What is the recommended dosing for Vyvanse (lisdexamfetamine) in patients with attention deficit hyperactivity disorder (ADHD)?

Vyvanse (Lisdexamfetamine) Dosing for ADHD

Start with 30 mg once daily in the morning, then titrate in 10-20 mg increments at weekly intervals to a maximum of 70 mg daily based on symptom control and tolerability. 1

Initial Dosing

• The FDA-approved starting dose is 30 mg once daily in the morning for both adults and pediatric patients 6 years and older 1
• An alternative starting approach of 20-30 mg is supported by the American College of Obstetricians and Gynecologists, though 30 mg remains the standard 2, 3
• Administer in the early morning to provide coverage throughout the day and avoid afternoon doses due to insomnia risk 3, 1

Titration Protocol

• Increase by 10 mg or 20 mg increments at approximately weekly intervals until optimal symptom control is achieved 3, 1
• The maximum recommended dose is 70 mg once daily 1
• Weekly intervals allow adequate time to assess both therapeutic response and side effects before making further adjustments 3

Administration Options

• Swallow capsules whole, OR 1
• Open capsules and mix entire contents with yogurt, water, or orange juice; consume immediately and do not store 1
• Never divide a single dose—take at least one full capsule or chewable tablet per day 1
• Can substitute with Vyvanse chewable tablets on a mg-per-mg basis (e.g., 30 mg capsule = 30 mg chewable) 1

Monitoring During Titration

• Use standardized ADHD rating scales (such as ADHD-RS-IV) from both parents and teachers before each dose increase to objectively assess response 3
• Assess blood pressure, pulse, height, and weight at each visit, as stimulants can affect growth and cardiovascular parameters 3
• Rating scales should be obtained through phone contact between visits if needed to guide titration decisions 3
• Schedule follow-up appointments at least monthly until symptoms are stabilized 3

Special Dosing Considerations

Renal Impairment

• Severe renal impairment (GFR 15 to <30 mL/min/1.73 m²): maximum 50 mg once daily 1
• End-stage renal disease (GFR <15 mL/min/1.73 m²): maximum 30 mg once daily 1

Drug Interactions Affecting Dosing

• Acidifying agents (e.g., ascorbic acid) decrease blood levels—may require dose increase 1
• Alkalinizing agents (e.g., sodium bicarbonate) increase blood levels—may require dose reduction 1

Time Course of Effect

• Efficacy begins as early as 1.5 hours post-dose and is maintained through 13 hours in school-aged children 4
• Peak behavioral effects occur when plasma concentrations are increasing, typically between 1-3 hours 5
• The prodrug formulation provides extended duration compared to immediate-release amphetamines 2

Common Pitfalls to Avoid

• Do not start at too high a dose, as this leads to unnecessary side effects and decreased medication adherence 6
• Do not increase doses more frequently than weekly, as insufficient time between adjustments prevents accurate assessment of response 6
• Do not fail to systematically assess both benefits and side effects during titration using standardized rating scales from multiple sources 3, 6
• Do not administer in the afternoon or evening due to insomnia risk 1

Pretreatment Screening Requirements

Before initiating lisdexamfetamine, assess for: 1

• Cardiac disease (perform careful history, family history of sudden death or ventricular arrhythmia, and physical exam)
• Family history and clinical evaluation for motor or verbal tics or Tourette's syndrome

Advantages of Lisdexamfetamine

• Lower abuse potential compared to other stimulants due to prodrug formulation that makes extraction of the stimulant component more difficult 2, 3
• This becomes increasingly relevant as children approach adolescence 3
• May be feasible even in patients with stimulant use disorder history due to unique pharmacokinetic profile 7