What is the recommended treatment approach for an adult patient with Attention Deficit Hyperactivity Disorder (ADHD) seeking treatment with Vyvanse (lisdexamfetamine)?

Vyvanse (Lisdexamfetamine) for Adult ADHD Treatment

Primary Recommendation

Start lisdexamfetamine at 30 mg once daily in the morning, titrate by 10-20 mg weekly to a target dose of 50-70 mg daily (maximum 70 mg), and monitor for cardiovascular effects, appetite suppression, and sleep disturbances. 1

Dosing Algorithm

Initial Dosing

• Begin with 30 mg once daily in the morning with or without food 1
• Avoid afternoon doses due to insomnia risk 1
• Administer as intact capsule or open and mix entire contents with yogurt, water, or orange juice and consume immediately 1

Titration Schedule

• Increase by 10-20 mg increments at approximately weekly intervals based on symptom response and tolerability 1
• Target dose: 50-70 mg daily for optimal ADHD symptom control 2, 1
• Maximum dose: 70 mg once daily 1

Duration of Effect

• Provides 13-14 hours of symptom control in adults, offering all-day coverage with once-daily dosing 3
• Long-acting formulation improves medication adherence and reduces rebound effects compared to immediate-release stimulants 2, 4

Clinical Advantages of Lisdexamfetamine

Efficacy Profile

• 70-80% response rate for ADHD treatment, consistent with other amphetamine-based stimulants 2, 5
• Demonstrates robust clinical efficacy with large effect sizes in treating core ADHD symptoms in adults 3, 6
• Works within days, allowing rapid assessment of treatment response 2

Unique Pharmacokinetic Properties

• Prodrug formulation that is therapeutically inactive until enzymatically hydrolyzed in the blood to active dextroamphetamine 3, 6
• Conversion is unaffected by gastrointestinal pH and variations in transit times, providing consistent plasma concentrations throughout the day 3
• Lower abuse potential compared to immediate-release amphetamines due to prodrug mechanism—does not produce high dextroamphetamine levels when injected or snorted 3, 6, 7

Critical Monitoring Parameters

Cardiovascular Monitoring

• Obtain baseline blood pressure and pulse before initiating treatment 2, 5
• Monitor blood pressure and heart rate at each medication adjustment and periodically during stable treatment 5
• Contraindicated in patients with uncontrolled hypertension, symptomatic cardiovascular disease, or structural cardiac abnormalities 2, 5

Weight and Appetite Monitoring

• Track height and weight regularly, as stimulants cause statistically significant reductions in weight gain 4
• Decreased appetite is among the most common adverse effects 1, 3

Sleep Assessment

• Monitor for insomnia, particularly with afternoon or evening dosing 1, 3
• Adjust timing if sleep disturbances occur 2

Common Adverse Effects

The most frequent treatment-emergent adverse events include:

• Dry mouth, headache, and insomnia (most common) 8, 3
• Decreased appetite and abdominal pain 3
• Irritability 3
• Most adverse effects are mild to moderate in intensity and transient 8, 3
• Adverse events infrequently lead to discontinuation 8

Special Clinical Scenarios

Patients with Substance Use History

• Lisdexamfetamine is a feasible option for patients with ADHD and stimulant use disorder due to its lower abuse potential 9
• Case reports demonstrate successful treatment without exacerbation of addictive behaviors and even reduction in stimulant cravings 9
• Long-acting formulations are preferred in patients with substance abuse concerns due to lower diversion potential 2
• However, assess each patient's risk for abuse, misuse, and addiction before prescribing and monitor throughout treatment 1

Comorbid Depression or Anxiety

• Stimulants remain first-line even with comorbid mood or anxiety symptoms 2
• If ADHD symptoms improve but depressive symptoms persist, add an SSRI to the stimulant regimen 2
• Presence of anxiety does not contraindicate stimulant use but requires careful monitoring 5

Inadequate Response

• If response to lisdexamfetamine is inadequate after adequate titration, trial methylphenidate before considering non-stimulants, as approximately 40% of patients respond to only one stimulant class 5
• Do not assume tolerance development—there is little evidence of tolerance to stimulant effects on ADHD symptoms, and most patients continue responding to the same dose over prolonged treatment 2

Critical Safety Warnings

Black Box Warning

• High potential for abuse and misuse, which can lead to substance use disorder, including addiction 1
• Misuse and abuse can result in overdose and death, with increased risk at higher doses or unapproved administration methods (snorting, injection) 1
• Educate patients and families about proper storage and disposal of unused medication 1

Absolute Contraindications

• Active stimulant abuse 2
• Symptomatic cardiovascular disease 2
• Uncontrolled hypertension 5
• Concurrent or recent (within 14 days) MAO inhibitor use 2

Common Pitfalls to Avoid

• Do not underdose—the 30 mg starting dose is at the low end of the therapeutic range; most adults require 50-70 mg daily for optimal control 2, 1
• Do not prescribe for weight loss—lisdexamfetamine is not indicated for obesity treatment, and use of sympathomimetics for weight loss has been associated with serious cardiovascular adverse events 1
• Do not assume single antidepressant will treat both ADHD and depression—no antidepressant is proven for this dual purpose; treat ADHD with stimulants first 2
• Do not discontinue effective treatment solely due to concerns about long-term use—untreated ADHD is associated with increased risk of accidents, substance abuse, and functional impairment 5