What advice should be given to a patient with Attention Deficit Hyperactivity Disorder (ADHD) when increasing their dose of Vyvanse (lisdexamfetamine) from 30 mg to 40 mg daily, and what behavioral changes should be discussed?

Dose Increase from Vyvanse 30 mg to 40 mg Daily

Increase the Vyvanse dose to 40 mg daily as planned, monitor cardiovascular parameters and side effects at this visit, and continue weekly titration by 10-20 mg increments until optimal symptom control is achieved, with a maximum dose of 70 mg/day. 1

Titration Protocol and Monitoring

• The FDA-approved titration schedule for lisdexamfetamine involves weekly dose increases of 10-20 mg until optimal effect is achieved, with a maximum daily dose of 70 mg. 2, 1

• At today's visit, measure and document blood pressure and pulse before dispensing the 40 mg dose, as stimulants can increase both parameters and cardiovascular monitoring is essential throughout treatment. 1

• Schedule follow-up in 1 week (by phone or visit) to assess symptom response using standardized ADHD rating scales and to evaluate for adverse effects. 3, 2

• If the patient shows continued room for improvement at 40 mg with tolerable side effects, plan to increase to 50 mg at the next visit, then potentially to 60 mg or 70 mg in subsequent weeks. 2, 1

Critical Side Effects to Discuss and Monitor

• Systematically assess for common adverse effects at each visit, including decreased appetite, insomnia, dry mouth, anxiety, irritability, headache, increased heart rate, and gastrointestinal symptoms (nausea, upper abdominal pain, diarrhea). 1

• Warn the patient that appetite suppression and weight loss are common—monitor weight at each visit and consider treatment interruption if significant weight loss occurs. 1

• Screen for emergence or worsening of psychiatric symptoms, including new-onset anxiety, agitation, psychotic symptoms, or manic episodes, as these may require dose reduction or discontinuation. 1

• Assess for peripheral vasculopathy symptoms (digital color changes, numbness, pain in fingers/toes) and tics or Tourette's syndrome, which may emerge or worsen with stimulant treatment. 1

• Insomnia is dose-dependent—if sleep disturbances occur, ensure the medication is taken early in the morning and avoid late-day dosing. 4

Behavioral Interventions to Discuss

• Emphasize that medication is most effective when combined with behavioral strategies, as pharmacological treatment targets core ADHD symptoms while behavioral interventions improve associated functional impairments and organizational skills. 3

• Recommend implementing structured daily routines with consistent sleep-wake times, meal schedules, and designated times for work/study tasks to maximize medication effectiveness. 3

• Discuss organizational strategies including use of planners, reminder systems, breaking large tasks into smaller steps, and minimizing environmental distractions during focus-intensive activities. 3

• Encourage regular physical exercise, which has independent benefits for ADHD symptom management and can help mitigate stimulant-related side effects like restlessness. 3

• For adults, consider referral to cognitive behavioral therapy (CBT) specifically adapted for ADHD, which addresses procrastination, time management, and emotional regulation. 3

Medication Safety and Abuse Potential Counseling

• Educate the patient that lisdexamfetamine is a Schedule II controlled substance with abuse potential, though it has lower abuse liability than immediate-release amphetamines because it is a prodrug requiring enzymatic conversion to active dextroamphetamine. 1, 5, 6

• Instruct on proper storage (secure location away from others) and disposal of unused medication to prevent diversion. 1

• The prodrug formulation means lisdexamfetamine cannot produce euphoric effects when crushed, snorted, or injected, as conversion to active drug occurs only through red blood cell enzymatic hydrolysis after oral ingestion. 7, 6

• Reassess abuse risk at each visit and monitor for signs of misuse, including requests for early refills, dose escalation without authorization, or obtaining prescriptions from multiple providers. 1

Common Pitfalls to Avoid

• Do not stop titration prematurely at 40 mg—many patients require 50-70 mg daily for optimal symptom control, and underdosing is the most common reason for apparent treatment failure. 2

• Avoid weight-based dosing, as evidence does not support this approach; instead, titrate to clinical effect within the approved dose range. 2

• Do not switch medications without completing a full dose range trial (up to 70 mg if tolerated), as premature switching before reaching optimal doses is a frequent error. 2

• Ensure teacher or workplace ratings are obtained if applicable, as school/work performance is a critical outcome measure that office-based assessments may miss. 3, 2