Choosing Between Vyvanse and Concerta for ADHD Treatment
Start with either medication as both are effective first-line stimulants, but choose Concerta (methylphenidate) first in most cases since over 70% of patients respond to methylphenidate when properly titrated, and you can reserve the amphetamine class (Vyvanse) for non-responders to maximize your treatment options. 1
Evidence-Based Selection Algorithm
Initial Medication Selection
Begin with methylphenidate-based medications (Concerta) because:
- More than 70% of children and adolescents with ADHD respond to methylphenidate when a full range of doses is systematically tried 1
- Over 90% of patients will respond to one of the psychostimulants if medications from both methylphenidate and amphetamine classes are sequentially tried 1
- This approach preserves the amphetamine class (Vyvanse) as a second-line option if methylphenidate fails 1
When to Choose Vyvanse (Lisdexamfetamine) First
Select Vyvanse as your initial medication in these specific circumstances:
- Adolescents with diversion risk: Vyvanse has lower abuse potential due to its prodrug design, making extraction of the stimulant component more difficult 2
- Patients with substance use concerns: Vyvanse's pharmacokinetic properties provide reduced abuse potential compared to immediate-release stimulants 3, 4
- History of stimulant use disorder: Lisdexamfetamine can successfully treat ADHD while potentially reducing cravings for illicit stimulants 3
Duration of Action Considerations
Match the medication's duration profile to the patient's functional needs:
- Concerta: Provides better symptom control in the early evening (12 hours post-dose), making it preferable when late-day coverage is critical 5
- Vyvanse: Offers approximately 12 hours of duration with once-daily dosing 4
- Metadate CD (another methylphenidate option): Provides superior morning control (1.5-4.5 hours post-dose) but less evening coverage than Concerta 5
Practical Titration Strategy
Response to stimulants is variable and unpredictable, requiring systematic dose titration rather than weight-based dosing: 1
Methylphenidate (Concerta) Titration
- Start low and titrate to maximum optimal effect without adverse effects 1
- Titrate on a 7-day basis (or as quickly as 3 days in urgent situations) 1
- Do not calculate dose based on mg/kg as variations are not related to height or weight 1
Lisdexamfetamine (Vyvanse) Titration
Critical Monitoring Requirements
Alert patients and families that changing medication dose or switching medications may be necessary and can require several months to achieve optimal success: 1
- Monitor medication efficacy at regular intervals 1
- Lower doses and less frequent monitoring in community settings produce inferior results compared to optimal medication management 1
Special Population Considerations
Preschool Children (Age 4-5 Years)
- Choose methylphenidate (not Vyvanse) as it has the strongest evidence for safety and efficacy in this age group, though still off-label 1
- Start with lower doses and increase in smaller increments due to slower metabolism 1
Adolescents with Diversion Risk
- Prefer Vyvanse due to lower abuse potential from its prodrug formulation 2
- Monitor prescription refill requests for signs of misuse or diversion 1
- Consider nonstimulant medications if diversion concerns are substantial 1
Breastfeeding Patients
- Methylphenidate (Concerta) is preferred with a relative infant dose less than 1% and no reported adverse effects in breastfed infants 6
- Amphetamines (Vyvanse) have higher relative infant doses but should not be stopped if required for daily functioning 6
Common Pitfalls to Avoid
Do not use inadequate doses or infrequent monitoring, as this produces significantly worse outcomes than optimal medication management 1
Do not assume one medication will work for all patients—individual response is unpredictable, requiring willingness to switch between methylphenidate and amphetamine classes 1
Do not calculate stimulant doses based on weight—titrate based on clinical response and adverse effects 1