Is it okay to prescribe stimulants, Vyvanse (lisdexamfetamine) 50 Mg twice a day (BID) and Adderall (amphetamine) 15 Mg daily, alongside Abilify (aripiprazole) 5 Mg, for a patient with autism?

Concurrent Use of Multiple Stimulants with Aripiprazole in Autism

The concurrent use of Vyvanse 50 mg BID and Adderall 15 mg daily is not recommended due to the risk of additive stimulant effects, potential for increased side effects, and lack of evidence supporting this combination. 1

Medication Combinations and Safety Concerns

The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters provide clear guidance on medication combinations:

• While combining medications from different classes may be appropriate for treating multiple disorders in the same patient, there is limited support for combining medications from the same class 1
• Using two stimulant formulations is only recommended when "sculpting" dosing for coverage throughout the day (e.g., combining short and long-acting forms of the same medication) 1
• Vyvanse (lisdexamfetamine) and Adderall (amphetamine) are both amphetamine-based stimulants, making this an inappropriate combination 1, 2

Appropriate Stimulant Use in Autism

For patients with autism who require stimulant medication:

• A single stimulant medication should be used at an appropriate dose:
  • Amphetamine starting dose: 5-10 mg daily
  • Maximum amphetamine daily dose: up to 50 mg daily 2
• Vyvanse 50 mg twice daily (100 mg total) exceeds the recommended maximum daily dose 2
• The addition of Adderall 15 mg further increases the total amphetamine load beyond safe limits

Aripiprazole Use in Autism

Aripiprazole is appropriate for treating irritability associated with autism:

• FDA-approved for treating irritability in autism spectrum disorders 3
• Effective for reducing irritability, hyperactivity, and stereotypies in children/adolescents with autism 3, 4
• Typical dose range is 5-15 mg/day for irritability in autism 1

Recommended Approach

1. Choose a single stimulant medication:

   • Either Vyvanse OR Adderall at an appropriate dose, not both
   • For extended coverage, consider a long-acting formulation with a small "booster" dose of the same medication if needed 2

2. Maintain aripiprazole for irritability:

   • Continue aripiprazole 5 mg for managing autism-related irritability
   • Monitor for potential side effects including weight gain, sedation, and tremor 3

3. Monitor for drug interactions:

   • Even with a single stimulant plus aripiprazole, monitor for:
     • Cardiovascular effects (blood pressure, heart rate)
     • Weight changes
     • Sleep disturbances
     • Emergence of tics or psychiatric symptoms 2

Common Pitfalls to Avoid

• Using multiple stimulants simultaneously increases risk of side effects without clear additional benefit 1
• Exceeding maximum recommended daily doses of stimulants increases cardiovascular and neuropsychiatric risks 1
• Failing to periodically reassess the need for continued medication treatment 3
• Not monitoring for metabolic effects of aripiprazole, which are often underemphasized 5

Following these guidelines will help ensure safe and effective pharmacological management for patients with autism who require both stimulant medication and aripiprazole.