What is the recommended starting dose of Vyvanse (lisdexamfetamine) for a newly diagnosed Attention Deficit Hyperactivity Disorder (ADHD) patient, a child or adolescent with no significant medical history or comorbid conditions?

Starting Dose of Vyvanse for Newly Diagnosed ADHD

Begin Vyvanse at 30 mg once daily in the morning for newly diagnosed ADHD patients, regardless of age (children 6 years and older, adolescents, or adults). 1, 2, 3

Initial Dosing Protocol

• The standard starting dose is 30 mg once daily administered in the early morning 1, 2, 3
• Take the medication with or without food, but avoid afternoon dosing to prevent insomnia 3
• The capsule can be swallowed whole or opened and mixed with yogurt, water, or orange juice if swallowing is difficult 3

Titration Strategy

• Increase the dose by 10 mg or 20 mg increments at approximately weekly intervals based on clinical response and tolerability 1, 3
• Maintain weekly contact (by telephone if needed) during initial titration to assess response and side effects 1
• The typical titration period requires 2-4 weeks to reach optimal dosing 1
• The therapeutic dose range is 30-70 mg daily, with most patients achieving optimal response at 50-70 mg 1
• The maximum approved daily dose is 70 mg 1, 3

Critical Monitoring Requirements

Before Starting Treatment

• Obtain baseline blood pressure, pulse, height, and weight in the context of a physical examination 1
• Assess for cardiac disease through careful personal and family history (particularly sudden death or ventricular arrhythmia) and physical exam 3
• Evaluate family history and clinically assess for motor or verbal tics or Tourette's syndrome 3
• Screen adolescents specifically for substance abuse symptoms before initiating treatment 4

During Titration

• Collect ADHD rating scales from teachers and parents (for children) or from the patient and significant others (for adults) before each dose increase 1, 2
• Systematically assess for specific side effects at each contact: insomnia, decreased appetite, headaches, and weight loss 1
• Monitor blood pressure and pulse at each dose adjustment 1
• Use standardized ADHD rating scales (such as ADHD-RS-IV) to objectively track response 2

After Stabilization

• Schedule follow-up appointments at least monthly to assess ongoing efficacy, side effects, and growth parameters (height, weight, blood pressure, pulse) 1, 2

Expected Timeline of Effects

• Efficacy begins as early as 1.5 hours post-dose and is maintained through 13 hours 5
• Most side effects (decreased appetite, weight decrease, insomnia, headache) peak in the first 4-12 weeks of treatment 6
• Continue regular assessment as dose adjustments are common due to changes in symptomatology, psychosocial situation, or normal development 2

When Maximum Dose Is Insufficient

• If adequate symptom control is not achieved at 70 mg daily, consider switching to alternative treatments or adding non-stimulant medications rather than exceeding the maximum dose 1, 2
• Lisdexamfetamine should be the preferred next stimulant option if methylphenidate fails 2

Special Populations

Adolescents

• Lisdexamfetamine has lower abuse potential compared to other amphetamines due to its prodrug formulation (requires conversion to dextroamphetamine after ingestion), making it particularly appropriate for adolescents at risk for diversion 4, 2
• Monitor prescription refill requests for signs of misuse or diversion 4
• Consider providing medication coverage for driving hours with the once-daily formulation 4

Patients with Renal Impairment

• Severe renal impairment (GFR 15 to <30 mL/min/1.73 m²): maximum dose 50 mg daily 3
• End-stage renal disease (GFR <15 mL/min/1.73 m²): maximum dose 30 mg daily 3

Common Pitfalls to Avoid

• Starting at too high a dose leads to unnecessary side effects and decreased medication adherence 1, 7
• Failing to systematically assess both benefits and side effects during titration 1, 7
• Not allowing sufficient time (approximately one week) between dose increases to evaluate response 1, 3
• Overlooking morning administration, which increases sleep disturbances when ignored 7, 3
• Continuing to escalate dose when symptom control plateaus—switch medications or add non-stimulant options instead 7, 2
• Not monitoring weight regularly, as weight loss is a common side effect requiring ongoing assessment 1, 6