What is the recommended propranolol (beta-blocker) dosing for a patient experiencing palpitations after taking the first dose of Vyvanse (lisdexamfetamine)?

Management of Palpitations After First Dose of Vyvanse: Propranolol Dosing

For a patient experiencing palpitations after taking the first dose of Vyvanse (lisdexamfetamine), propranolol should be administered at 0.5-1 mg intravenously over 1 minute, which can be repeated up to a total dose of 0.1 mg/kg if required. 1

Immediate Management

When a patient presents with palpitations after taking Vyvanse, follow this approach:

1. Initial assessment: Determine if the patient is stable or unstable

   • If unstable (hypotension, altered mental status): Immediate intervention required
   • If stable with symptomatic palpitations: Proceed with medication management

2. First-line propranolol dosing:

   • IV administration: 0.5-1 mg over 1 minute 1
   • Can be repeated every 5 minutes as needed
   • Maximum total dose: 0.1 mg/kg (typically not exceeding 5-10 mg in most adults)

3. Oral propranolol alternative:

   • For less severe symptoms: 10-20 mg orally
   • Can be titrated up to 40-160 mg in divided or single dose with long-acting formulations 1
   • Maximum daily dose: 160 mg when using standard formulation

Monitoring and Precautions

• Vital sign monitoring: Check blood pressure and heart rate before each dose and 5-10 minutes after administration

• Contraindications: Avoid in patients with:

  • Asthma or obstructive airway disease
  • Decompensated heart failure
  • AV block greater than first degree
  • Severe bradycardia 1

• Warning signs to monitor:

  • Hypotension
  • Bradycardia
  • Bronchospasm
  • Worsening heart failure symptoms

Ongoing Management

For patients requiring continued management of stimulant-induced palpitations:

• Maintenance dosing:

  • 30-60 mg daily in divided doses or single dose with long-acting formulations
  • Adjust based on symptom control and tolerability 1

• Alternative options if propranolol is contraindicated:

  • Metoprolol: 5 mg IV over 1-2 minutes, repeated as required every 5 minutes to maximum 15 mg 1
  • Atenolol: 5 mg IV over 5 minutes, repeat 5 mg in 10 minutes if symptoms persist 1

Special Considerations

• Stimulant interaction: Beta-blockers effectively counteract the peripheral sympathetic effects of stimulants like Vyvanse
• Duration of therapy: Consider short-term use until patient adapts to Vyvanse or Vyvanse dosing is adjusted
• Timing: For preventive use, administer propranolol 30-60 minutes before Vyvanse

Common Pitfalls

• Overtreatment: Excessive beta-blocker dosing can cause significant bradycardia or hypotension
• Undertreatment: Inadequate dosing may fail to control symptoms
• Abrupt discontinuation: Never stop beta-blockers abruptly as this can lead to rebound tachycardia
• Overlooking anxiety: Some patients may have anxiety-induced palpitations exacerbated by stimulants, which may respond well to propranolol 2

By following this protocol, you can effectively manage palpitations in patients starting Vyvanse therapy while minimizing adverse effects from both medications.