Can You Start at 20mg for Moderate ADHD Cases?
No, you should not start at 20mg for moderate ADHD cases—the standard initial dose of Vyvanse (lisdexamfetamine) is 30mg once daily in the morning, regardless of ADHD severity. 1, 2
Standard Initial Dosing Protocol
- The FDA-approved starting dose is 30mg once daily in the morning for both adults and pediatric patients 6 years and older with ADHD 2
- This 30mg starting dose represents the standard across all treatment guidelines and is not adjusted based on whether ADHD is mild, moderate, or severe 1
- The American College of Obstetricians and Gynecologists confirms that 30mg is the recommended initial dose, with typical maintenance doses ranging from 50-70mg daily after titration 1
Why Not Start Lower?
- Starting below 30mg (such as at 20mg) is not supported by FDA labeling or clinical guidelines 2
- The 20mg capsule strength exists for titration purposes during dose adjustments, not as an initial starting dose 2
- Clinical trials demonstrating efficacy used 30mg as the starting point, with dose increases of 10-20mg weekly based on response 1, 3
Proper Titration Schedule
- After starting at 30mg, increase by 10mg or 20mg weekly based on clinical response and tolerability 1
- The recommended therapeutic range is 30-70mg daily, with 50-70mg representing the most common maintenance doses in clinical practice 1
- Maximum approved daily dose is 70mg 1, 2
- Weekly contact should be maintained by telephone during initial titration, which typically requires 2-4 weeks to reach optimal dosing 1
Monitoring During Initiation
- Systematically assess for side effects by asking specific questions about insomnia, anorexia, headaches, and weight loss at each dose adjustment 1
- Monitor weight regularly as weight loss is a common side effect of stimulant medications 1
- Assess vital signs (blood pressure and pulse) at baseline and with each dose increase 4
- Obtain ADHD rating scales from teachers and parents for children, or from the patient and significant others for adults, to assess therapeutic response 1
Common Pitfalls to Avoid
- Starting at too high a dose can lead to unnecessary side effects and decreased medication adherence, but starting below the recommended 30mg is not evidence-based 1, 4
- Failure to systematically assess both benefits and side effects during titration is a common error 1, 4
- Not allowing sufficient time between dose increases (at least one week) to evaluate response 4
- Overlooking the importance of morning administration to minimize sleep disturbances 4