What can be done for Vyvanse (lisdexamfetamine) wearing off in the afternoon?

Managing Vyvanse Wearing Off in the Afternoon

For patients experiencing Vyvanse (lisdexamfetamine) wearing off in the afternoon, adding a small dose of immediate-release stimulant medication in the early afternoon is the most effective solution to extend coverage through the remainder of the day. 1

Understanding the Problem

Vyvanse is a long-acting prodrug stimulant that is converted to its active form (d-amphetamine) primarily in the blood. While designed to provide extended coverage, its effects typically last about 13-14 hours in clinical studies 2, 3, but many patients experience a decline in effectiveness before this time.

The pharmacokinetics explain this issue:

• Vyvanse is enzymatically hydrolyzed to d-amphetamine and l-lysine 4
• Peak plasma concentrations of d-amphetamine occur around 3-3.5 hours after dosing 5
• Effects gradually diminish as blood levels decrease later in the day

Management Options

1. Add a Small Afternoon Booster Dose

• First-line approach: Add a small dose (2.5-5 mg) of immediate-release methylphenidate or amphetamine when Vyvanse begins to wear off 1
• Timing is crucial:
  • Administer no later than 2:00 PM to avoid interfering with sleep
  • Give approximately when symptoms begin to return
• Start with the lowest effective dose to minimize side effects

2. Split Dosing of Vyvanse

• Take a smaller second dose of Vyvanse in the early afternoon 1
• Note: This approach is less common since:
  • Vyvanse capsules cannot be divided (per FDA labeling) 5
  • Requires a separate prescription for a lower-dose capsule
  • May have more variable absorption with afternoon dosing

3. Dose Adjustment of Morning Vyvanse

• Consider increasing the morning Vyvanse dose if currently below the maximum (70 mg daily) 5
• Dosage may be adjusted in increments of 10-20 mg at weekly intervals 5
• Higher doses may extend duration but also increase risk of side effects

Monitoring and Managing Side Effects

When adding an afternoon dose:

• Sleep disturbances: Monitor for insomnia, which may worsen with extended stimulant coverage 1
• Appetite suppression: May further reduce appetite throughout the day; encourage high-calorie snacks or drinks when medication effects wear off in the evening 1
• Rebound irritability: Watch for irritability as medication effects diminish; overlapping dosing patterns can provide smoother transitions 1
• Cardiovascular effects: Monitor blood pressure and heart rate, as stimulants can cause increases in these values 1

Behavioral and Lifestyle Interventions

Implement these alongside medication adjustments:

• Establish a regular sleep schedule to minimize exacerbation of ADHD symptoms 1
• Limit caffeine intake to avoid worsening symptoms (generally <300 mg/day) 1
• Incorporate structured physical activity (≥150 minutes/week) combining aerobic and resistance exercise, which improves executive functioning 1
• Consider cognitive-behavioral therapy specifically adapted for ADHD 1

Follow-Up Recommendations

• Schedule follow-up visits every 3-4 weeks during the initial treatment phase 1
• Once stable, follow-up every 3-6 months using standardized rating scales to monitor symptoms 1
• Regularly assess appetite, weight, sleep patterns, and mood changes 1

Important Considerations

• Avoid afternoon dosing of Vyvanse itself, as the FDA label specifically states to "avoid afternoon doses because of the potential for insomnia" 5
• Remember that Vyvanse is a controlled substance with potential for abuse and misuse 5
• For patients with severe renal impairment, maximum Vyvanse dosage should not exceed 50 mg daily 5

By implementing these strategies, most patients experiencing afternoon wear-off with Vyvanse can achieve more consistent symptom control throughout the day while minimizing side effects.