What is the recommended use and dosage of Lisdexamfetamine (Vyvanse) for attention deficit hyperactivity disorder (ADHD) and binge eating disorder?

Lisdexamfetamine (Vyvanse): Recommended Use and Dosing

Lisdexamfetamine is FDA-approved for treating ADHD in patients aged 6 years and older, and for moderate to severe binge eating disorder in adults, with dosing starting at 30 mg daily and titrating up to 50-70 mg daily based on response. 1

ADHD Treatment

Indications and Patient Selection

• Lisdexamfetamine is indicated for ADHD in adults and pediatric patients 6 years and older 1
• According to the American Academy of Pediatrics, pharmacological treatment should be initiated when ADHD symptoms cause persistent significant impairment in at least one domain despite environmental modifications 2
• Lisdexamfetamine provides the longest duration of any stimulant (13-14 hours), making it the preferred choice when extended coverage beyond typical school/work hours is required 3

Dosing Algorithm for ADHD

• Start with 30 mg orally once daily in the morning 1, 4
• After one week at 30 mg, increase to 50 mg daily if clinically indicated and tolerated 1
• Maximum dose is 70 mg daily, with weekly titration increments as needed 1, 4
• The medication can be taken with or without food 1
• Duration of action extends 13 hours post-dosing in children and 14 hours in adults 5, 6

Efficacy Data

• Clinical trials demonstrated 70-80% response rates when adequately dosed, with large effect sizes for reducing ADHD core symptoms 3
• All doses (30,50, and 70 mg) showed statistically significant superiority over placebo in reducing ADHD-RS-IV scores in both pediatric and adult populations 1
• Maintenance of efficacy was demonstrated with only 9% treatment failure rate compared to 75% with placebo during a 6-week double-blind withdrawal phase 1

Binge Eating Disorder Treatment

Indications and Patient Selection

• Lisdexamfetamine is the only FDA-approved medication for moderate to severe binge eating disorder in adults 1, 7
• The American Psychiatric Association suggests lisdexamfetamine for adults with BED who prefer medication or have not responded to psychotherapy alone 2
• Patients must have at least 3 binge days per week for 2 weeks and a Clinical Global Impression Severity score ≥4 to meet treatment criteria 1

Dosing Algorithm for BED

• Begin with 30 mg daily for one week 1
• Increase to 50 mg daily after the first week 1
• Target dose is 50-70 mg daily, with additional increases to 70 mg made as tolerated and clinically indicated 1
• Continue dose optimization for 4 weeks, then maintain on optimized dose 1

Efficacy Data

• The 50-70 mg daily doses showed statistically significant reductions in binge days per week compared to placebo, with placebo-subtracted differences of -1.35 and -1.66 days per week in two pivotal trials 1
• Higher proportions of patients achieved 4-week binge cessation and showed greater improvement on CGI-I ratings compared to placebo 1
• Long-term studies up to 52 weeks demonstrated marked reduction in BED relapse risk relative to placebo 7

Treatment Selection Strategy

When to Choose Lisdexamfetamine Over Methylphenidate

• Switch to lisdexamfetamine when methylphenidate is ineffective, as recommended by the American Academy of Child and Adolescent Psychiatry 3
• Select lisdexamfetamine when 13-14 hour coverage is required, as it provides longer duration than methylphenidate's 12-hour maximum 3
• Consider methylphenidate first if sleep disturbances are present, as amphetamines cause significantly more sleep disruption 3
• When both stimulant classes are tried sequentially, overall response rates approach 90% 3

Critical Safety Monitoring

Cardiovascular Considerations

• Obtain baseline electrocardiogram in patients with cardiac risk factors, as lisdexamfetamine can prolong QTc intervals 2
• Monitor blood pressure and heart rate regularly, as cardiovascular effects are common dose-related adverse events 3

Growth and Weight Monitoring

• Both ADHD and BED patients require careful monitoring of height and weight, as dose-related effects on growth are well-documented 3
• Pediatric patients younger than 6 years experienced more long-term weight loss than older patients 1
• Lisdexamfetamine is not indicated for weight loss, and use of sympathomimetic drugs for obesity has been associated with serious cardiovascular adverse events 1

Common Adverse Effects

• Most frequent treatment-emergent adverse events include decreased appetite, insomnia, dry mouth, headache, and irritability 7, 5, 4
• Most adverse events are mild to moderate in intensity and transient in nature 5
• Adverse events infrequently lead to discontinuation 7

Important Clinical Caveats

Abuse Potential

• Lisdexamfetamine is a prodrug requiring enzymatic hydrolysis, which decreases liability for misuse and diversion compared to immediate-release amphetamines 4
• The rate-limiting nature of hydrolysis reduces toxicity potential and chances of overdose 4

Reassessment Requirements

• Periodic reassessment is essential to determine continued need for treatment, as recommended by the American Academy of Pediatrics 3
• Evaluate effectiveness based on reduction in core symptoms AND improvement in functional domains 3
• Once-daily long-acting formulations like lisdexamfetamine significantly improve adherence compared to multiple daily dosing 3