What is the best course of action for a patient with a history of Attention Deficit Hyperactivity Disorder (ADHD) and binge eating disorder who has experienced an increase in excessive eating after stopping lisdexamfetamine (Vyvanse)?

Management of Excessive Eating After Stopping Lisdexamfetamine

Restart lisdexamfetamine at 50-70 mg/day as the first-line treatment for the recurrence of binge eating symptoms after discontinuation, as it is the only FDA-approved medication for moderate to severe binge eating disorder and has demonstrated significant efficacy in reducing binge eating days. 1, 2, 3

Understanding the Rebound Phenomenon

• Discontinuation of lisdexamfetamine commonly leads to return of binge eating symptoms, as the medication's therapeutic effects on appetite regulation, reward processing, and impulse control are no longer present 4
• The drug works by potentiating central noradrenergic and dopaminergic neurotransmission, which reduces the core psychopathologies of impulsivity, compulsivity, and perseveration that drive binge eating 5, 4
• When stopped, these neurochemical effects cease, allowing the underlying disorder to re-emerge 4

Immediate Treatment Strategy

Reinitiate lisdexamfetamine using forced dose titration over 3 weeks, starting at 30 mg/day and increasing to 50-70 mg/day based on response and tolerability. 3

• The 50 mg/day and 70 mg/day doses have demonstrated superior efficacy compared to placebo, with mean reductions in binge eating days of 4.1 days per week 3
• The 30 mg/day dose did not show significant efficacy over placebo and should be considered only as a titration step 3
• Maintain the therapeutic dose for at least 8-11 weeks to assess full response 3

Combined Treatment Approach

Simultaneously initiate or continue eating disorder-focused cognitive-behavioral therapy (CBT), as the American Psychiatric Association recommends this as first-line psychotherapy for binge eating disorder. 1, 6

• CBT should focus on normalizing eating patterns, addressing psychological factors driving binge eating, and improving cognitive control over eating behaviors 1, 4
• Interpersonal therapy represents an alternative evidence-based psychotherapy option if CBT is not available or preferred 1, 7
• The combination of medication and psychotherapy provides superior outcomes compared to either modality alone 1, 6

Alternative Pharmacological Options

If lisdexamfetamine is contraindicated or not tolerated:

• Consider topiramate as a second-line medication, which has demonstrated efficacy in reducing binge eating behaviors 8
• Antidepressants, particularly SSRIs (fluoxetine, sertraline, citalopram), represent another alternative pharmacological option 1, 8
• Note that these alternatives lack FDA approval for binge eating disorder and have smaller effect sizes compared to lisdexamfetamine 8

Monitoring and Follow-up

Quantify binge eating frequency at baseline and monitor weekly to assess treatment response, with the expectation that 50% of patients on 70 mg/day will achieve 4-week binge eating cessation. 3

• Assess vital signs including heart rate and blood pressure at each visit, as lisdexamfetamine can increase both parameters 3
• Monitor weight changes, as lisdexamfetamine typically produces mean weight loss of 4-5 kg over 11 weeks 3
• Evaluate for common adverse effects including dry mouth, headache, and insomnia, which occur frequently but rarely lead to discontinuation 2, 3

Critical Pitfalls to Avoid

• Do not prioritize weight loss as the primary treatment goal—focus instead on normalizing eating patterns and addressing psychological factors, as emphasized by the American Psychiatric Association 1, 6
• Do not abruptly discontinue lisdexamfetamine without a plan for managing symptom recurrence, as this leads to the exact situation you're now facing 3, 4
• Do not use medications that cause weight gain (olanzapine, clozapine, mirtazapine, valproate) for comorbid conditions, as these will worsen binge eating disorder outcomes 8

Long-term Management

Plan for extended treatment duration, as studies demonstrate that lisdexamfetamine markedly reduces the risk of binge eating disorder relapse when continued beyond the acute treatment phase. 2

• Consider maintenance therapy for up to 52 weeks based on clinical response and tolerability 2
• Implement a coordinated multidisciplinary team approach incorporating medical, psychiatric, psychological, and nutritional expertise 1, 6
• If discontinuation is attempted in the future, taper gradually and ensure robust psychotherapeutic support is in place 1