Can Vyvanse (lisdexamfetamine) be initiated for eating disorder treatment in a patient with a history of illicit drug use, currently on Seroquel (quetiapine) and first-generation antipsychotics, with a psychotic disorder?

Vyvanse in Patients with Eating Disorders, History of Drug Use, and Psychosis

Vyvanse (lisdexamfetamine) should NOT be initiated for eating disorder treatment in a patient with a history of illicit drug use who is currently on Seroquel and first-generation antipsychotics with psychotic disorder due to high risk of abuse, misuse, and potential exacerbation of psychotic symptoms.

Contraindications and Risks

High Abuse Potential

• Lisdexamfetamine has a high potential for abuse and misuse which can lead to substance use disorder and addiction 1
• The FDA label explicitly warns about the risk of diversion for non-medical use, particularly concerning in patients with a history of illicit drug use 1
• Patients must be assessed for risk of abuse, misuse, and addiction before prescribing, and this patient's history of illicit drug use represents a significant risk factor 1

Psychiatric Adverse Effects

• Vyvanse can exacerbate symptoms of behavior disturbance and thought disorder in patients with pre-existing psychotic disorders 1
• CNS stimulants may cause psychotic or manic symptoms (hallucinations, delusional thinking, or mania) even in patients without prior history 1
• The risk is particularly concerning in this patient who already has a psychotic disorder and is taking antipsychotic medications 1

Drug Interactions

• Significant risk of serotonin syndrome when amphetamines are used in combination with other serotonergic drugs like antipsychotics (including quetiapine/Seroquel) 1
• Potential for pharmacodynamic antagonism between Vyvanse (stimulant) and antipsychotics (which block dopamine), potentially reducing the efficacy of both medications 2

Alternative Approaches for Eating Disorder Treatment

Evidence-Based Psychotherapy

• A multidisciplinary team approach incorporating disorder-specific psychotherapy, nutritional rehabilitation, and medical monitoring is the recommended first-line treatment for all eating disorders 3
• Cognitive-behavioral therapy (CBT) is strongly recommended as the primary treatment for eating disorders, particularly for bulimia nervosa and binge eating disorder 3

FDA-Approved Medication Options

• Fluoxetine is the only medication approved in Germany (and the US) for the treatment of bulimia nervosa 4
• For binge eating disorder specifically, lisdexamfetamine is approved in some countries but should be avoided in patients with psychosis or substance use history 2, 4

Monitoring and Management

Medical Assessment

• A thorough initial evaluation of patients with eating disorders should include vital signs, height, weight, BMI calculations, physical examination, laboratory testing, and electrocardiogram 3
• Laboratory assessment should include complete blood count, comprehensive metabolic panel, and electrolyte monitoring 3

Treatment Goals

• The primary goal of treatment for binge eating disorder is reduction in binge eating episodes, not weight loss 3
• Treatment should include eating disorder-focused psychotherapy that normalizes eating behaviors, restores weight, and addresses psychological aspects 3

Key Considerations

• The combination of a history of illicit drug use, current psychotic disorder, and concurrent antipsychotic medications creates multiple absolute contraindications to Vyvanse use
• The risk of abuse, addiction, and exacerbation of psychosis outweighs potential benefits for eating disorder treatment in this specific patient population
• Focus should remain on optimizing the current antipsychotic regimen while adding evidence-based psychotherapy for the eating disorder

In conclusion, initiating Vyvanse in this patient would pose significant risks with minimal potential benefit. Alternative non-stimulant approaches to eating disorder treatment should be pursued.