre-Guanfacine, but returning.

- January 2nd: we upped the Guanfacine dose to 3mg ER, but within 2 days we saw the hyperactivity escalating even more and the impulsivity. It was weird. LOTS of issues created by this at school. So after 6 days on 3mg ER, the NP bumped us back down to 2mg.

January 12th: So, just a few days ago, after two weeks of escalating issues at school, our NP has suggested adding Qelbree into the mix. Since it was in the "yellow' our NP is recommending stopping titration at 200mg. So, we have a pack of samples and after 2 days, we had a sleepless night with little one last night. He was up all night (super pleasant!) with insomnia. Finally crashed at 5:30 and fell asleep.

- Meds were given at 7:30AM alongside the Guanfacine 2mg ER and Zoloft 50mg + Qelbree 100mg (first week titration).

- Going to deliver Qelbree at bedtime tonight and see if it mitigates the insomnia.

Any insight? Help? Anything from someone who is further down the road?

[Meangreenllamabean]

I wish I had more input to give you but I will say that my 6 year old has been on Guanfacine (immediate release) alone for 5 months and experienced the same waning results as you. Initial dose of 1 MG worked well for about 3 weeks then tapered off. We went up to 1.5 Mg and worked well for about one week. I didn't feel continued increase in dosage was sustainable so pediatrician suggested splitting the dose. Now she takes 1 MG in morning and 0.5 MG at night and have seen only mind improvements. We've stayed here about 4 weeks. No substantial change in BMI though.

A recent visit to a pediatric psychiatrist left us with a plan to add Zoloft to help manage her anxiety before discontinuing the Guanfacine and adding Vyvanse in its place. Prior stimulants made her anxiety horrible so I was hopeful that having a SSRI in place first would reduce that. Your experience makes me nervous.

[PrettyGrey in reply to Meangreenllamabean]

Thanks for your reply. I had hoped the same. The SSRI was definitely in place for about 7 weeks prior to trying stimulants.

When you try them, be sure you have the day at home to watch her! We had some pretty epic crying episodes at what I think was peak concentration in his system.