What should be monitored in patients taking Vyvanse (lisdexamfetamine)?

Monitoring Parameters for Vyvanse (Lisdexamfetamine)

Patients taking Vyvanse require systematic monitoring of cardiovascular parameters, growth metrics in pediatric patients, psychiatric symptoms, and signs of abuse or misuse throughout treatment. 1

Cardiovascular Monitoring

Blood pressure and heart rate must be monitored regularly, as CNS stimulants cause mean increases of 2-4 mmHg in blood pressure and 3-6 bpm in heart rate, with some patients experiencing larger increases. 1

• Monitor all patients for potential tachycardia and hypertension at each visit 1
• Before initiating treatment, obtain baseline blood pressure and heart rate measurements 1
• Patients with pre-existing cardiac conditions require heightened vigilance, as sudden death has been reported in patients with structural cardiac abnormalities treated with CNS stimulants at recommended ADHD dosages 1

Growth Monitoring in Pediatric Patients

Weight and height must be closely monitored in pediatric patients, as CNS stimulants are associated with weight loss and slowing of growth rate. 1

• Monitor weight and height at baseline and regularly throughout treatment 1
• In a 4-week placebo-controlled trial, lisdexamfetamine caused dose-related weight decrease in pediatric patients ages 6-12 years 1
• Patients not growing or gaining weight as expected may need treatment interruption 1
• Growth suppression studies in juvenile animals showed effects that only partially reversed after drug discontinuation, particularly in males 1

Psychiatric Symptom Monitoring

Screen for and monitor psychiatric symptoms including psychosis, mania, and behavioral disturbances before and during treatment. 1

• Before initiating treatment, screen patients for risk factors for developing manic episodes (comorbid or history of depressive symptoms, family history of suicide, bipolar disorder, or depression) 1
• CNS stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with pre-existing psychotic disorders 1
• At recommended dosages, psychotic or manic symptoms (hallucinations, delusional thinking, mania) occurred in approximately 0.1% of CNS stimulant-treated patients in pooled analyses 1
• If psychotic or manic symptoms occur, consider discontinuing lisdexamfetamine 1

Monitoring for Tics and Tourette's Syndrome

Assess family history and clinically evaluate patients for tics or Tourette's syndrome before initiating treatment, then regularly monitor for emergence or worsening. 1

• CNS stimulants have been associated with onset or exacerbation of motor and verbal tics 1
• Discontinue treatment if tics or Tourette's syndrome emerge or worsen and this is clinically appropriate 1

Peripheral Vasculopathy Monitoring

Careful observation for digital changes is necessary during treatment, as CNS stimulants are associated with peripheral vasculopathy including Raynaud's phenomenon. 1

• Signs and symptoms are usually intermittent and mild but can include digital ulceration and soft tissue breakdown 1
• These effects have been observed at therapeutic dosages in all age groups throughout treatment 1
• Symptoms generally improve after dosage reduction or discontinuation 1
• Patients developing signs or symptoms may require further clinical evaluation (e.g., rheumatology referral) 1

Monitoring for Abuse, Misuse, and Addiction

Throughout treatment, reassess each patient's risk of abuse, misuse, and addiction, and frequently monitor for signs and symptoms of these behaviors. 1

• Lisdexamfetamine has high potential for abuse and misuse which can lead to substance use disorder 1
• The medication can be diverted for non-medical use into illicit channels 1
• Despite being a prodrug with theoretically lower abuse potential, vigilant monitoring remains essential 2

Serotonin Syndrome Monitoring

When lisdexamfetamine is used with other serotonergic drugs or CYP2D6 inhibitors, monitor patients for emergence of serotonin syndrome during drug initiation or titration. 1

• Symptoms include mental status changes (agitation, hallucinations, delirium, coma), autonomic instability (tachycardia, labile blood pressure, hyperthermia), neuromuscular symptoms (tremor, rigidity, myoclonus), seizures, and gastrointestinal symptoms 1
• Discontinue lisdexamfetamine immediately if serotonin syndrome occurs 1
• Concomitant use with MAOIs is contraindicated 1

Common Pitfalls to Avoid

• Do not assume cardiovascular monitoring is unnecessary in young, healthy patients - all patients require blood pressure and heart rate monitoring regardless of baseline cardiac health 1
• Do not overlook growth monitoring in adolescents - growth suppression can occur throughout the pediatric age range, not just in younger children 1
• Do not dismiss mild psychiatric symptoms - early identification allows for intervention before symptoms become severe enough to require discontinuation 1
• Do not forget to inquire about over-the-counter sympathomimetic medications - pseudoephedrine and phenylephrine can cause hypertensive crisis when combined with lisdexamfetamine due to potential MAO inhibition 1