What is the recommended approach to convert a patient from 70mg of Vyvanse (lisdexamfetamine) to 54mg of Concerta (methylphenidate)?

Switching from Vyvanse 70mg to Concerta 54mg

When switching a patient from Vyvanse 70mg to Concerta 54mg, a washout period of 24 hours is recommended, followed by starting Concerta at 54mg, with potential need for supplemental immediate-release methylphenidate to address end-of-day coverage gaps. 1

Understanding the Medication Differences

Vyvanse (lisdexamfetamine) and Concerta (methylphenidate) belong to different stimulant classes:

• Vyvanse: An amphetamine prodrug that is converted to active d-amphetamine after ingestion 2
• Concerta: A methylphenidate formulation using OROS (osmotic-release oral system) technology 3

Conversion Protocol

1. Discontinue Vyvanse

   • Allow 24 hours after the last Vyvanse dose before starting Concerta
   • This minimizes potential drug interactions while preventing significant symptom recurrence

2. Initiate Concerta

   • Start with 54mg Concerta once daily in the morning
   • Note that this may not be a fully equivalent dose (explained below)

3. Monitor for Efficacy

   • Assess symptom control throughout the day
   • Pay particular attention to late afternoon/evening coverage

4. Adjust as Needed

   • Be prepared to add immediate-release methylphenidate (5-10mg) in the afternoon if end-of-day coverage is inadequate 4
   • Up to 43% of patients switching to Concerta require supplemental immediate-release methylphenidate 4

Important Clinical Considerations

Dose Equivalence Issues

The conversion between amphetamine and methylphenidate products is not straightforward:

• 70mg of Vyvanse is approximately equivalent to 30mg of d-amphetamine 2
• Methylphenidate and amphetamine have different potencies and mechanisms of action
• Research indicates that 55% of patients require higher than mathematically equivalent doses of Concerta when switching from immediate-release methylphenidate 4

Duration of Action Differences

• Vyvanse: Provides 13-14 hours of symptom control
• Concerta: Provides 10-12 hours of coverage 3
• This difference may necessitate supplemental immediate-release methylphenidate in the late afternoon

Monitoring for Efficacy and Side Effects

Monitor for:

• Changes in symptom control throughout the day
• Appetite changes
• Sleep quality
• Mood changes
• Cardiovascular effects (heart rate, blood pressure)

Common Pitfalls to Avoid

1. Underestimating dose requirements: Many patients need higher than mathematically equivalent doses of Concerta 4

2. Ignoring end-of-day coverage: The shorter duration of Concerta compared to Vyvanse may leave a coverage gap in the evening

3. Failing to prepare the patient: Inform patients that they may experience different side effect profiles with methylphenidate vs. amphetamine products

4. Not considering alternative options: If the switch is unsuccessful after adequate trial and adjustments, consider switching back to an amphetamine-based product, as 41% of patients require switching between stimulant classes due to tolerability issues 5

Follow-up Recommendations

• Schedule follow-up within 1-2 weeks after the switch
• Use validated ADHD rating scales to objectively assess symptom control
• Be prepared to make dose adjustments or add supplemental immediate-release methylphenidate
• Consider that some patients may ultimately respond better to one stimulant class than another 5

By following this structured approach, the transition from Vyvanse 70mg to Concerta 54mg can be managed effectively while minimizing disruption to symptom control.