Transitioning from Vyvanse 70mg to Concerta
When switching from Vyvanse 70mg to Concerta, start with Concerta 54mg once daily and titrate based on clinical response, as there is no established direct dose equivalency between amphetamine-based and methylphenidate-based stimulants.
Rationale for Initial Dosing
The recommended approach involves starting at a moderate-to-high dose of Concerta given the patient's current high-dose amphetamine therapy:
- Vyvanse 70mg represents the maximum approved dose for lisdexamfetamine, indicating the patient requires substantial stimulant coverage 1
- Concerta 54mg is a reasonable starting point as it represents a moderate-to-high dose in the methylphenidate range, though clinical trials have used doses ranging from 18-54mg 2, 3
- The lack of direct cross-equivalency tables between amphetamine and methylphenidate formulations necessitates empirical dose finding 4
Transition Strategy
Direct Switch Approach (Preferred)
- Stop Vyvanse and start Concerta 54mg the next morning as a direct switch
- This approach is generally safe given both are stimulants with similar mechanisms (though different pharmacology) 4
- Monitor closely for the first week to assess adequacy of symptom control
Titration Plan
- If symptom control is inadequate on Concerta 54mg, the dose can be increased to 72mg (though this exceeds typical studied doses, it may be necessary for patients previously on maximum amphetamine doses) 2
- If side effects are problematic or the patient appears over-stimulated, reduce to Concerta 36mg and reassess 3
- Adjustments should occur at weekly intervals to allow steady-state assessment 4
Key Pharmacokinetic Differences to Discuss with Patient
- Concerta provides 12-hour coverage using an osmotic pump delivery system, with effects lasting throughout the school/work day and into early evening 2, 5
- The time course differs from Vyvanse: Concerta reaches peak effect at 1-3 hours post-dose, whereas Vyvanse (as a prodrug) has a more gradual onset 4
- Patients may notice different "feel" to the medication due to methylphenidate's dopamine reuptake blocking mechanism versus amphetamine's dopamine release properties 4
Monitoring Parameters
- Assess symptom control at multiple time points throughout the day (morning, midday, afternoon, early evening) during the first 1-2 weeks 3
- Monitor for common methylphenidate side effects: appetite suppression, insomnia, and potential increases in blood pressure and heart rate 4
- Use standardized rating scales or individualized daily report cards to objectively track response across settings 2
Common Pitfalls to Avoid
- Do not assume 1:1 dose equivalency between amphetamine and methylphenidate formulations—they are pharmacologically distinct 4
- Avoid starting too low (e.g., Concerta 18mg) in a patient on maximum-dose Vyvanse, as this will likely result in inadequate symptom control and unnecessary titration delays 3
- Do not make dose adjustments more frequently than weekly, as behavioral effects need time to stabilize 4
- Be prepared for the patient to report differences in efficacy timing—Concerta's delivery profile may provide different coverage patterns than Vyvanse 5