Perioperative Management of Lisdexamfetamine
Lisdexamfetamine should be continued up to the day of surgery, including the morning of the operation.
Rationale for Continuation
Lisdexamfetamine (Vyvanse) is an amphetamine-based medication commonly used to treat ADHD and other conditions. According to the Mayo Clinic Proceedings guidelines, amphetamines should be continued perioperatively 1. This recommendation is based on several important considerations:
- Amphetamines do not block the action of full mu agonists but rather act synergistically with them 1
- Abrupt discontinuation may lead to withdrawal symptoms that could complicate perioperative management
- There is evidence supporting the safety of continuing amphetamines during surgery 2
Pharmacological Considerations
Lisdexamfetamine is a prodrug that is converted to dextroamphetamine after ingestion 3. Key characteristics include:
- Long-acting formulation with once-daily dosing 4
- Gradual release of active d-amphetamine through rate-limited hydrolysis 3
- Half-life that supports continuation rather than requiring discontinuation
Unlike other stimulants such as phentermine (which should be discontinued 4 days before surgery due to risks of refractory hypotension) 5, lisdexamfetamine has not been associated with significant anesthetic complications when continued perioperatively.
Perioperative Management Approach
Preoperative Phase
- Continue lisdexamfetamine at the usual dose on the morning of surgery 1
- Inform the anesthesiologist about the medication to ensure appropriate monitoring
- Document the dose and timing of the last dose in the preoperative assessment
Intraoperative Considerations
- Monitor for potential interactions with anesthetic agents
- Be prepared for possible hemodynamic changes, though these are not commonly reported with lisdexamfetamine
- Consider multimodal analgesia approaches that may work synergistically
Postoperative Phase
- Resume regular dosing schedule as soon as the patient can take oral medications
- Monitor for return of ADHD symptoms if doses are missed during recovery
Special Considerations
- Patients with cardiovascular disease: Exercise additional caution with monitoring, but continuation is still generally recommended
- Patients on multiple psychotropic medications: Consider potential drug interactions, especially with serotonergic agents 1
- Patients with substance use disorders: Differentiate between therapeutic use of prescribed lisdexamfetamine (which should be continued) versus non-prescribed amphetamine use
Conclusion
The evidence supports continuing lisdexamfetamine up to and including the day of surgery. This approach minimizes the risk of withdrawal symptoms and maintains therapeutic effects while not significantly increasing anesthetic risks. The 2021 Mayo Clinic Proceedings guidelines specifically recommend continuation of amphetamine-based medications perioperatively 1, and case series have demonstrated the safety of this approach 2.