What medication can be substituted for Vyvanse (lisdexamfetamine) in a patient taking 70mg of Vyvanse in the morning and 5mg of methylphenidate at noon, and at what starting dose?

Switching from Vyvanse to an Alternative Stimulant

Switch to methylphenidate extended-release (such as OROS-methylphenidate/Concerta) starting at 36 mg once daily in the morning, as this provides 12-hour coverage and represents a reasonable cross-titration from the patient's current 70 mg Vyvanse dose. 1, 2

Rationale for Methylphenidate Extended-Release

The patient is already using methylphenidate 5 mg at noon to manage afternoon "crash," which indicates they respond to methylphenidate and suggests the Vyvanse duration may be inadequate despite being at maximum dose. 1

Key advantages of switching to long-acting methylphenidate:

• OROS-methylphenidate (Concerta) provides 12 hours of continuous coverage, eliminating the need for midday dosing and preventing the plasma concentration troughs that cause rebound symptoms 2, 3
• The ascending delivery profile prevents tachyphylaxis (acute tolerance) that can occur with immediate-release formulations, maintaining efficacy throughout the day 3
• Onset of action occurs within 1-2 hours, similar to Vyvanse, ensuring morning symptom control 3

Starting Dose Recommendation

Start with 36 mg OROS-methylphenidate once daily in the morning. 1, 2

This starting dose is based on:

• The patient is already on maximum-dose Vyvanse (70 mg) and tolerating stimulants well 1, 4
• They are already using supplemental methylphenidate, demonstrating tolerability 1
• Starting at 36 mg allows room for upward titration to 54 mg if needed, while avoiding starting too low given their current high-dose stimulant use 1, 2

Titration Strategy

• Assess response after 1 week at 36 mg 1
• If inadequate response, increase to 54 mg once daily (maximum dose for OROS-methylphenidate) 1, 2
• Monitor for peak-related side effects (irritability, sadness) occurring 1-3 hours post-dose, which would indicate the dose is too high 2
• Eliminate the noon methylphenidate dose once the long-acting formulation is optimized, as the 12-hour coverage should eliminate afternoon crash 2, 3

Alternative Option: Mixed Amphetamine Salts Extended-Release

If the patient prefers to remain on an amphetamine-based medication:

Consider mixed amphetamine salts extended-release (Adderall XR) starting at 30 mg once daily. 2, 5

However, this option has significant limitations:

• Provides only 8-9 hours of coverage compared to 12 hours with OROS-methylphenidate 2
• May still require afternoon supplementation, defeating the purpose of switching 2, 5
• The patient is already experiencing inadequate duration with Vyvanse (which provides 13-14 hours theoretically), suggesting they may need the longer methylphenidate coverage 2

Common Pitfalls to Avoid

• Do not start with immediate-release methylphenidate multiple times daily, as this creates predictable plasma troughs and rebound effects that the patient is already experiencing 2, 6
• Do not use older sustained-release methylphenidate formulations (generic SR), as these provide only 4-6 hours of action with delayed onset and lower peaks 2, 6
• Do not assume all afternoon irritability is "crash" - if symptoms occur 1-3 hours after the morning dose, this represents peak effects from excessive dosing rather than wear-off 2
• Avoid dosing OROS-methylphenidate after morning to prevent insomnia, as the 12-hour duration means an 8 AM dose provides coverage until 8 PM 2, 3

Monitoring Parameters

• Assess ADHD symptoms hourly throughout the day during the first week to identify any gaps in coverage 3
• Monitor for appetite suppression and insomnia, which may be more pronounced with methylphenidate than with lisdexamfetamine 7
• Check blood pressure and heart rate at each follow-up, as required for all stimulant medications 4
• Evaluate for rebound symptoms in late afternoon/evening - if present despite 12-hour formulation, consider overlapping doses or adding small immediate-release dose in late afternoon 2