What is the preferred treatment between Vyvanse (lisdexamfetamine) and Adderall (amphetamine and dextroamphetamine) for patients with Attention Deficit Hyperactivity Disorder (ADHD) and hypertension (HTN)?

Vyvanse vs. Adderall for ADHD Patients with Hypertension

For ADHD patients with hypertension, non-stimulant medications should be considered as first-line treatment, but if stimulants are necessary, lisdexamfetamine (Vyvanse) is preferred over amphetamine mixed salts (Adderall) due to its more predictable pharmacokinetic profile and potentially lower cardiovascular impact. 1

Treatment Algorithm for ADHD with Hypertension

First-Line Options:

1. Non-stimulant medications
   • Atomoxetine (Strattera)
   • Extended-release guanfacine (Intuniv)
   • Extended-release clonidine (Kapvay)

Second-Line Options (if non-stimulants ineffective):

1. Lisdexamfetamine (Vyvanse)
2. Methylphenidate formulations
3. Amphetamine mixed salts (Adderall) - least preferred option

Rationale for Medication Selection

Non-Stimulants as First-Line

Non-stimulants should be considered first for patients with hypertension because:

• Alpha-2 agonists (guanfacine, clonidine) can actually lower blood pressure 1, 2
• Atomoxetine has less impact on cardiovascular parameters than stimulants 1
• Non-stimulants provide "around-the-clock" effects without the blood pressure spikes associated with stimulants 1

Vyvanse vs. Adderall Comparison

If stimulants are necessary due to inadequate response to non-stimulants:

Cardiovascular Effects

• Both medications can increase blood pressure and heart rate 1
• Amphetamine compounds have been shown to increase systolic blood pressure by approximately 5.4 mm Hg 3
• Both should be avoided in patients with uncontrolled hypertension, coronary artery disease, and tachyarrhythmias 1

Pharmacokinetic Differences

• Lisdexamfetamine (Vyvanse) is a prodrug that is converted to dextroamphetamine in the bloodstream 4, 5
• This conversion results in a more gradual onset of action and more predictable blood levels 5, 6
• Adderall has a more immediate release profile that may cause more abrupt changes in blood pressure 5

Duration of Action

• Vyvanse provides a longer duration of action (up to 14 hours) with a single daily dose 7
• Adderall immediate-release requires multiple daily dosing, which can lead to more fluctuations in blood pressure 1
• Even Adderall XR has a shorter duration than Vyvanse 7

Monitoring Requirements

For patients with hypertension taking either medication:

• Baseline assessment of blood pressure, pulse, height, and weight 1, 2
• Regular monitoring of vital signs, particularly blood pressure and heart rate 2
• More frequent monitoring during dose titration periods 1
• Consider home blood pressure monitoring between office visits

Practical Considerations

Dosing

• Start with lower doses in patients with hypertension
• For Vyvanse: Start at 20-30 mg daily, increase gradually if needed 1
• For Adderall: If used, start at 5 mg daily or twice daily, with careful titration 1

Warning Signs

Monitor for:

• Significant increases in blood pressure (>140/90 mmHg)
• Symptoms such as headache, chest pain, palpitations
• Signs of cardiovascular distress

Common Pitfalls to Avoid

1. Ignoring baseline cardiovascular status - Always assess cardiovascular health before initiating stimulants
2. Inadequate monitoring - Regular blood pressure checks are essential
3. Rapid dose escalation - Gradual titration is critical for patients with hypertension
4. Overlooking non-stimulant options - These may be safer for hypertensive patients
5. Failing to consider drug interactions - Both medications can interact with antihypertensive medications

In conclusion, while both medications carry cardiovascular risks, the prodrug nature of lisdexamfetamine (Vyvanse) offers pharmacokinetic advantages that may translate to a more stable cardiovascular profile compared to Adderall in patients with hypertension. However, non-stimulant options should be thoroughly explored before resorting to any stimulant medication in this population.