What is the recommended dosage and usage of Vyvanse (lisdexamfetamine) for treating Attention Deficit Hyperactivity Disorder (ADHD) and binge eating disorder?

Vyvanse (Lisdexamfetamine) Dosage and Usage

For ADHD, start with 30 mg once daily in the morning and titrate by 10-20 mg weekly up to a maximum of 70 mg daily; for binge eating disorder, start with 30 mg daily and titrate by 20 mg weekly to a target dose of 50-70 mg daily (maximum 70 mg). 1

ADHD Treatment

Dosing Protocol

• Starting dose: 30 mg once daily in the morning for adults and children ≥6 years 1
• Titration: Increase by 10-20 mg increments at approximately weekly intervals 1
• Maximum dose: 70 mg once daily 1
• Administration timing: Morning dosing only; avoid afternoon doses due to insomnia risk 1

Line of Therapy Considerations

• In the United States: Lisdexamfetamine is approved as first-line therapy 2
• In many European countries: It is approved as second-line therapy after methylphenidate 2
• After methylphenidate failure: Lisdexamfetamine should be preferred as the next option over non-stimulants 2
• Stimulants generally: Recommended as first-line therapy with large effect sizes for reducing ADHD core symptoms 2

Key Advantages

• Duration of action: Efficacy demonstrated at 14 hours post-dose in adults 3
• Abuse potential: Lower abuse potential compared to other stimulants due to prodrug formulation, making it potentially preferable in adolescents 4
• Rapid onset: Treatment effects begin quickly 2

Binge Eating Disorder Treatment

Dosing Protocol

• Starting dose: 30 mg once daily in the morning 1
• Titration: Increase by 20 mg increments at approximately weekly intervals 1
• Target dose: 50-70 mg daily 1
• Maximum dose: 70 mg daily 1

Evidence Base

• FDA approval: Lisdexamfetamine is the only FDA-approved medication for moderate to severe BED in adults 1, 5, 6
• Efficacy: The 50 mg and 70 mg doses demonstrated significant reductions in binge eating days per week compared to placebo 7
• Cessation rates: 4-week binge eating cessation was achieved in 42.2% with 50 mg and 50.0% with 70 mg versus 21.3% with placebo 7
• Long-term data: Efficacy maintained up to 52 weeks with marked reduction in relapse risk 5

Treatment Position

• First-line consideration: Psychotherapy (CBT or interpersonal therapy) is recommended first-line 2
• Medication role: The American Psychiatric Association suggests lisdexamfetamine for adults who prefer medication or have not responded to psychotherapy alone 2
• Alternative options: Antidepressants are also suggested as alternatives 2

Administration Methods

Capsule Administration Options 1

• Swallow whole, OR
• Open capsule and mix contents with yogurt, water, or orange juice:
  • Break apart any compacted powder with a spoon
  • Mix until completely dispersed
  • Consume entire mixture immediately (do not store)
  • A film of inactive ingredients may remain after consumption

Important Administration Rules 1

• Take with or without food
• Do not divide a single dose
• Minimum dose is one capsule per day
• Can substitute with Vyvanse chewable tablets on a mg-per-mg basis

Monitoring Requirements

Pre-Treatment Screening 1

• Cardiac assessment: Careful history, family history of sudden death or ventricular arrhythmia, and physical examination
• Tic assessment: Evaluate family history and clinically assess for motor/verbal tics or Tourette's syndrome

During Treatment 2

• Height and weight: Monitor regularly due to appetite suppression
• Vital signs: Blood pressure and pulse (stimulants increase both)
• Sleep disturbances: Common adverse effect requiring monitoring

Safety Profile and Adverse Effects

Common Treatment-Emergent Adverse Events 5, 7

• Most frequent: Dry mouth, headache, insomnia
• Generally: Mild to moderate intensity
• Discontinuation: Adverse events infrequently led to study drug discontinuation

Serious Warnings 1

• Boxed Warning: High potential for abuse, misuse, and addiction
• Overdose risk: Increased with higher doses or unapproved administration methods (snorting, injection)
• Not for weight loss: Use of sympathomimetic drugs for weight loss has been associated with serious cardiovascular adverse events

Weight Effects

• In BED trials: Mean weight loss of 3.1-4.9 kg with treatment versus 0.1 kg with placebo 7
• In ADHD: Decreased appetite is a major adverse effect requiring weight monitoring 2

Special Populations

Pediatric Considerations

• Age restriction: Approved for ADHD in children ≥6 years 1
• Young children (<6 years): Experience more long-term weight loss than older patients 1
• Adolescents: May be preferred due to lower abuse potential from prodrug formulation 4

Pregnancy

• Placental transfer: Amphetamines cross the placental barrier 4
• Malformation risk: No association with major congenital malformations or cardiac malformations 4
• Possible risks: Small increased risk for gastroschisis (aOR 3.0) and preeclampsia (aRR 1.29) 4
• Preterm birth: Continued use in second half of pregnancy may increase risk (aRR 1.30) 4
• Neonatal monitoring: Monitor infants for irritability, insomnia, and feeding difficulties 4

Clinical Pearls

Mechanism of Action

• Prodrug: Lisdexamfetamine is enzymatically converted to dextroamphetamine, predominantly by red blood cells 4, 3
• Pharmacology: Reuptake inhibition plus release of dopamine and norepinephrine 2

Controlled Substance Status

• DEA classification: Controlled substance requiring careful prescribing practices 2
• Abuse assessment: Assess each patient's risk for abuse, misuse, and addiction before prescribing and throughout treatment 1