What are the next steps for a 12-year-old child experiencing angry outbursts while taking Vyvanse (lisdexamfetamine)?

From the Guidelines

If a 12-year-old child is experiencing angry outbursts while taking Vyvanse, the most appropriate next step is to contact their healthcare provider immediately to discuss these side effects and consider adjusting the treatment plan, which may include reducing the current Vyvanse dosage, switching to a different stimulant medication, or adding a mood stabilizer such as divalproex sodium, as suggested by the study published in the Journal of the American Academy of Child and Adolescent Psychiatry 1. The healthcare provider may recommend several options, including reducing the current Vyvanse dosage or switching to a different stimulant medication like Concerta or Adderall.

• The provider may also consider adding a mood stabilizer such as divalproex sodium, which has been shown to be effective in reducing aggressive outbursts in children with ADHD, as reported in the study by Donovan et al. 1.
• Additionally, the provider may suggest trying a non-stimulant alternative such as Strattera (atomoxetine) or Intuniv (guanfacine), which can help alleviate ADHD symptoms without exacerbating angry outbursts. While waiting for medical advice, parents should document when these outbursts occur, particularly noting if they happen as the medication wears off in the afternoon (known as "rebound irritability").
• Ensuring the child gets adequate sleep, regular meals, and consistent routines may help minimize these reactions, as suggested by the clinical practice guideline published in Pediatrics 1.
• The American Academy of Pediatrics recommends that children with ADHD receive a comprehensive treatment plan that includes medication, behavioral therapy, and educational interventions, as outlined in the clinical practice guideline 1. These angry outbursts occur because stimulant medications like Vyvanse (lisdexamfetamine) affect brain chemicals like dopamine and norepinephrine, which can sometimes intensify emotions or lower frustration tolerance in some children.
• Medication adjustments often resolve these issues, as finding the right ADHD medication and dosage frequently requires some trial and error, as noted in the practice parameter on the use of psychotropic medication in children and adolescents published in the Journal of the American Academy of Child and Adolescent Psychiatry 1.

From the FDA Drug Label

Psychiatric Adverse Reactions: Prior to initiating lisdexamfetamine dimesylate capsules, screen patients for risk factors for developing a manic episode. If new psychotic or manic symptoms occur, consider discontinuing lisdexamfetamine dimesylate capsules. (5. 4) Mental (psychiatric) problems, including: new or worse behavior and thought problems new or worse bipolar illness new psychotic symptoms (such as hearing voices, or seeing or believing things that are not real) or new manic symptoms Tell your healthcare provider about any mental problems you or your child have or about a family history of suicide, bipolar illness, or depression Call your healthcare provider right away if you or your child have any new or worsening mental symptoms or problems during treatment with lisdexamfetamine dimesylate capsules, especially hearing voices, seeing or believing things that are not real, or new manic symptoms.

The next steps for a 12-year-old child experiencing angry outbursts while on Vyvanse (lisdexamfetamine) would be to:

• Monitor the child's behavior and mental status closely
• Inform the healthcare provider about the angry outbursts and any other new or worsening mental symptoms
• Consider discontinuing lisdexamfetamine dimesylate capsules if the symptoms are severe or worsening 2
• Seek immediate medical attention if the child experiences any signs of serious psychiatric problems, such as suicidal thoughts or behaviors 2

From the Research

Next Steps for a 12-Year-Old Child with Angry Outbursts While on Vyvanse

• The child's angry outbursts while on Vyvanse (lisdexamfetamine dimesylate) may be a treatment-emergent adverse event, as irritability is a common side effect of the medication, reported in 8.5% of subjects in one study 3.
• It is essential to monitor the child's behavior and adjust the treatment plan as needed, as lisdexamfetamine dimesylate has been shown to improve executive function behaviors and ADHD symptoms in adults 3, 4, 5.
• A multimodal treatment approach, involving both pharmacological and psychological measures, may be the best management approach for the child's ADHD, as recommended by clinical guides 6.
• The child's frustration tolerance may improve with the use of lisdexamfetamine dimesylate, as significant improvement in frustration tolerance was observed in a study of children with ADHD 7.
• Behavioral modification may also be beneficial in addressing the child's angry outbursts, as it appears to have an additive effect in extending the duration of frustration tolerance 7.

Considerations for Treatment Adjustment

• The child's treatment plan may need to be adjusted to minimize the occurrence of angry outbursts, which could involve adjusting the dose of lisdexamfetamine dimesylate or adding behavioral therapy to the treatment plan.
• Close monitoring of the child's behavior and adjustment of the treatment plan as needed can help to minimize the risk of treatment-emergent adverse events, such as irritability.
• The use of lisdexamfetamine dimesylate in children with ADHD has been shown to be effective in improving symptoms, but it is essential to weigh the benefits and risks of treatment and adjust the plan accordingly 7, 6.