What is the proper use and dosage of Vyvanse (lisdexamfetamine) for conditions like Attention Deficit Hyperactivity Disorder (ADHD) or binge eating disorder?

Vyvanse (Lisdexamfetamine): Proper Use and Dosing

Indications

Vyvanse is FDA-approved for treating ADHD in adults and children ≥6 years old, and for moderate to severe binge eating disorder (BED) in adults. 1

• For ADHD, stimulants like lisdexamfetamine are recommended as first-line therapy, though approval status varies by country (first-line in the US, second-line in many European countries) 2
• For BED, lisdexamfetamine is currently the only FDA-approved medication for this indication 3
• Not indicated for weight loss or obesity treatment - use of sympathomimetic drugs for weight loss has been associated with serious cardiovascular adverse events 1

Dosing for ADHD

Starting Dose

Start at 30 mg once daily in the morning for both adults and children ≥6 years old 1

Titration Protocol

• Increase in increments of 10 mg or 20 mg at approximately weekly intervals 1
• Maximum recommended dose: 70 mg once daily 1
• Administer in the morning with or without food to avoid insomnia 1

Administration Options

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

Dosing for Binge Eating Disorder

Starting and Target Dose

Start at 30 mg once daily, then titrate in 20 mg increments at weekly intervals to reach target dose of 50-70 mg daily 1

• The 50 mg and 70 mg doses demonstrated superior efficacy compared to placebo in reducing binge eating days per week 4
• Maximum dose: 70 mg daily 1
• At week 11, the 50 mg dose reduced binge eating days by mean 4.1 days/week, and 70 mg by 4.1 days/week, compared to 3.3 days/week with placebo 4
• 4-week binge cessation rates: 42.2% (50 mg), 50.0% (70 mg) vs 21.3% (placebo) 4

Mandatory Pretreatment Screening

Before initiating lisdexamfetamine, assess: 1

• Cardiac disease: Perform careful history, family history of sudden death or ventricular arrhythmia, and physical exam 1
• Tics/Tourette's: Evaluate family history and clinically assess for motor or verbal tics before starting 1
• Abuse risk: Assess each patient's risk for abuse, misuse, and addiction given the high potential for substance use disorder development 1

Monitoring Parameters

During Treatment

• Height and weight (stimulants decrease appetite) 2
• Pulse and blood pressure (can cause increases) 2
• Sleep disturbances 2
• Signs of abuse, misuse, or addiction throughout treatment 1

For BED Patients

• Body weight changes: Mean weight loss of 4.9 kg observed with 50-70 mg doses vs 0.1 kg with placebo 4

Common Adverse Effects

Most treatment-emergent adverse events are mild to moderate in severity 3

• Decreased appetite 2, 5
• Insomnia 3, 5
• Dry mouth 3
• Headache 2, 3
• Irritability 5
• Dizziness 5
• Weight loss 5

In BED trials, 84.7% of treatment groups experienced any adverse event vs 58.7% with placebo, with only 1.5% experiencing serious adverse events 4

Key Advantages of Lisdexamfetamine

As a prodrug requiring enzymatic hydrolysis, lisdexamfetamine has reduced abuse potential compared to immediate-release amphetamines 5, 6

• The rate-limiting hydrolysis reduces toxicity potential and overdose risk 5
• Pharmacodynamic studies showed 50-100 mg oral doses had less likability than d-amphetamine 40 mg in stimulant abusers 6
• May be preferred in adolescents due to lower abuse potential 7
• Provides "around-the-clock" effects with once-daily dosing 2
• Large effect sizes for reducing ADHD core symptoms with rapid onset 2

Critical Warnings

Black Box Warning

Lisdexamfetamine has high potential for abuse and misuse, which can lead to substance use disorder and addiction 1

• Misuse and abuse can result in overdose and death, with increased risk at higher doses or unapproved administration methods (snorting, injection) 1
• Educate patients and families about proper storage and disposal 1
• Reassess abuse risk frequently throughout treatment 1

Controlled Substance Status

• Lisdexamfetamine is a controlled substance 2

Special Populations

Pediatric Considerations

• Children <6 years with ADHD experienced more long-term weight loss than older patients 1
• Efficacy and safety in adolescents with ADHD have not been fully assessed 5
• Safety in children with ADHD and comorbid psychiatric disorders remains to be evaluated 5

Pregnancy

• Amphetamines cross the placental barrier 7
• Possible small increased risks for gastroschisis (aOR 3.0) and preeclampsia (aRR 1.29) 7
• Continued use in second half of pregnancy may increase preterm birth risk (aRR 1.30) 7
• Monitor infants for irritability, insomnia, and feeding difficulties if mother took amphetamines during pregnancy 7

Breastfeeding

• Atomoxetine (non-stimulant alternative) should be used with caution as no breastfeeding studies exist 8
• Monitor breastfed infants for irritability, jitteriness, feeding difficulties, poor weight gain, and sleep disturbances 8

When to Switch from Lisdexamfetamine

If no benefit after adequate treatment with methylphenidate, lisdexamfetamine should be the next option over non-stimulants 2

• Consider alternative treatments if maximum dose (70 mg) provides inadequate symptom control or causes intolerable side effects 9
• Options include switching to different stimulant formulation or adding non-stimulant like atomoxetine 9