What is the recommended titration schedule for Vyvanse (lisdexamfetamine) for Attention Deficit Hyperactivity Disorder (ADHD)?

Vyvanse Titration for ADHD

Start Vyvanse at 30 mg once daily in the morning, then increase by 10-20 mg weekly based on clinical response and tolerability, with a target dose of 50-70 mg/day and a maximum of 70 mg/day. 1

Initial Dosing

• Begin with 30 mg once daily every morning for both adults and pediatric patients 6 years and older 1
• Administer in the morning to minimize sleep disturbances 2
• Confirm the patient has no contraindications, particularly cardiac disease, before initiating treatment 1

Titration Schedule

• Increase by 10 mg or 20 mg at weekly intervals based on symptom control and side effect profile 1
• The American Academy of Child and Adolescent Psychiatry recommends maintaining weekly contact (by telephone is acceptable) during the initial titration phase 2
• Titration typically requires 2-4 weeks to reach optimal dosing 2
• Allow at least one week between dose adjustments to accurately assess both therapeutic response and adverse effects 2

Target and Maximum Doses

• The recommended therapeutic dose range is 30-70 mg per day 1
• Maximum dose is 70 mg/day for patients with normal renal function 1
• For severe renal impairment: maximum dose is 50 mg/day 1
• For end-stage renal disease (ESRD): maximum dose is 30 mg/day 1

Monitoring During Titration

Before each dose increase, systematically assess:

• Clinical response using standardized ADHD rating scales from both parents and teachers (for pediatric patients) or from the patient and significant others (for adults) 2
• Vital signs, particularly blood pressure and heart rate, as stimulants can increase both 2
• Specific side effects by directly asking about insomnia, decreased appetite, headaches, weight loss, irritability, and anxiety 2
• Weight at each visit to objectively measure appetite suppression effects 3

When to Stop Titration

• Stop increasing the dose when adequate symptom control is achieved 2
• Stop if intolerable side effects develop 2
• If the maximum dose of 70 mg is reached without adequate symptom control, consider switching to a different stimulant formulation or adding a non-stimulant medication like atomoxetine 4

Follow-Up Schedule

• Weekly contact (in-person or by phone) during initial titration 2
• After stabilization, schedule follow-up appointments at least monthly until symptoms are fully stabilized 2
• Continue regular monitoring for signs of abuse, misuse, or addiction throughout treatment 1

Critical Pitfalls to Avoid

• Never start at too high a dose (above 30 mg), as this leads to unnecessary side effects and decreased medication adherence 2
• Never increase doses more frequently than weekly, as insufficient time between adjustments prevents accurate assessment of response 3
• Never fail to systematically assess both benefits and side effects during each titration step—this is the most common error leading to inappropriate medication adjustments 2
• Never overlook morning administration timing, as evening doses significantly increase insomnia risk 2
• Never neglect cardiac screening before initiating treatment, particularly in patients with known or suspected cardiac disease 1

Special Considerations for Older Adults

• Older adults may be more sensitive to both therapeutic and adverse effects due to age-related pharmacokinetic changes 4
• Consider a more conservative titration schedule in older adults, such as increasing by 10 mg every 2 weeks instead of weekly 4
• Monitor vital signs particularly carefully in this population 4