What is the recommended dosing for Vyvanse (lisdexamfetamine) in patients with attention deficit hyperactivity disorder (ADHD)?

Vyvanse (Lisdexamfetamine) Dosing for ADHD

Start Vyvanse at 30 mg once daily in the morning, then increase by 10-20 mg weekly based on clinical response and tolerability, targeting a maintenance dose of 50-70 mg daily with a maximum of 70 mg daily. 1

Initial Dosing

• Begin with 30 mg once daily in the morning - this is the FDA-approved and guideline-recommended starting dose for both adults and children 6 years and older 2, 3, 1
• Administer in the early morning (with or without food) to provide all-day coverage and avoid insomnia from afternoon dosing 3, 1
• The capsule can be swallowed whole OR opened and mixed with yogurt, water, or orange juice if swallowing is difficult - consume the entire mixture immediately 1

Titration Protocol

• Increase by 10 mg or 20 mg increments at approximately weekly intervals until optimal symptom control is achieved 2, 3, 1
• Maintain weekly contact (by telephone is acceptable) during initial titration to assess response and side effects - this typically requires 2-4 weeks to reach optimal dosing 2
• Use standardized ADHD rating scales from parents and teachers (for children) or from the patient and significant others (for adults) before each dose increase to objectively guide titration decisions 3, 4

Alternative "Forced Titration" Approach

• Some clinicians use a systematic approach where patients receive each dose level (30 mg, 50 mg, 70 mg) for one week each, with rating scales collected at each dose to identify the optimal dose 3

Maintenance Dosing

• Target maintenance dose: 50-70 mg daily - these represent the most common therapeutic doses in clinical practice 2
• Therapeutic range: 30-70 mg daily 2
• Maximum approved dose: 70 mg daily 2, 1
• Continue titration until symptoms resolve and functional impairment diminishes - different target symptoms may require different doses 4

Special Population Adjustments

Renal Impairment

• Severe renal impairment (GFR 15-29 mL/min/1.73 m²): Maximum 50 mg daily 1
• End-stage renal disease (GFR <15 mL/min/1.73 m²): Maximum 30 mg daily 1

Pediatric Considerations

• Exercise caution in children weighing less than 25 kg 4
• For children weighing less than 20 kg (45 lb), omit the 15 mg dose step in titration 4

Monitoring Requirements

Initial Phase

• Assess clinical response and tolerability before each dose increase to minimize side effects 2
• Systematically ask specific questions about known stimulant side effects: insomnia, decreased appetite, headaches, weight loss, increased blood pressure/pulse 2, 4
• Obtain ADHD rating scales from multiple sources (teachers, parents, significant others) to assess therapeutic response 2, 4

Ongoing Monitoring (After Stabilization)

• Schedule follow-up appointments at least monthly to assess ongoing efficacy, side effects, and growth parameters 2
• Monitor at each visit: blood pressure, pulse, height, and weight - stimulants can affect growth and cardiovascular parameters 3, 4
• Continue regular assessment as dose adjustments are the rule, not the exception, due to changes in symptomatology, psychosocial situation, or normal development (e.g., weight gain) 5

When to Consider Alternatives

• If adequate symptom control is not achieved at the maximum dose (70 mg), consider alternative treatments or adding non-stimulant medications 2
• If no desired benefit is observed after adequate treatment with methylphenidate, lisdexamfetamine should be the preferred next option over non-stimulants 5

Critical Pitfalls to Avoid

• Starting at too high a dose leads to unnecessary side effects and decreased medication adherence 2
• Failure to systematically assess both benefits and side effects during titration - use structured rating scales, not just subjective impressions 2
• Dividing a single dose - do not take anything less than one capsule per day; a single dose should not be divided 1
• Ignoring drug interactions - acidifying agents (e.g., ascorbic acid) decrease blood levels while alkalinizing agents (e.g., sodium bicarbonate) increase blood levels; adjust dosing accordingly 1

Special Clinical Considerations

• Lisdexamfetamine is a prodrug converted to dextroamphetamine after ingestion, providing lower abuse potential compared to other amphetamines - this becomes increasingly relevant in adolescents and patients with substance use history 3, 6
• The medication provides efficacy lasting up to 14 hours post-dose, including coverage into evening and early morning hours 7, 8
• Lisdexamfetamine is a Schedule II controlled substance with high potential for abuse and misuse - reassess each patient's risk throughout treatment and monitor for signs of abuse 1