Is Concerta Better Than Vyvanse for Hyperactive-Type ADHD?
Neither Concerta (methylphenidate) nor Vyvanse (lisdexamfetamine) demonstrates clear superiority for hyperactive-type ADHD, but current guidelines recommend methylphenidate as the first-line stimulant for children and adolescents, while amphetamines (including lisdexamfetamine) show stronger evidence in adults. The choice should be guided by age, with methylphenidate preferred in pediatric populations and amphetamines showing superior efficacy in adult populations 1.
Age-Based Treatment Recommendations
Children and Adolescents (Ages 6-18)
Methylphenidate is the guideline-recommended first-line stimulant for elementary and middle school-aged children with ADHD, supported by the American Academy of Pediatrics 2.
The evidence base for methylphenidate in children is more robust, with effect sizes of 0.8-0.9 in typically developing children 2.
A 2018 network meta-analysis of 133 trials found methylphenidate superior to placebo in children based on both clinician ratings (SMD -0.78) and teacher ratings (SMD -0.82), making it one of only two medications showing efficacy across both rating sources 1.
Adults
Amphetamines (including lisdexamfetamine/Vyvanse) demonstrate superior efficacy in adults compared to methylphenidate, with a larger effect size (SMD -0.79 vs -0.49) 1.
The same 2018 network meta-analysis found amphetamines significantly more effective than methylphenidate in head-to-head adult comparisons (SMD difference -0.29 to -0.94) 1.
Direct Comparison Evidence
Lisdexamfetamine vs Methylphenidate Head-to-Head Data
A 2013 post-hoc analysis comparing lisdexamfetamine to OROS methylphenidate in children/adolescents found lisdexamfetamine statistically superior, with a difference in ADHD-RS-IV total score of -5.6 points (95% CI -8.4 to -2.7, p<0.001) 3.
Response rates (≥30% symptom reduction plus CGI-I score of 1-2) favored lisdexamfetamine by 18.3% (NNT=6) 3.
However, this was a post-hoc analysis rather than a prospectively designed head-to-head trial, limiting the strength of this evidence 3.
Tolerability Considerations
Side Effect Profiles
Amphetamines show inferior tolerability compared to placebo in both children (OR 2.30) and adults (OR 3.26) for treatment discontinuation due to adverse events 1.
Methylphenidate demonstrates better tolerability in children (no significant difference from placebo) but worse tolerability in adults (OR 2.39) 1.
Lisdexamfetamine causes higher rates of decreased appetite, insomnia, weight loss, nausea, and anorexia compared to OROS methylphenidate 3.
Clinical Decision Algorithm
Step 1: Consider Patient Age
- Ages 6-17: Start with methylphenidate (Concerta) as first-line 2, 1
- Adults: Consider amphetamines (Vyvanse) as first-line given superior efficacy 1
Step 2: Optimize Dosing
Use flexible-dose titration strategies rather than fixed dosing, as this improves both efficacy and acceptability across the FDA-licensed dose range 4.
For methylphenidate, incremental benefits plateau beyond 30 mg MPH-equivalent in fixed-dose trials, but continue with flexible dosing 4.
For amphetamines, incremental benefits plateau beyond 20 mg AMP-equivalent in fixed-dose trials, but continue with flexible dosing 4.
Step 3: Trial Alternative Stimulant Class if Inadequate Response
If methylphenidate fails or is poorly tolerated, switch to an amphetamine preparation (or vice versa) before considering non-stimulants 5.
The 2018 network meta-analysis supports trying both stimulant classes, as individual response varies 1.
Important Caveats
Hyperactive Subtype Specificity
No evidence demonstrates differential efficacy between stimulant types based on ADHD presentation (hyperactive vs inattentive vs combined) 2.
Both medications target core ADHD symptoms including hyperactivity, impulsivity, and inattention equally 1, 3.
Preschool-Aged Children (4-5 Years)
Methylphenidate is the only stimulant with evidence in preschool-aged children, and should only be used after behavioral interventions fail and with moderate-to-severe functional impairment 2.
No data support lisdexamfetamine use in this age group 2.