Would you prescribe Vyvanse (lisdexamfetamine) for Attention Deficit Hyperactivity Disorder (ADHD) to a patient with bipolar type 1 disorder who is controlled with medication?

Prescribing Vyvanse for ADHD in Controlled Bipolar Type 1

Yes, you can prescribe Vyvanse (lisdexamfetamine) for ADHD in a patient with bipolar type 1 disorder who is controlled on mood stabilizers, but only after ensuring the patient is on adequate combination therapy for bipolar disorder (mood stabilizer plus antipsychotic) and the mood symptoms are fully stabilized. 1

Prerequisites Before Initiating Vyvanse

Do not initiate any ADHD medication until bipolar symptoms are well-controlled on the current mood stabilizer regimen. 1 This is critical to avoid triggering manic episodes or worsening mood instability. The patient must be on appropriate combination therapy for bipolar disorder—specifically a mood stabilizer plus an antipsychotic—which provides the necessary foundation for safely adding ADHD treatment. 1

Why Vyvanse Can Be Considered

• Lisdexamfetamine is approved as first-line therapy for ADHD in the United States and can be used as second-line therapy in many European countries. 2
• Recent systematic review data (2024) shows no increased risk of mania when ADHD medications are used alongside mood stabilizers in bipolar disorder patients. 3
• Lisdexamfetamine is a prodrug that converts to d-amphetamine, which inhibits dopamine and norepinephrine reuptake and promotes neurotransmitter release, providing therapeutic effects for ADHD. 4

Important Caveats About Stimulants in Bipolar Disorder

The risk of stimulant-associated mania/hypomania is substantial (40% in one study) when stimulants are used in bipolar disorder patients. 5 However, this risk is significantly mitigated when patients are on concurrent mood stabilizers. 5 In fact, absence of axis-I comorbidity was associated with higher rates of stimulant-associated mania, suggesting that proper psychiatric management reduces this risk. 5

Methylphenidate should actually be preferred as the initial stimulant choice over lisdexamfetamine in this population, starting with long-acting formulations for around-the-clock coverage. 1 If methylphenidate fails after adequate trial, then lisdexamfetamine should be the next option. 2

Dosing and Titration Strategy

• Start with the lowest effective dose (amphetamine salts 5-10mg daily) and titrate slowly by 5mg increments weekly while monitoring for mood destabilization. 1
• Monitor blood pressure and pulse regularly, as stimulants cause increased blood pressure and pulse. 2, 1
• Monitor appetite and weight, as decreased appetite is a major adverse effect of stimulants. 2, 1

Alternative Non-Stimulant Options If Concerned

If you have concerns about using stimulants despite adequate mood stabilization:

• Atomoxetine provides around-the-clock effects with smaller effect size than stimulants but is an uncontrolled substance with 6-12 weeks until full effects are observed. 2, 1 Research suggests atomoxetine may be effective in treating ADHD symptoms in bipolar patients with only modestly increased risk of hypomanic switches when used with mood stabilizers. 6
• Bupropion has demonstrated efficacy for ADHD in adults with lower risk of mood destabilization. 1
• Alpha-2 agonists (clonidine, guanfacine) provide around-the-clock effects with 2-4 weeks until effects are observed and smaller effect sizes than stimulants. 2, 1

Critical Monitoring Requirements

• Continue regular monitoring of mood stabilizer levels and hepatic function every 3-6 months. 1
• If the patient is on an antipsychotic like olanzapine, monitor metabolic parameters: BMI monthly for 3 months then quarterly, blood pressure/glucose/lipids at 3 months then yearly. 1
• Assess for mood destabilization at each visit, particularly during the first 8-12 weeks of stimulant treatment.

Common Pitfalls to Avoid

Do not assume all hyperactivity/impulsivity represents ADHD—these symptoms can represent residual manic symptoms or behavioral reactions to psychosocial stressors rather than true ADHD. 1 A complete psychiatric evaluation with particular focus on core ADHD symptoms starting in childhood is essential. 2

Do not use antidepressants for ADHD symptoms in bipolar disorder, as antidepressant monotherapy or inappropriate combinations risk mood destabilization, mania induction, and rapid cycling. 1

Do not prescribe stimulants if there is comorbid active substance use disorder or concern for malingering/stimulant diversion, as this may be contraindicated. 6 A detailed history of drug and alcohol use must be undertaken, and consider obtaining a urine drug screen. 2

Hierarchical Treatment Approach

A hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms. 6 The majority of evidence supports stabilizing the bipolar disorder first before addressing ADHD, as ADHD-bipolar comorbidity is associated with more severe symptoms, worse course, and worst outcome of both conditions. 6

ADHD medications should be continued as long as they provide benefit and are well-tolerated, with periodic reassessment every 6-12 months to determine ongoing need. 1