Phone Visit
Narrative: SPRUCE MESSAGE VISIT Date: 2024-05-27 Encounter: Spruce text message CC: Initiation of Guanfacine ER for ADHD/behavioral management with ongoing dose titration and side effect monitoring. HPI: Following the stimulant trial that was discontinued in March 2024, Eamon was started on Guanfacine ER 1mg daily around late May 2024. The prescription was initially sent to the wrong pharmacy and redirected. Insurance required a 90-day supply but Dr. Hobbs negotiated a 30-day fill. In late June, parents reported depressive symptoms emerging out of nowhere and concern about negative impact on athletic performance. The dose was increased to 2mg, after which Eamon developed significant insomnia — waking during the night, taking afternoon naps (very unusual), and exhibiting low energy in the pool. Changing timing from evening to morning dosing was tried. Parents ultimately discontinued the 2mg dose early due to ongoing sleep disruption. Assessment: Guanfacine ER 1mg was initially tolerated but at 2mg caused significant sleep disruption and fatigue affecting athletic performance. Emotional/depressive symptoms reported around June 26 may be related to guanfacine. The 2mg dose was not appropriate; plan to return to 1mg and reassess. Plan: Guanfacine ER 1mg prescribed and dispensed (30-day fill, ~$16, CVS York). Dose increased to 2mg; timing switched from evening to morning to address insomnia. Ultimately discontinued 2mg early. Plan to resume 1mg at start of school year; 90-day fill to be called in to CVS. Possible medication change discussed for future. Medications: - Guanfacine ER 1mg daily, increased to 2mg daily, then back to 1mg daily (new, then adjust) Key clinical quotes: "I'd switch the the timing of the dosing first and see if it helps" "No concern. So the plan will be no meds over the summer and then 1mg for school or changing meds entirely?" "I'm completely understand and agree 2mg isn't the answer." Source: Spruce conversation t_27GA7V0S3U800