What are the next steps for treating Attention Deficit Hyperactivity Disorder (ADHD) in a patient who has not responded to Vyvanse (lisdexamfetamine) 70mg and is currently taking Adderall (amphetamine and dextroamphetamine) with a duration of action of only about 4 hours?

Treatment Options for ADHD with Inadequate Response to Vyvanse and Short-Duration Adderall

For a patient with ADHD who has not responded to Vyvanse 70mg and is experiencing only 4 hours of efficacy with Adderall, switching to a different stimulant formulation or adding a non-stimulant medication like atomoxetine is recommended.

Assessment of Current Treatment Response

• Evaluate whether the patient is consistently taking the current dose of Adderall and rule out other factors contributing to perceived lack of efficacy, such as sleep issues or comorbid conditions 1
• The short duration of action (4 hours) with Adderall suggests a need for either a longer-acting formulation or a different medication approach 2
• Consider that the patient has already tried lisdexamfetamine (Vyvanse) at maximum dose (70mg) without improvement, indicating a possible non-response to amphetamine-based stimulants 2

Next-Step Treatment Options

Option 1: Switch to Methylphenidate Formulations

• Methylphenidate should be considered as the next option when amphetamine-based medications (Vyvanse, Adderall) have not been effective 2
• Different extended-release formulations of methylphenidate allow for individualization of treatment with potentially longer duration of action 2
• Consider OROS methylphenidate (Concerta) which provides up to 12 hours of coverage with once-daily dosing 2
• Start with low doses of methylphenidate (5-10mg) and titrate upward in 5-10mg intervals weekly until symptoms are controlled 2

Option 2: Non-Stimulant Medications

• Atomoxetine is recommended as a second-line therapy when stimulants have failed to provide adequate symptom control 2
• Atomoxetine provides "around-the-clock" effects rather than time-limited coverage 2
• Starting dose for adults over 70kg is 40mg daily, increased after a minimum of 3 days to a target dose of 80mg daily, with a maximum of 100mg daily 3
• Allow 6-12 weeks to observe full therapeutic effects with atomoxetine 2

Option 3: Combination Therapy

• Consider combining a stimulant with a non-stimulant medication if monotherapy is inadequate 2
• The combination of atomoxetine with a stimulant may provide more comprehensive symptom control throughout the day 2
• This approach addresses both the need for immediate symptom control (stimulant) and continuous coverage (non-stimulant) 1

Optimizing Current Adderall Treatment

If continuing with Adderall:

• Consider switching to Adderall XR (extended-release) which provides 12-hour coverage with a single morning dose 4
• Add a second dose of immediate-release Adderall in the afternoon to extend coverage beyond the 4-hour window 2
• Maximum daily doses for adults should generally not exceed 50mg of Adderall 5
• Monitor for side effects including decreased appetite, sleep disturbances, increased blood pressure, and headaches 2, 6

Monitoring and Follow-Up

• Schedule follow-up appointments at least monthly until symptoms are stabilized 1
• Assess vital signs (blood pressure, pulse) at baseline and with each dose increase 2, 1
• Use standardized ADHD rating scales to objectively measure response to treatment 1
• Monitor for side effects with each medication adjustment 2

Common Pitfalls to Avoid

• Failing to systematically assess both benefits and side effects during medication changes 1
• Not allowing sufficient time between dose increases (at least one week) to evaluate response 1
• Overlooking the importance of morning administration of stimulants to minimize sleep disturbances 1
• Ignoring the potential for rebound symptoms when stimulant effects wear off in the afternoon/evening 2