Talk:Adderall/Archive 5

This whole article reads like a brochure

So much praise and carefully reassuring phrasing, for something that garners considerable mistrust (at least outside the USA) and has very little information about long-term use.

The whole first paragraph supposedly describing side-effects is, in fact, an explanation of how they're not really that serious (despite describing them as many and varied).

I know there are well-funded interests who have a vested interest in biasing this page (and it's clearly working) but can we at least try to look like a NPOV policy? 86.153.54.114 (talk) 23:13, 27 December 2016 (UTC)

NPOV means we have to give WP:DUEWEIGHT to viewpoints. You'll have to be more specific. What is the article currently missing? Sizeofint (talk) 23:34, 27 December 2016 (UTC)

Any particular reason to move this to the bottom of the talk section? Don't worry, I fixed that for you. As to the article.. No mention whatsoever of it being over-prescribed http://www.recoveryanswers.org/blogs/adderall/ https://www.minnpost.com/second-opinion/2016/09/overprescribing-drugs-adult-adhd-causing-trail-misuse-addiction-and-death?

Plus, NPOV is not only about giving due weight, it's also about writing in a neutral tone. Eg not this: "The risk of developing an addiction is insignificant when Adderall is used as prescribed at fairly low daily doses". There are many, many sources online chronicling people becoming addicted from prescribed doses.

I'll assume good faith on your part, but the overly-optimistic tone of this article at present makes it nothing more than a marketing tool to convince parents when they first start researching the drug. 86.153.54.114 (talk) 23:54, 27 December 2016 (UTC)

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When taken as prescribed, amphetamine doesn't sufficiently induce ΔFosB expression in the nucleus accumbens to allow it to accumulate. When it's taken in larger doses than a doctor has prescribed, Adderall can sufficiently induce that protein and allow it to accumulate. That causes an addiction. This is why most medical professionals insist strongly that patients only take the medication as prescribed.

I'm not sure what you mean by overly-optimistic tone; what statements are you referring to? Seppi333 (Insert 2¢) 05:05, 28 December 2016 (UTC)

"When it's taken in larger doses than a doctor has prescribed" So you're aware of how it's prescribed worldwide, and are comfortable making that statement based on what evidence?

As to the overly optimistic tone, I gave examples. If you'd like another, why does the "side-effects" section include disclaimers about how safe it is? (As do most other sections). You also haven't addressed the issue of being over-prescribed as per the links I referenced above 86.153.54.114 (talk) 16:05, 29 December 2016 (UTC)

You don't seem to be aware that MAS/Adderall (the subject of this particular article) is only available in North America, specifically the US and Canada. Other ADHD medications such as dextroamphetamine, lisdexamfetamine, methylphenidate, atomoxetine, etc are more widely available worldwide; however, MAS/Adderall is not even near being available "worldwide" as you claim it to be.

I'm not quite sure what you're trying to insinuate anyways, that doctors are prescribing too-high doses? Hah! Nowhere near the truth. Evidence? Well if you want truly "hard" evidence of what real-world prescribing practices look like, I recall reading more than a few scientific articles analyzing prescribing practices at a large scale, and I'm sure you're more than capable of going to pubmed and digging those articles up if you're truly interested in rational discourse... I am not here to spoon-feed you those particular type of refs though, so don't whine about me not citing them inline.

If you actually meant evidence of MAS/Adderall's safety and efficacy at treating ADHD, well, I honestly don't feel obliged to back up that claim with any additional evidence - you can easily verify this claim over and over and over and over again if you start reading some of the major refs used in this article alone, and there's plenty more duplication of that proof (specifically and generally) in refs spread out across quite a few articles related to this subject...

So you claim you gave examples. I see you mentioning the side effects descriptions (I disagree with your assessment - the side effects are described appropriately and comply with WP:PHARMMOS guidelines), then a claim made by you that Adderall is overprescribed which was backed by two completely unreliable and arguably very misleading sources (we require the use of a much higher standard of evidence on Wikipedia than you're probably used to - you'll need to come back with some quality sources if you want to continue arguing that angle), and then another claim that an entirely accurate statement ("The risk of developing an addiction is insignificant when Adderall is used as prescribed at fairly low daily doses") is false based off of your claim that anecdotal accounts to the contrary exist (indicating quite clearly that you urgently need to read WP:MEDRS).

But hey, let's talk about anecdotes for a bit. Even if we considered these anecdotes to be a valid source, you would have to compensate for one huge glaring issue with most of these anecdotes - they are from people who were not using Adderall as prescribed. Indeed, I would bet that a significant portion of them never had a prescription for the drug in the first place, and that many others were faking symptoms of ADHD in order to obtain prescriptions under false pretenses for the explicit purpose of misusing the drug. A smaller number of them would be people who legitimately had a prescription for ADHD but voluntarily began misusing the drug for whatever reason. Absolutely none of these people can legitimately claim to be able to refute the article's statement based on personal experience - because all of them failed to fulfill an extremely simple condition within the statement. You are left with very few anecdotes now, generally with rather questionable validity. Good luck refuting the statement with the remaining candidates. Of course all of these were always completely worthless anyways because they're just anecdotes and fail miserably as a source at complying with WP:MEDRS, but maybe now you have a better idea of why this statement is considered accurate. Garzfoth (talk) 02:39, 30 December 2016 (UTC)

@86.153.54.114: I'm aware that amphetamine pharmaceuticals in general are prescribed worldwide. Garzfoth is correct that the prescription of Adderall is limited to North America. I also know that 60 mg of Adderall is routinely recommended as a maximum dose in adults and that a weight-based dosing method is often used by doctors/psychiatrists to compute a dose to prescribe to patients. The maximum dose and the weight-based dosing method were both borne out of data derived from randomized controlled trials (RCTs). Similarly, my statement about long-term use of this drug at therapeutic doses not producing psychostimulant addiction is also borne out of data derived from longer-term RCTs (e.g., those with a duration of over 6 months) involving the treatment of narcolepsy or ADHD with amphetamine. It is possible to get addicted to amphetamine if a doctor prescribes a high dose of amphetamine via oral and particularly via an injectable route (e.g., the intravenous administration of ≫ 80 mg/day of liquid dextroamphetamine from ampoules for the treatment of narcolepsy would likely produce an addiction after a few months of treatment; this dosage form for this condition is prescribed in the UK). In any event, if a doctor/psychiatrist chooses to prescribe more than is recommended (i.e., a supratherapeutic dose) by governmental regulatory agencies (e.g., the USFDA) or the drug manufacturers (via their prescribing information, which the prescribing physician would have to read), the onus is on the clinician that prescribes amphetamine in such a manner to prevent the development of addiction in their patient. Consequently, I'm comfortable with this article making assertions relative to the term "therapeutic dose" because that dosage range is not specific to certain countries; it's derived from evidence-based medicine.
More relevant to actual WP content policy, the sources which support statements which include that term also directly support those statements, so there's no issue with verifiability.

Re: your claim about NPOV, these two sources - [1] and [2] - don't satisfy WP:MEDRS (or even WP:RS for that matter); WP:MEDRS is the wikipedia policy that covers the type of references that can be cited to support article statements which include medical claims. If you read that policy and can point me to a reliable medical source which supports the claim that you're making, I'm more than willing to include a statement in the article about that. At the moment, I know of no medical sources which make a claim like "The use of amphetamine for the treatment of ADHD has produced an addiction in some individuals when it was taken as prescribed". Also, the under- and over-prescription of psychostimulants, including amphetamine, for the treatment of ADHD is already covered in the ADHD article. This type of claim is more appropriate for that article since amphetamine pharmaceuticals, including Adderall, are also medically indicated for conditions other than ADHD.

I don't see anything that reads like a "disclaimer" in the side effects section. Can you be more specific? Seppi333 (Insert 2¢) 18:48, 30 December 2016 (UTC)

On a completely off-topic note, it amuses me that the author of this article used the image that I uploaded to commons. Seppi333 (Insert 2¢) 17:28, 30 December 2016 (UTC)

Hey look, it's that horrifically disgusting generic formulation! Is it just me or is that pill almost gag-inducing to take? I'm on it QID and I'm very tempted to beg my pharmacist to switch generics, I cannot tolerate the sickly-sweet nastiness when it starts to dissolve as you swallow it (and god forbid you don't swallow it the second it's in your mouth!). Garzfoth (talk) 20:49, 30 December 2016 (UTC)

Also, I've found several sources using my image of propranolol tablets COMMONS:File:Propranolol_tablets.png - it's always nice to see it being reused, even if a few of the sources are using it in entirely the wrong context (at least they all seem to properly attribute it to me/Wikimedia Commons). That picture was not easy to take with the equipment I used, and required a lot of work in photoshop to eliminate imperfections (although ironically the result of the work in photoshop was closer to reality than the original image). Garzfoth (talk) 21:12, 30 December 2016 (UTC)

Yes, the taste sometimes makes me cringe if it dissolves in my mouth. Seppi333 (Insert 2¢) 20:02, 1 January 2017 (UTC)

Holy crap, they prescribe d-amp injections of that size in the UK? What the hell are the doctors there smoking? It doesn't even make sense to inject d-amp for narcolepsy in the first place, you'd want an oral form...

I want to clarify that if the doctor prescribes a supratherapeutic dosage (which is fairly rare), it's an exception made based on that clinician's judgement call that this (off-label) dosage of the drug is necessary for optimal treatment of the patient's condition and that the clinician has assessed the risk-benefit equation of a supratherapeutic dosage in this particular case and determined it to be positive. I thought that simplifying the description the way you did wasn't quite clear enough.

I do feel the need to point out that the specific "maximum dosage" for psychostimulants does vary to a small extent depending on the country, but that these differences are minimal. By the way, the maximum dosage is generally not determined by evidence-based medicine in the case of psychostimulants, it is an arbitrary limit based on what the regulatory agency will approve (which is only in part based on evidence from clinical trials and involves a few too many overly-cautious and highly subjective judgement calls). I have a MEDRS-compliant ref somewhere that explicitly supports this for at least one psychostimulant if you want me to cite that claim. Garzfoth (talk) 21:06, 30 December 2016 (UTC)

they prescribe d-amp injections of that size in the UK - no, I was stating that as an example of an excessive daily dose that a doctor could prescribe, not a dose that doctors typically prescribe.
The maximum recommended dose for amphetamine pharmaceuticals isn't arbitrary; it's based upon clinical trials that examine differences in treatment efficacy of amphetamine for ADHD when it is administered at different doses. In most people, the treatment efficacy for ADHD plateaus beyond a certain dose - that particular dose varies by formulation. Seppi333 (Insert 2¢) 20:02, 1 January 2017 (UTC)

As far as I can tell dextroamphetamine ampoules aren't available in the UK. If you wanted to use it as an example, you should have used a plausible one - I don't think there is a single reason to ever prescribe >> 80mg injectable doses of dextroamphetamine daily (assuming it's even possible to acquire the injectable form anywhere in the world - as far as I know only research studies have ever been allowed to acquire and use injectable forms of common stimulants), as it's all but guaranteed to end very very very poorly. A more plausible excessive daily dose that's relevant to this article is 120mg daily of MAS/Adderall, taken orally in divided doses - this is a very high dose, but it's actually a plausible one (although it's quite rare to see).

Amphetamines are actually a unique case, as both Dexedrine and Adderall have excessively vague dosing guidelines in product monographs. Both monographs both only discuss pediatric dosing - adult dosing is not discussed at all (and Dexedrine in particular actually explicitly says that the indications are for pediatric patients up to 16 years old). For pediatric ADHD, it states that dosage should be increased until an optimal response is obtained, and that "only in rare cases will it be necessary to exceed a total of 40 mg per day". For pediatric narcolepsy, it states "usual dose [is] 5 mg to 60 mg per day in divided doses, depending on the individual patient response" (the "is" in this quote only appears in the Dexedrine monograph). Neither condition-specific dosing guideline in the product monograph for the two most important amphetamine formulations specifies an actual maximum dosage. In contrast, Ritalin's monograph mentions adults (although I think this is solely because it only exists as a combined monograph for Ritalin SR and Ritalin IR), and while it is less vague about adult dosage maximums (only saying that "some patients may require 40 to 60 mg daily"), it's not perfectly clear until you come to the child dosing guidelines, which state "daily dosage above 60 mg is not recommended". Even the more modern products are still vague in their product monographs - the only one that explicitly defines a maximum is Concerta (it explicitly says 72mg is the "maximum"), Aptensio says "Daily doses above 60 mg have not been studied and are not recommended" (even though it's false that doses above 60mg have not been studied and even the fucking product monograph contains numerous references to data involving the 80mg dose form, which is the maximum dose form approved in Canada where this product was originally marketed as Biphentin (which is actually really odd given Health Canada's approval of a max dose of 54mg for Concerta rather than 72mg, the lack of Adderall IR in Canada, that one massive mess with Adderall XR getting withdrawn temporarily, etc)), and I was extremely surprised to see that the Vyvanse monograph only says "the maximum recommended dose for children is 70 mg/day; doses greater than 70 mg/day of Vyvanse have not been studied in children" - the only other constraint on dosing is that it should be individualized to needs/response and should be administered at the lowest effective dosing - which isn't really a constraint.

Now on the above, I know in particular that we have strong trial data supporting Concerta's efficacy at doses of up to 108mg/day, and that trial data on methylphenidate in general is mixed but does not support the arbitrary 60mg limit that is generally accepted and roughly defined in most product monographs. I dug up that paper on Methylphenidate dosing ([3]), and here's the quote:

"While the dosage range varies for children, the average daily dose of methylphenidate for adults is 20 to 30 mg/day. Most texts recommend that the daily dose should not exceed 60 mg, although some individuals may require higher doses. This limit of 60 mg/day appears to be arbitrary and not based on clinical research. Studies for adults with ADHD suggest 1 mg/kg/day as the usual dose with lower doses producing less response. These dosages refer to the therapeutic oral dose."

Here's a relevant quote from a completely different paper (PMID 14594733) that quantifies typical responses (and is a really good paper in general): "[...]the requirement for very high doses to produce clinical effects, which is required in about 20% of those who are considered responsive to stimulants"

I don't want to undermine your argument too much, because its core is completely valid, but the idea that we have strongly evidence-based maximum doses for psychostimulants in use today is pure baloney. There's a reason why these monographs all emphasize titrating to effect first and foremost, why professional guidelines from groups like CADDRA and a major narcolepsy-related organization strongly emphasize this much further while uniformly and often drastically redefining maximum dosages, why clinical practice involves as many as 20% of patients taking doses beyond monograph limits, why scientific data disagrees so strongly with the generally-accepted guidelines for methylphenidate, why so many psychiatric professionals with sizable amounts of actual experience prescribing psychostimulants disagree with the "generally accepted typical guidelines", etc... Unfortunately this is a case where too many pieces of the puzzle are disconnected from each other and nobody really cares enough about clarifying incorrect information since it usually doesn't affect the people that know it's wrong.

Really, it'd be better to say this about psychostimulants: addiction potential is only a serious concern if the drug is being misused in some way, as opposed to being taken as prescribed. If you're taking it by ANY non-oral route (or non-transdermal in the case of Daytrana) - you are misusing it, and it's much more addictive (nasal is very bad, rectal is extremely bad, IV is game-over). If you're taking more than prescribed in ANY way (more doses per day, multiple doses at once, time between doses too short, defeating the time-release mechanism via crushing/chewing/etc to turn an XR pill into IR) - you are misusing it, and it's much more addictive (although the magnitude varies based on what you're doing). If you combine taking it via the wrong route with taking more than prescribed, you are practically guaranteed addiction. I didn't mention a few Daytrana-specific misuse signs, but I'll go over them quickly - attempting to artificially increase the rate of release from the patch by ANY means, leaving it on longer than the maximum allowable time (9 hours?), attempting to use it orally (or via any other non-transdermal method), and of course the other non-specific misuse signs still apply alone and in combination with these and others.

Psychostimulants should of course always be prescribed at the lowest effective dose, but that's very different from a "low dose", and even a low dose can easily be misused and lead to addiction. We don't have enough evidence to actually say if someone who requires a high dose is actually at a significantly higher risk for addiction (and I honestly don't even know how strong the data is on accidental overmedication past the effective dose as a factor in addiction risk - it's definitely very bad practice, but the addiction-specific risk isn't clearly known past the knowledge about too-strong effects being generally linked to increased drug liking). Part of the reason the "generally accepted typical guidelines for maximum doses" are low is because of the desire to avoid overmedication in general, but it's a knee-jerk response to that issue that fails to solve anything (if someone would respond well to 10mg/day but you prescribe them 20mg/day because the product monograph says that's an okay dose and you're too stupid to follow the titration guidelines properly, that person is going to have similar issues to someone who responds to 40mg/day but ends up with 80mg/day - the only difference is that skipping titration completely will make things temporarily nastier with higher doses for the first few days mostly irregardless of your personal "response dosage", but that's a minor factor). That's an extreme example too, it's more common to see people titrated normally with a subsequent failure to wrap up titration correctly when the therapeutic response is achieved, so the target is overshot and stays that way. It can be argued that a higher max dose makes doctors more comfortable titrating to higher doses, but that's not necessarily a bad thing at all (if they're titrating like they're supposed to, this is a good thing, and it helps address undertreatment - which is a pretty significant issue - and a surprisingly large amount of doctors are ignorant about psychostimulant treatment in weird ways, like having personal definitions of the maximum dose that's far below even the monograph doses, or not understanding a LOT of basic dosing concepts for psychostimulants in general that any prescriber should understand before prescribing this type of drug).

ANYWAYS, while this is a fascinating subject to discuss, I really need to wrap this up. I think I've addressed everything, keep in mind that the dosage plateau follows the "target" or "response" dosage (just making sure the terms I used are in concordance), and if it's not clear enough already, I'll repeat it again: the target/response dosage and thus the location of the start of a dosage plateau is COMPLETELY individualized and fluctuates WILDLY, setting an arbitrary maximum dose that flat-out cuts off ~20% of medication responders is extremely harmful (leading to extremely suboptimal treatment for that ~20% at absolute best, but usually to mistakenly perceived nonresponse, plus some level of suboptimal treatment for a significant portion of responders). Garzfoth (talk) 20:34, 2 January 2017 (UTC)

I don't disagree with what you said. What you've stated and quoted (e.g., clinical practice involves as many as 20% of patients taking doses beyond monograph limits) is entirely consistent with what I've claimed (In most people, the treatment efficacy for ADHD plateaus beyond a certain dose); a corollary to my statement is: "in a minority of people, treatment efficacy dose not plateau beyond the same dose at which it does in the majority".

In any event, I strongly disagree with that reference's claim that these recommended limits are arbitrary and not based upon clinical research; regulatory agencies like the FDA don't make "arbitrary" decisions when it comes to dosing information; just imagine how much that practice could fuck people who take a drug with a narrow therapeutic index. More than likely, the maximum recommended dose is the largest dose that has been used in clinical trials of a sufficient size. The selection of that "largest dose" by the trial coordinators likely was arbitrary; but, the selection of the same dose as the maximum recommended dose by manufacturers/regulatory agencies is not precisely because it is based upon what has been used in the available clinical research. Nonetheless, the maximum recommended doses for ADHD drugs are simply recommendations and not actual prescribing limits since, as you've pointed out, exceptions occur in clinical practice where efficacy improves at higher doses which are still tolerable to the patients. Seppi333 (Insert 2¢) 21:30, 2 January 2017 (UTC)

Fair enough, although I'll make a point related to this at the end of my message... Now for the rest:

Limits can easily be arbitrarily determined without fucking people over (at least not in terms of drug toxicity - efficacy is another matter) when the drug has a very very wide therapeutic index. You're also using an extremely absolute interpretation of the term arbitrary - arbitrary is defined as "subject to individual will or judgment without restriction; contingent solely upon one's discretion", this does not mean that an arbitrary decision is by nature utterly irrational and random, just that one has a great deal of choice in how to decide the result and that they are completely free to ignore external rationale/information to whatever extent they desire.

Now, Ritalin was approved by the FDA on Dec 5th 1955. I have no clue if there even was a product monograph back then, nor do I know exactly when it was first published, but in theory it was published by 1981 at the latest according to the FDA's rather frustratingly flawed records. I have no clue if any clinical trial data ever went into this drug's dosage limit. However, a closer examination of the monograph reveals that there are two maximum dosages listed - the maximum daily dose of 60mg, and a "do not exceed" dose of 2mg/kg. The "do not exceed" dose appears to be a relic of pediatric weight-based dosing with some limited grounding in clinical trial data, while the maximum daily dose has no grounding in clinical trial data.

But I want to prove a different point. Let's look at Concerta, another methylphenidate-based drug. This was originally tested in clinical trials at doses of up to 54mg/day and was approved for doses of up to 54mg/day. However in 2004 the drug's indication was revised to reflect an increase in the maximum dosage to 72mg, making it the only methylphenidate product in the history of the FDA (and there have been many!) to receive an approval for a maximum dosage beyond (and not equal to) 60mg. One may argue that this is solely because the company introduced new clinical trial data to support this new dosage level, which would make sense at first glance. Yet in 2008 when Concerta's indication was revised again to include an adult indication, the dosage limit remained the same despite new trial data being included that spanned a dosage range of 18mg-108mg. Over time, a number of trials conducted for reasons related to FDA approval were subsequently published in the scientific literature. A 5-week randomized fixed-dose study assessed the results of 18-72mg doses, but produced mixed data in some areas due to the fixed-dose component. A 7-week open-label extension of this trial assessed a dosage range of 18-90mg with favorable results. A 7-week randomized dose-escalation trial spanned a dosage range of 36-108mg, with results that strongly supported approval of 90mg-108mg dose limits. These trials appear to have all been assessed by the FDA at the time of the approval of Concerta for adults with ADHD. Despite strong scientific evidence, similar or greater in quality to the evidence used to approve the previous adolescent dose increase to 72mg, the FDA only approved a maximum dosage of 72mg in adults. A minimum of 90mg would have been warranted given the evidence at their disposal. To add insult to injury, a one-year open-label extension of the initially-randomized 7-week dose-escalation trial produced results that were in concordance with the previous two >72mg trials and very firmly proved that sufficient clinical trial data existed to approve a limit of 90mg-108mg. The data did not just prove that these high dosages were safe and effective - it also proved that a significant portion of responders ended up at these dosages. This goes above and beyond the FDA's requirements. Yet the higher dosage forms were never approved.

Similarly strong proof of the FDA's bias against approving higher dosage forms of methylphenidate-based drugs despite strong clinical trial evidence can be found in the case of Biphentin (rebranded as Aptensio for the US market). Biphentin is a methylphenidate-based extended-release drug that has been marketed in Canada for some time now. It was approved in Canada at dosages of up to 80mg, despite Canada using the original 54mg maximum dosage in their Concerta monograph (while acknowledging in that same monograph that studies covered up to 72mg in adolescents and up to 90mg in adults - although oddly enough they omitted the fact that up to 108mg in adults was covered, and seem to have decided that they don't want to approve higher dosages in either adolescents or adults despite the evidence and FDA approval). Quite a lot of data exists to support Biphentin's safety and efficacy in dosages of up to 80mg per day. A document on the FDA site related to the drug application for Aptensio contains redacted mentions of what can only be the 80mg dosage form, indicating that the 80mg dosage form was part of the application to the FDA - and they rejected it, despite a foreign approval, years of successful use, and a avalanche of supporting data. Yet ironically, the Aptensio product monograph contains numerous mentions of the 80mg dose form in study data while simultaneously claiming that dosage forms beyond 60mg were never evaluated! The FDA didn't even bother trying to say that 60mg was the max dose (which would at least stop some of their hypocrisy), but no, they decided to lie and say that it was the maximum dosage evaluated despite the data in the monograph contradicting this!

So there's two major examples of some solid proof that the FDA doesn't give a shit about your trial data when it comes to methylphenidate (and likely other psychostimulants), and another example from a different regulatory authority (Health Canada) that did similar things with Concerta. As this shows, the decisions of these regulatory agencies are arbitrary. If they were based in fact, they would conform to the evidence - which they do not!

So again I need to wrap things up. The idea that this is just a "suggestion" is a problem, because like I said, a LOT of doctors don't understand how to RX psychostimulants, and if you don't know how to RX psychostimulants, you're going to follow the monograph. And the uncertainty in the product monographs as a whole with regards to maximum dosage contrasted against how people view maximum dosage as a much more rigid thing (as well as the non-uniformity everywhere) proves that there is a serious problem here. So, well, none of this shit is okay. Btw empirical data in the Concerta trials shows that well over 20% (like closer to twice that) require higher-than-US-monograph-maximum doses for optimal response, so exact numbers aren't necessarily just 20% (this might reflect partially impacted + fully impacted users), but even if it's actually just 20%, that's still 20% of responders that you are throwing away for no good reason. 20% isn't fringe cases only, it's one in five people, that's a LOT. Garzfoth (talk) 00:15, 3 January 2017 (UTC)

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Footnotes

I like the way the footnotes are organized in this article, keeping the clutter out of the article. —PermStrump(talk) 19:03, 30 December 2016 (UTC)

Salt/enantiomer composition

Hi - organic chemist here. I don't want to make an edit in case I'm missing something here (I'm not necessarily familiar with pharmacological conventions), but it seems a little silly to me to include both this

amphetamine sulfate

25% - stimulant

(12.5% levo; 12.5% dextro)

and this

dextroamphetamine sulfate

25% - stimulant

(0% levo; 25% dextro).

Rather than taking out the latter altogether and changing the former to

amphetamine sulfate

50% - stimulant

(12.5% levo; 37.5% dextro).

Another alternative would be to list the levo and dextro enantiomers separately, but the aforementioned suggestion seems to follow the convention used for the aspartate salt. --129.10.29.29 (talk) 00:16, 14 March 2018 (UTC)