What is the recommended dosing when switching from Vyvanse (lisdexamfetamine) 40mg to Focalin XR (dexmethylphenidate)?

Switching from Vyvanse 40mg to Focalin XR

Start Focalin XR at 20mg once daily in the morning, which represents approximately half the total daily dose of the racemic methylphenidate equivalent to your current Vyvanse dose. 1

Conversion Rationale

• Vyvanse 40mg is a prodrug that converts to dextroamphetamine, providing amphetamine-based stimulation throughout the day 2
• Focalin XR contains only the d-isomer of methylphenidate (dexmethylphenidate), which is the pharmacologically active component, making it roughly twice as potent per milligram as racemic methylphenidate 3
• The recommended starting dose of Focalin XR for patients switching from other stimulants is half the total daily dose of racemic methylphenidate equivalent, which for Vyvanse 40mg translates to approximately 20mg of Focalin XR 1

Discontinuation and Initiation Protocol

• Discontinue Vyvanse abruptly without tapering when switching to Focalin XR, as amphetamines can be stopped immediately when transitioning to another ADHD medication 4
• No washout period is required between stopping Vyvanse and starting Focalin XR, as these medications work through different mechanisms (amphetamine vs. methylphenidate) 4
• Begin Focalin XR the morning after the last dose of Vyvanse to maintain continuous symptom coverage 1

Titration Schedule

• Titrate weekly in increments of 5mg if symptom control is inadequate, assessing response through parent and teacher reports 2, 1
• The maximum recommended dose is 30mg daily for pediatric patients and 40mg daily for adults, with doses above these levels not studied and not recommended 1
• Expect immediate therapeutic effects with Focalin XR, unlike non-stimulant alternatives which require 6-12 weeks for full efficacy 4

Monitoring Requirements

• Assess target ADHD symptoms weekly during titration using standardized rating scales from both parents and teachers 2
• Monitor blood pressure and heart rate at each visit, as methylphenidate can cause increases in both parameters (mean increases of 0.4-2.6 mmHg systolic, 2.2-3.3 mmHg diastolic, and 4.7-7.6 bpm) 5
• Weigh the patient at each visit to objectively monitor for appetite suppression and weight loss 2
• Systematically assess for specific side effects including insomnia, decreased appetite, headaches, social withdrawal, and tics 2

Expected Efficacy Comparison

• Lisdexamfetamine (Vyvanse) has demonstrated statistically superior efficacy compared to extended-release methylphenidate formulations in head-to-head trials, with treatment differences of -3.4 to -5.6 points on ADHD-RS-IV total scores 6, 5
• However, both amphetamine and methylphenidate-based stimulants show robust efficacy, with approximately 75% of methylphenidate responders also responding to amphetamines and vice versa 7
• If inadequate response occurs after 4 weeks at maximum tolerated dose, consider switching back to an amphetamine-based stimulant rather than further dose escalation 2, 1

Common Pitfalls to Avoid

• Do not start at doses higher than 20mg in adults or 10mg in children, as this increases the risk of cardiovascular and appetite-related side effects 1
• Do not divide the contents of a single Focalin XR capsule—the entire capsule contents must be taken as one dose, though it may be sprinkled on applesauce if swallowing is difficult 1
• Do not assume equivalent efficacy—some patients may require a return to amphetamine-based therapy if methylphenidate proves less effective for their individual symptom profile 6, 5
• Do not neglect cardiovascular screening before initiating, including careful history for cardiac disease, family history of sudden death or ventricular arrhythmia, and physical examination 1

Administration Considerations

• Focalin XR provides bimodal release with two distinct plasma concentration peaks, designed to mimic twice-daily immediate-release dosing with once-daily administration 3
• The capsule may be taken whole or opened and sprinkled onto applesauce, which should be consumed immediately without chewing the beads 1
• Administer in the morning with or without food for optimal daytime coverage 1