What is the recommended starting dose and titration schedule for Vyvanse (lisdexamfetamine) in Attention Deficit Hyperactivity Disorder (ADHD) treatment?

ADHD Starting Vyvanse Pathway Checklist

Start Vyvanse at 30 mg once daily in the morning, then titrate by 10-20 mg increments at weekly intervals up to a maximum of 70 mg daily, with systematic monitoring of symptoms, vital signs, and growth parameters at each visit. 1, 2

Pre-Treatment Assessment

Before initiating Vyvanse, complete the following mandatory screening:

• Cardiac evaluation: Obtain detailed personal and family history of sudden death, ventricular arrhythmia, or structural heart disease, plus physical examination with baseline blood pressure and pulse 3, 2
• Movement disorder screening: Assess family history and clinically evaluate for motor/verbal tics or Tourette's syndrome 2
• Growth parameters: Document baseline height and weight 3, 1
• Substance use history: Screen for personal or household history of stimulant abuse (relative contraindication requiring close supervision) 3
• Psychiatric comorbidities: Rule out active psychosis (absolute contraindication) 3
• Medication review: Confirm patient is not taking MAOIs or has not taken them within 14 days 2

Contraindications to Verify

Vyvanse is absolutely contraindicated in patients with: 2

• Known hypersensitivity to amphetamine products
• Current MAOI use or use within 14 days
• Active psychotic disorder 3

Use with extreme caution (not absolute contraindications despite older package insert warnings): 3

• Controlled seizure disorder (can initiate after seizures controlled)
• Tics or Tourette's syndrome (may not worsen with treatment per recent literature)
• Marked anxiety (may not worsen per recent literature)

Initial Dosing Protocol

Standard starting dose: 30 mg once daily in the morning 1, 2

• Alternative conservative approach: 20 mg once daily for patients where tolerability is a concern 1
• Administer early morning (ideally around 0700 hours) to provide all-day coverage and minimize insomnia 2, 4
• Can be taken with or without food 2
• May swallow whole or open capsule and mix entire contents with yogurt, water, or orange juice (consume immediately, do not store) 2

Titration Schedule

Weekly dose escalation: 1, 2

• Increase by 10 mg or 20 mg increments at approximately weekly intervals
• Maximum dose: 70 mg daily
• Typical effective range: 50-70 mg daily 3, 5
• Continue titration until optimal symptom control achieved without intolerable adverse effects 1

Alternative forced titration approach: Some clinicians use systematic dose trials where patient receives each dose level (30 mg, 50 mg, 70 mg) for one week each, collecting rating scales at each dose to identify optimal level 1

Monitoring Parameters at Each Visit

Vital signs: 3, 1

• Blood pressure and pulse at every visit
• For adults, quarterly BP/pulse checks minimum

Growth monitoring: 3, 1

• Height and weight at each visit
• Weight loss is common and expected with stimulants

Symptom assessment: 1

• Use standardized ADHD rating scales (e.g., ADHD-RS-IV) from both parents and teachers before each dose increase
• Rating scales can be obtained via phone contact between visits if needed to guide titration
• Assess response as early as week 1 (efficacy demonstrated within first week) 5

Systematic adverse effect screening: 6

• Specifically ask about: insomnia, decreased appetite, headaches, social withdrawal, irritability, weight loss
• Common adverse effects include: dry mouth, decreased appetite, insomnia (generally mild) 5
• Discontinuation rates due to adverse events typically <5% 7

Visit Schedule During Titration

• Week 1: Initial visit, start 30 mg
• Weeks 2-4: Weekly phone contact to assess response and side effects, adjust dose as needed 1
• Monthly thereafter: In-person visits once symptoms stabilized 8

Special Dosing Considerations

Renal impairment: 2

• Severe renal impairment (GFR 15-29 mL/min/1.73 m²): Maximum 50 mg daily
• End-stage renal disease (GFR <15 mL/min/1.73 m²): Maximum 30 mg daily

Drug interactions affecting dosing: 2

• Acidifying agents (e.g., ascorbic acid): Decrease amphetamine levels, may need higher Vyvanse dose
• Alkalinizing agents (e.g., sodium bicarbonate): Increase amphetamine levels, may need lower Vyvanse dose

When Maximum Dose Fails

If 70 mg daily does not provide adequate symptom control: 8, 6

• Do not exceed maximum dose - more is not better
• Consider switching to alternative stimulant or non-stimulant medication
• Add behavioral/psychosocial interventions
• Reassess diagnosis and evaluate for comorbid conditions affecting treatment response

Common Pitfalls to Avoid

• Starting too high: Leads to unnecessary side effects and poor adherence 6
• Inadequate time between increases: Allow full week to assess response before escalating 8
• Afternoon dosing: Causes insomnia; always dose in early morning 2
• Failure to use objective measures: Rely on standardized rating scales, not just subjective reports 1
• Not monitoring growth: Weight loss common and requires tracking 1
• Ignoring cardiovascular monitoring: BP/pulse must be checked regularly 3
• Exceeding maximum dose when ineffective: Switch medications rather than continuing to escalate 8

Advantages of Vyvanse Formulation

• Prodrug design: Converted to active d-amphetamine by red blood cells, providing lower abuse potential compared to other amphetamines 9, 10
• Long duration: Efficacy demonstrated at 14 hours post-dose in adults, providing coverage into evening 9, 4
• Once-daily dosing: Simplifies adherence 9
• Smooth delivery: Enzymatic conversion provides gradual release of active medication 9