Going for a routine physical exam? New guidelines suggest less is more.

January 4th, 2019

By Natan Schleider, M.D.

Early Electrocardiogram called a String Galvinometer Circa 1911

My primary care physician is a very bright internist in his early 70s who I saw recently for a routine physical exam. He examined my head, neck, chest, and abdomen and then, putting on gloves and grabbing some KY jelly, told me to bend over for a prostate exam.

‘Prostate exam!’ I said, ‘Why? I have no prostate or urinary issues, no personal or family history of prostate cancer, and don’t see the need.’

‘Just being thorough,’ he replied.

While I like my doctor, there is thorough and then there is ‘too thorough.’ Moreover, I reminded him, routine prostate exams are no longer indicated [Source: US Preventive Task Force].

‘We’ll skip the prostate exam.’ I said. He shrugged as if to say he wasn’t doing his job properly. He then checked my legs and the exam was over.

While some of you may like the comprehensive check every nook and cranny exam, I personally don’t nor do I recommend or perform them. I stick to what the data supports. Why some patients seem disappointed that I haven’t probed every orifice is beyond me but to each their own.

Next time you’re in for an adult physical, here are tests which are no longer considered routine or necessary unless, of course, the doctor feels they are needed based on your medical history, symptoms, or other risk factors.

  • Digital Rectal Exam (meaning sticking a finger into your anus and rectum)
  • Pelvic Exams in Women
  • Testicular exams are up in the air but consensus is that male patients, especially those age 20-35 (when testicular cancer is most common) can perform their own monthly self-examination and/or have the doctor do the exam. The US Preventive Task Force recommends against testicular exams during a normal physical [Source: https://www.ncbi.nlm.nih.gov/books/NBK82767/table/vaphysical.t1/?report=objectonly]
  • Thyroid exam for thyroid cancer
  • Abdominal exam for pancreatic cancer, liver enlargement, or spleen enlargement
  • Lymph node palpation
  • Back exam for determining mobility
  • Checking reflexes in arms and legs
  • Breast exams need not be done if more sophisticated tests like mammograms are available

Some testing on routine physical exam are still being reviewed but as I peruse the medical literature, it seems that, to my old school doctor’s chagrin, much of the physical exam in adults is probably not helpful and may even lead to false positives.

Certainly some patients will swear that their doctor caught a disease by poking around or hammering on the knees with a reflex hammer and all I can say is: God bless those doctors. I’m interested in the facts here, just the facts.

Thx for reading,

Natan Schleider, M.D.

Source: https://www.ncbi.nlm.nih.gov/books/NBK82767/

Evidence Brief: Role of the Annual Comprehensive Physical Examination in the Asymptomatic Adult

Hanna E Bloomfield, MD, MPH and Timothy J Wilt, MD, MPH.

Created: October 2011

‘I don’t need the flu vaccine, it always makes me sick plus I can count on ‘herd immunity.’

January 4th, 2019

By Natan Schleider, M.D.

Poster by Board of Health Advising People wear mask in 1918 to protect against Spanish Flu


‘I don’t need the flu vaccine,’ said a mid 30s healthy female patient to me yesterday, ‘it always makes me sick plus I can count on herd immunity.’

My patients are well read, opinionated, and know plenty of medical jargon to make their point. Herd immunity, if you’re wondering, means that if everyone else around you is vaccinated and immune to a disease, the chances of them giving it to you is very low.

Let me also add the influenza vaccines do not give live virus, just the proteins of the virus to illicit an antibody and immune response if you are exposed to the virus. The immune response caused by the vaccine results in some cold symptoms like fever, sore throat, runny nose, cough, aches/pains, but DOES NOT cause the flu.

So why all the hype about the flu vaccine?

There are several answers:

  1. The media often has nothing really news worthy so given the mantra’ if it bleeds it reads’ they can always turn to the dangers of the latest deadly flu virus bound to land you on a ventilator before you can change the channel. Remember all the media hype about Avian Flu (H5N1) about 5-10 years ago. Turned out to be nothing. And the dreaded Swine Flu of a few years ago infected the airwaves aggressively (and fortunately did not infect many people). If you really want information about influenza ask your doctor, check the CDC and WHO websites, and ignore the publish or perish journalists.
  2. Historically, certain strain of influenza were actually quite deadly. the most infamous in Spanish flu, an aggressive form of H1NI influenza virus that spread quickly and was unusual in that it killed more young health adults (ages 20-40) than the young or elderly. Over 100 years later, this pandemic killed more people than those that died in WWI.
  3. If another aggressive flu virus rears its head, the flu vaccine does a nice job at keeping you alive–presuming the CDC and WHO have guesstimated the right 3 or 4 viruses to put into the vaccine that season.

I recommend all my patients get the flu vaccine. I get it annually and have never had the flu (which let me remind you results in days of miserable fever and chills and 2-4 weeks to recover…this isa cold on steroids).

My flu vaccine of choice is the quadrivalent vaccine (meaning it has four flu virus proteins in it) while the classical influenza vaccine has three. If you are worried about mercury (thimerosal) get the preservative free vaccine. If you are worried about autism note there is little if any data to support vaccines causing autism but it is up to you. If you are worried the shot will hurt, make sure the doctor injects with a brand new needle (that is, not the same needle used to draw up the vaccine from the vial as this will blunt the end of the needle and cause more pain).

After the flu vaccine, you can take Tylenol or Advil or Alleve and can expect your arm to be sore for a day or three.

Take home message: get the flu vaccine yearly and stop wasting your time and losing sleep over the myriad of journalists that have nothing better to do than scare you about so they can make a living.

Thx for reading,

Natan Schleider, M.D.

Weight Loss & Lifestyle Tips to A Lean Healthy Physique: Dr. Natan Schleider Shares His Nutritional Low Calorie Food Secrets (Shhh Don’t Tell)–Part II

December 24th, 2018

By Natan Schleider, MD

DON’T BE TOO FAT VINTAGE ADVERTISEMENT ON OBESITY TREATMENT CIRCA EARLY 1900S

So I wanted to follow-up with the nitty gritty foods I eat that have been working for me to maintain reasonable weight loss (current weight 203, I peaked at 222 earlier this month).

Disclaimer: These are not official physician or nutritionist recommend foods as some are high in sodium for example BUT they taste great (to me) and are low calorie…

Dr. Schleider Go-To Meals and Snacks for weight loss including calories per serving:

  1. Canned artichoke hearts–I love salty foods and while these tend to have high sodium, at only 20 calories per serving or 60 calories per can these are a great snack when you have a strong craving for something like chips.
  2. Mushroom Bisque Soup with little to no cream–This is actually easy to prepare and there are lots of great recipes on line. Given mushrooms have virtually no calories nor nutritional value while tasting great, you can substitute White Kidney Beans (Cannellini Beans) for cream which gives the bisque a nice creamy texture when blended. These beans are nutritional with zero fat, 19 grams carbs, and 7 grams protein per 1/2 cup serving which only has 100 calories.
  3. Salsa–I love salsa and put this on everything from egg whites in the morning to chicken breast in the evening. At 10 calories per two tablespoons I get a lot of flavor for otherwise tiresome foods.
  4. Unsweetend Almond Milk–At only 30 calories per serving vs 70 for skim milk, I use this in my morning tea or coffee.
  5. Bone and Vegetable broth–If you are a quasi-serious cook, you know that a good broth serves as key base to great soups (I’m big on soups if you can’t tell, especially in winter). One cup of chicken bone broth has 35 calories, 9 grams protein, no carbs, no fat. Vegetable broth at 20 calories per cup has no fat, no protein, and 4 grams of carbs.
  6. Boneless Pork chops–At roughly 300 calories per 8 ounce serving, these have virtually same calorie and protein as chicken breast which just gets dry and tiresome for me week after week.
  7. Sumo tangerines–I get these on freshdirect and at 40 calories they are delicious and better yet, peel so easily (unlike most oranges where I spend about an hour removing peel).
  8. Cucumbers–I get the foot long ones and when starving or cooking I can easily polish a whole one which for about 100 calories is quite filling.

So the above foods have been working for me this month. My next challenge is to balance exercise with diet in that days when I work-out, I am way hungrier (like 5 times as hungry) then days I don’t and I HATE feeling hungry. I turn into a grouchy, ‘hangry,’ sleepless man so when I figure this out, I’ll let you know.

Happy Holidays!

Dr. Natan Schleider

‘Stop the heroin,’ says the New York doctor to his opiod dependent patient, ‘medical marijuana will ease pain and save your life!’

December 23rd, 2018

By Natan Schleider, M.D.

PROHIBITION ERA PRESCRIPTION FOR MEDICAL ALCOHOL 1930





Mr. J.B., a 24 year old male up and coming advertising executive for a NYC start-up looks great on paper. He has a Masters Degree from a reputable Ivy League school. His rowing strength, skills, and discipline landed him an undergraduate scholarship, at least until he injured his back and was prescribed Percocet. He is from an affluent family, the kind that consider yachting a sport.

Issue is, he may be getting drug screened as part of his promotion at work. The recreational once monthly use of oxycodone that started a few years ago has ‘blossomed’ into daily use of what is supposedly heroin–he suspects it is ‘some garbage laced with fentanyl, different high you see’ which he snorts every few hours so he doesn’t ‘get sick.’

Appropriately concerned that his habit may be life threatening, I find him sitting in my office, nose running, pale and fatigued, yawning, and rubbing the goose bumps on his restless legs.

JB is clearly in opiod withdrawal and in New York State medical marijuana is recently approved to prescribe for Opiod Use Disorder.

Why? Because studies show that marijuana reduces the dose of opiods needed by at least 1/3rd and relieves pain.

As my predecessor physicians did during prohibition which began 100 years ago in 1919 when one of the few legal means of obtaining medicinal alcohol was by prescription, so now can New York State doctors prescribe marijuana for various medical ailments from cancer to post traumatic stess disorder to Opiod Use Disorder.

Given that New York like the rest of the USA is in the midst of an opiod epidemic causing countless deaths, any tool we can use to save lives from naloxone to buprenorphine to methadone to medical marijuana should be easily at doctor’s disposable.

This begs several questions:

  1. Why do doctors need a special DEA number and special training to prescribe buprenorphine, a medicine FDA approved for treating opiod withdrawal and dependence which it is virtually impossible to overdose on.
  2. Why do doctors need special training to prescribe medical marijuana as patients drop like flies from illegal pain killer and opiod use?
  3. Why don’t doctors need a special DEA number to write for powerful prescription opiods that are highly addictive and cause respiratory depression and death at high doses.

These complicated questions are based on history dating back to prohibition, reflect lobbying power of ‘big pharma,’ and ignorance that leaves marijuana a Schedule 1 medicine meaning the following according to the DEA:

Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Some examples of Schedule I drugs are:heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote. [See https://www.dea.gov/drug-scheduling].

Should marijuana become legalized for recreational use as Govenor Cuomo intends next year, perhaps medical marijuana prescribing will become a relic like the 100 year old prescription for medical alcohol?

For the interim New York doctors can and should, where medically indicated, offer patients medical marijuana instead of opiods.

Thanks for reading!

Natan Schleider, M.D.

BOARD CERTIFIED ADDICTION MEDICINE DOCTOR

So Your Doctor Says You Have High Cholesterol: How To Read Your Cholesterol Report

December 22nd, 2018

By Natan Schleider, M.D.

Dr. Schleider Cholesterol Report

So you had a physical and your doctor told you you have ‘high cholesterol’ but what does this really mean?

Historically, labs could only test ‘Total Cholesterol’ so alevel above 200 was considered high and below 200 was considered normal. This is a vast oversimplification to the point that in the 21st Century, Total Cholesterol tells doctors very little as it includes both Good (HDL) and Bad (LDL) cholesterol. So, for example, if your LDL cholesterol in 90 (which is quite low) and your HDL cholesterol is 120 (which is quite high but that’s good, the higher the better) your Total Cholesterol would be above 200 and you would have enviable cholesterol.

I included my own cholesterol test results above. This is a fancier panel which some insurance companies will not cover but it is detailed and a good teaching tool.

The common cholesterol test (aka lipid test panel) your doctor performs includes the following which I will help you to interpret (so you can decide whether to skip the bacon cheeseburger and/or exercise more and/or add a medicine for cholesterol.

Cholesterol Tests:

  1. LDL (Low Densiy Lipoprotein)–If you remeber anything, the LDL is THE MOST IMPORTANT NUMBER ON YOUR CHOLESTEROL TESTING. Commonly called bad cholesterol, LDL is the stuff that sticks to and clogs arteries anywhere in the body cauisng heart attacks and strokes and peripheral vascular disease. [Note different sub-types of cholesterol are sometimes called ‘particles’ and the smaller the particle the more likely it is to clog arteries. You will note my test has a ‘Lipoprotein Particle Evaluation’ which for our purposes is too complex to review and not that relevant for most patients]. As a general rule, if your LDL is above 160 treatment is immediately indicated, generally with a medicine. This does not mean you are committed to Lipitor for life but if your cannot keep you cholesterol below 160 you may need medicine indefinitely. Note I take Lipitor 40 mg daily for prevention reasons as current USPTF guidelines show that artifically lowering your cholesterol from normal to low reduces risk of artery clogging, heart attack, and stroke. If LDL is below 100 you are in the clear (unless you have high risk factors for artery clogging like diabetes, tobacco smoking, or perosnal history of heart attack or stroke) in which case LDL should be below 70. If your LDL is between 100 and 160 there is some debate but as a general rule, if you have zero risk factors for artery clogging try to get LDL to 130 or less without medicine. If you have some risk factors for artery clogging like obesity or high blood pressure try to get LDL to 100 or lower.
  2. HDL or Good Cholesterol–This should be above 40 ideally but the higher the better. While some new injectable medicines can raise HDL, as of 2018 these are not commonly used in primary care. Only regular exercise brings up good cholesterol although statin medicines like Lipitor may help a bit.
  3. Triglycerides–These are a type of fat that do not stick to arteris very well so I won’t say they are not important but will say try to keep levels below 150 with diet and exercise and consider a medicine if they run above 150.
  4. Total Cholesterol–As mentioned before, no real information here, the devil is in the details of the other tests.

So that covers the basics on cholesterol. I know I am seeing an educated intelligent patient when they say “Tell me about my LDL and HDL, the total cholesterol doesn’t matter much.’

Thanks for reading,

Natan Schleider, M.D.

DO I Really Need all these Adult Vaccines?

By Natan Schleider M.D.

December 19th, 2018

Vintatge Diptheria Vaccine Poster Circa Early to Mid 20th Century

Which routine (IE not for exotic travel) adult vaccines do I really ‘need’?

The Center of Disease Control (cdc.gov) provides up to date information on what vaccines each adult ‘needs’

Note ‘needs’ is in quotations as many of my patients say ‘every time I get the flu shot I get sick and I’ve never had the flu so I don’t want it.’ Hard to argue with this logic.

Other patients ‘pass out’ when they see a needle and the CDC doesn’t have much to add for these people.

My goal is a succinct review of all vaccines you’ll need in adulthood based on current 2018 CDC guidelines.

FYI, while I get all vaccines and have no issues with them, my daughter flipped out and cryed and cryed for her 4 year old vaccination so I haven’t had the heart to get her annual flu booster–bad Dr. Schleider.

So here are the vaccine you need in no particular order:

  1. Influenza recommended annually for everybody (unless you are allergic to it).
  2. Tetanus–Recommended every 10 years (5 years if it is a nasty wound like on a rusty fence). Try to get the tetanus booster that contains pertussis at least once in your adult life.
  3. Measles Mumps Rubella and Chicken Pox–You’ve probably had these in childhood (unless born before 1957). If there is any question as to whether you are immune I like to do blood tests for antibodies to confirm immunity.
  4. Shingrix 2 doses after age 50 2 to 6 monthts apart. No one is really using Zostavax anymore…
  5. Pneumonia Vaccine PCV13 (Prevnar) one dose after age 65 unless you have chronic medical issues like kidney or lung disease in which case have it earlier.
  6. Pneumonia Vaccine PPSV23 (Pneumovax) one dose after age 65 (don’t give at the same time as Prevnar) or 1-2 doses before age 65 if you have chronic medical issues.
  7. Human Papilloma Virus–3 doses through age 26 in females, age 21 in males
  8. Meningitis-There a re afew vaccines but bottom line get these before going to college or if you have any immune system disease
  9. Haemopholis Influenza B–Again for patient with compromised immune systems
  10. Hepatitis A and B–Hep B vaccine has become standard and I recommend Hep A to all travelers.

So that is my bare bones synopsis. We haven’t gotten into the exact timing of the vaccines but that is ok, just so you know what to ask your doctor or pharmacist (they get busy and may forget to remind you).

FYI I am a big advocate of vaccines and have had every one from yellow fever to rabies.

Reach out if you have any questions.

Thanks for reading!

Dr. Natan Schleider M.D.

Weight Loss & Lifestyle Tips to A Lean Healthy Physique: Dr. Natan Schleider Shares His Medical Secrets (Shhh Don’t Tell)

ARE YOU TOO FAT. Vintage weight loss advertisement circa 1900

By Natan Schleider, M.D.

December 12th, 2018

Gone are the days where I could simply skip desert and stay rather lean and toned. Having just turned 43, I literally feel my metabolism slowing and all I need to do is look at carbs and they go straight to my gut by osmosis. 

I weighed about 175 pounds (standing 5’9″) into my late 30s but after a recent physical I weighed in at 220 pounds and have shrunk to 5’8″. At this rate I’d be a walking doughnut with a head so I left my doctors office determined to get lean using every bit of advice I could find in the world of medicine, science, and technology.

Its been two weeks and I am down to 205 pounds. I could say I feel great but I’d be lying. My internal barometer seems to want me obese which I qualify for using a Body Mass Index Calculator. I’m tired as I don’t sleep well when I’m hungry. I’m cranky but fortunately I get a lot of telemarketing calls which allow me to toy with people trying to sign me up for ‘limited time offers’ on credit cards, business loans, and Nigerian Gold Mines.

I presume my mood and body will get used to my goal weight which is 180 to 190 pounds if I can get there. 

So here is what has been working to get the weight off…

  1. I go to the gym at least 5 days a week and workout with a trainer. This is my life one big luxury but I am so lazy if I didn’t pay the trainer I would barely work out. The trainer doesn’t let me skimp on those last few squats that leave me dizzy and gets a good laugh when I fall on my face doing box jumps. Bottom line: if you can afford a trainer or have a motivated work out partner that really helps. That said, weight loss is about 80 percent diet so if you cannot afford a trainer and hate the gym most of success lies in meticulous eating.
  2. I started using a My Fitness Pal app which is a real pain because it takes about 5 minutes to enter calories for every meal depending on the number of ingredients. The simpler the meal the faster I can enter and count calories. I’m aiming for 1500 calories daily, a few hundred more if the workout has been strenuous. Some of the things I snacked on like a slice of American Cheese or Prosuciutto have way more calories than I thought so the app has been educational. Even cucumbers have calories and if you are going to lose weight, you need to be rather meticulous in your calculations
  3. I’ve stopped eating out or ordering take out as I cannot count these calories–plus I like to cook so not a biggie for me.
  4. I have prepared healthy meals ready to be cooked or simply heated. I have a great healthy tomato bisque recipe–if anyone is interested let me know.
  5. I have my ‘skinny jeans’ front and center in my closet and try to put them on every few days. They obviously don’t fit (yet) and this negative reinforcement pisses me off, re-motivating me to stick to the diet exercise plan.
  6. Studies show drinking diet beverages can actually cause weight gain and other issues but when I have a sweet craving, I’ll go for a Diet Cherry Coke which is better than Cherry Garcia.
  7. I bough a food scale for about 10 dollars and while I think anyone weighing their tomato wedges is nuts, it is the only way for me to know exactly how many calories I am eating (because the common advice ‘just portion control’ means instead of eating an entire pizza pie, I eat half for dinner and half for dessert).

Some of the above I am sure you’ve read while other may seem somewhere between fanatical and disciplined but if I am serious about weight loss, this is a discipline which takes time and I just hope I can stick with it to the point it becomes routine.

Anyway, thanks for reading!

Natan Schleider, M.D.

Humorism: Why Modern Medicine is Still an Infant or Maybe a Young Toddler

December 11th, 2018

By Natan Schleider, M.D.

‘The Four Humors’ by Granger Drawing Circa 1574

So its the 21st century, you had a physical, and the doctor collected body fluids like blood and urine for ‘sophisticated’ testing. Ah the marvels of modern medicine.

But wait, doctors have been doing this for thousands of years. I would have been one impressed Gladiator in Ancient Rome if my doctor tasted my urine and explained I was feeling weak and urinating a lot because I had too much sugar in my blood. And doctors did just that. No glucose strips or little battery powered devices. Diabetes mellitus was diagnosed with a simple taste test, not blood test. 

Perhaps that doctor sends me to a specialist in Gladiators (who had the status and value of today’s NBA and NFL stars when Rome ruled the world) who likely would do a blood test. Sounds perfectly reasonable. Who wouldn’t want to know if their four humors (black bile, yellow bile, phlegm, and blood) were out of whack.

Today, we honor those four humors and their inventor, a physician known as Hippocrates (460-370 BC):

  1. Doctors take the Hippocratic Oath
  2. We take humors like phlegm and blood of out peoples bodies to test (IE for infection or anemia) and treat them (IE for Polycythemia)
  3. Doctors keep their patients humors in balance by reducing phlegm if they have too much of it so they can breathe

Around the 1500s doctors realized that there may be more to medicine than the four humors but that didn’t stop doctors from bleeding patients therapeutically for virtually any ailments into the early 1900s. Did you know George Washington died of being bled by his doctors for a throat infection. Seriously!

The greatest advances in medicine in the last few centuries include soap (probably saved more lives than all the antibiotics ever created), antiseptic surgical technique, and Viagra (not necessarily written in order of importance).

Sure we have fancy breathing machines, pictures that let us see inside our bodies, and robotic surgery. 

I’m no surgeon but I have to wonder about the bedside manner of robots, I mean, after fixing my heart valve will they reassuringly rest their arm on my shoulder and take a sip of my urine to confirm my diabetes is under control?

Thanks for reading!

Natan Schleider M.D.

Ten Signs You Are Seeing the Wrong Doctor

December 8th, 2018

By Natan Schleider M.D.

If dustballs in the corner of the doctor’s exam room and bullet proof glass separating your from the receptionist aren’t good enough, here are ten signs that you probably are not seeing the best doctor:

  1. An old expression states if the ink on the diploma is to wet or too dry, seek treatment elsewhere. If the diploma is a pile of dust behind a dingy glass frame, run.
  2. The doctor’s lab coat is dirty. This simple observation reflects the doctor’s hygiene and their respect for medicine. Dirty lab coat, dirty doctor.
  3. Magazines in the waiting room are over 10 year old. This shows the office is not up on the times, that is, if they can’t even update their magazines, what kind of archaic medicine is being practiced.
  4. The doctor spends less than a minute with you and can never remember your name. While I grant many doctors are overworked, they can spare a few minutes and knowing their patient’s names.
  5. The doctor is a social media star who does nothing but tweet, post, take selfies, and promote his brand. While I’m sure these doctors are attractive and interesting, they probably are not practicing as much medicine as the good old fashioned doctor–oh, excuse me for a second, someone just liked my latest post on instagram, just joking.
  6. The appointment is spent talking about the doctor and not about the patient (for example, ‘So you just had a little heart attack, big deal, I get my coronaries rota-rootered every year and since my 8th heart attack and some Lipitor, I eat at the buffet daily).
  7. The doctor cannot make a decision and refers you to a specialist for every problem (IE that splinter in your finger is tiny but just to be safe, let’s have a dermatologist look at it to make sure nothing is being missed).
  8. The doctor’s office frequently cancels your appointment or is late for your appointment.
  9. You arrive on time for your appointment and realize yo have read Was and Peace before being called in to see the doctor.
  10. You are asked to disrobe in the exam room for a talk therapy visit.

I’ve seen variants of all of the above so keep the above in mind before choosing your next doctor.

Natan Schleider MD

Which ADHD Medicine is Right for Me?

by Natan Schleider M.D.

December 7th, 2018

So you think you have attention deficit hyperactiviy disorder (ADHD formerly ADD) and you are considering medicine options. If you are like most patients I see, you’ve already queried friends, family, and the internet so you can tell the doctor what you think is best. I have no issues with educated patients so I’ve put together a list of medicines I use and why.

Note the family of stimulants (IE methylphenidate, Adderall, Vyvanse, and others) are the first recommended treatment in general for patients but that varies by patient and whether they have other medical or mental health issues.

Stimulants can be habit forming so considering a non-controlled medicine (bupropion aka Wellbutrin, Strattera) for ADHD may be a nice option as they are not habit forming although tend to be milder and less strong.

While discussing stimulants, let me add that I am often asked ‘Can’t I just drink a lot of caffeine for my ADHD?’ Caffeine is a unique molecule and while it keeps most people awake and is activating, it does NOT help ADHD symptoms.

The first question to ask when it comes to stimulants are whether your want a short acting medicine that can be used a few times a day or a long acting medicine taken once a day. This is patient preference as some like flexible dose options with a short acting medicine while others just like to take one pill a day.

So here are your stimulantmedicine options for ADHD:

  1. methylphenidate (best known as Ritalin) which is the oldest and comes as short acting (last 2-4 hours) and long acting (last 6-12 hours for Concerta or Focalin or Vyvanse–I find they last closer to 6 hours in most patients). Note Daytrana is a patch that lasts up to 10 hours
  2. Dextroamphetamine/amphetaime (Adderall) which comes as short acting or long acting (Adderall XR) and super long acting (Mydayis) at up to 12 hours.
  3. Dexedrine and Dexedrine Spansules are popular amongst a handful of my patients althugh they re hard to find at pharmacies.

 
And here are your non-stimulant medicine options for ADHD:

  1. Atomoxetine (Strattera) which takes about 3 days to kick in and dose can be adjusted from 40 mg to 80 mg (the standard dose) in 3 days.
  2. bupropion (Wellbutrin) is a very activating antidepressant approved for ADHD, tobacco cessation, and depression.

My patients tend to prefer Vyvanse which is the least speedy of the stimulants but every patient breaks the medicines down differently so it may take some trial and error to find the right choice.

When reviewing medicine options with patients I go over the above in detail. While talk therapy helps for most other mental health illneses, it is less effective for ADHD (but no harm in trying it).

If you have any questions or comments please reach out to me on Twiter or Instagram or facebook.

Thanks for reading,

Natan Schleider, M.D.