What is Vyvanse (lisdexamfetamine) used for and what are its dosing recommendations?

Vyvanse (Lisdexamfetamine): Uses and Dosing Recommendations

Vyvanse (lisdexamfetamine) is primarily used for treating attention-deficit/hyperactivity disorder (ADHD) in both children and adults, with a recommended starting dose of 20-30 mg once daily in the morning, which can be titrated up weekly by 10 mg increments to a maximum of 70 mg daily. 1

Primary Indications

Vyvanse is FDA-approved for:

• ADHD in children (6-12 years), adolescents, and adults
• Moderate to severe binge eating disorder (BED) in adults 2

Pharmacology

Lisdexamfetamine is a unique prodrug stimulant with several important characteristics:

• It is pharmacologically inactive until enzymatically converted to d-amphetamine and the amino acid lysine 3
• Conversion occurs primarily via red blood cells, providing more consistent drug delivery 3
• The prodrug formulation results in decreased potential for misuse, diversion, and overdose compared to immediate-release stimulants 4
• It works by inhibiting dopamine and norepinephrine transporters and promoting neurotransmitter release 5

Dosing Guidelines

For ADHD:

• Starting dose: 20-30 mg once daily in the morning 1
• Titration: Increase by 10 mg weekly 1
• Maximum dose: 70 mg daily 1
• Administration: Once-daily oral dosing, which improves medication adherence compared to multiple daily doses 1

Special Populations:

1. Children (6-12 years):

   • Same dosing protocol as adults
   • Clinical trials have demonstrated significant improvements in ADHD symptoms 4

2. Adolescents:

   • Lisdexamfetamine is considered one of the stimulant medications with lower abuse potential, making it a preferred option for adolescents 1
   • Provides extended symptom control, which may be beneficial for driving safety in adolescents with ADHD 1

3. Pregnancy and Breastfeeding:

   • Limited published information specifically on lisdexamfetamine in pregnancy
   • As a prodrug of dextroamphetamine, amphetamine safety data may apply
   • Amphetamines generally do not appear to be associated with major congenital malformations 1
   • For breastfeeding, monitor infants for irritability, insomnia, and feeding difficulties 1

Clinical Efficacy

• Provides symptom control for up to 14 hours post-dose in adults 3
• Significantly improves ADHD rating scales, Clinical Global Improvement scores, and executive function 3
• In BED, significantly reduces binge eating days/week compared to placebo 2

Common Adverse Effects

• Decreased appetite and weight loss
• Sleep disturbances/insomnia
• Headaches
• Dry mouth
• Increased blood pressure and pulse 1

Monitoring Recommendations

• Height and weight (particularly in children)
• Blood pressure and pulse
• Sleep quality
• Appetite and nutritional status 1

Clinical Pearls

1. Advantages over other stimulants:

   • Once-daily dosing improves adherence
   • Lower abuse potential due to prodrug formulation
   • Extended duration of action (up to 14 hours) 3

2. Common pitfalls to avoid:

   • Not monitoring vital signs regularly
   • Failing to assess for substance abuse before prescribing to adolescents 1
   • Not providing adequate coverage for symptom control during critical activities like driving for adolescents 1

3. Alternative options:

   • If stimulants are contraindicated, non-stimulants like atomoxetine, guanfacine, or clonidine may be considered, though they generally have smaller effect sizes 1
   • For patients with comorbid substance use disorders, non-stimulants may be preferred as first-line options 1

Vyvanse represents an important treatment option for ADHD with its prodrug formulation providing extended symptom control with reduced abuse potential compared to immediate-release stimulants.