What is the recommended dosage and management of Vyvanse (Lisdexamfetamine) for a patient with ADHD or binge eating disorder, considering potential side effects and underlying medical conditions?

Vyvanse (Lisdexamfetamine) Dosing and Management

Starting Dose and Titration Protocol

Begin with 30 mg once daily in the morning for both ADHD and binge eating disorder (BED), then titrate in increments of 10-20 mg at weekly intervals to a maximum of 70 mg daily. 1

• Take Vyvanse orally in the morning with or without food; avoid afternoon doses due to insomnia risk 1
• For ADHD: Start at 30 mg, increase by 10-20 mg weekly up to 70 mg maximum 1
• For moderate-to-severe BED: Start at 30 mg, titrate in 20 mg increments weekly to target dose of 50-70 mg daily 1
• Maintain weekly telephone contact during initial titration, which typically requires 2-4 weeks to reach optimal dosing 2
• After stabilization, schedule follow-up appointments at least monthly 2

Renal Dosing Adjustments

Reduce maximum dose to 50 mg daily in severe renal impairment (GFR 15-30) and 30 mg daily in end-stage renal disease (GFR <15). 1

Pre-Treatment Screening Requirements

Before initiating Vyvanse, you must assess: 1

• Cardiovascular disease: Perform careful history, family history of sudden death or ventricular arrhythmia, and physical exam
• Tics or Tourette's syndrome: Evaluate family history and clinically assess for motor or verbal tics
• Substance abuse history: Screen for current or past abuse, as this represents a relative contraindication requiring close supervision 3
• Baseline vital signs: Obtain blood pressure and pulse before starting treatment 4

Monitoring During Treatment

Systematically assess at each visit: 2

• Side effects: Ask specifically about insomnia, decreased appetite, headaches, and weight loss
• Weight: Monitor regularly as weight loss is common with stimulants 2
• Vital signs: Check blood pressure and pulse at each visit 4
• ADHD rating scales: Use standardized scales from patient and significant others to objectively measure improvement 2
• Growth parameters: Monitor height and weight, particularly in younger patients 4

Common Side Effects

The most frequent treatment-emergent adverse events include: 5

• Dry mouth
• Headache
• Insomnia
• Decreased appetite
• Nausea

Most adverse events are mild to moderate in intensity and infrequently lead to discontinuation 5

Absolute Contraindications

Do not prescribe Vyvanse in patients with: 1

• Known hypersensitivity to amphetamine products (anaphylaxis, Stevens-Johnson Syndrome, angioedema, urticaria have been reported)
• Current MAOI use or within 14 days of stopping MAOIs (including linezolid or IV methylene blue) due to hypertensive crisis risk
• Symptomatic cardiovascular disease 3

Drug Interactions Requiring Dose Adjustment

Agents that alter urinary pH impact amphetamine blood levels and require dose adjustment: 1

• Acidifying agents (e.g., ascorbic acid) decrease blood levels—may need to increase Vyvanse dose
• Alkalinizing agents (e.g., sodium bicarbonate) increase blood levels—may need to decrease Vyvanse dose

Administration Options

Vyvanse can be taken in two ways: 1

1. Swallow capsule whole, or
2. Open capsule and mix contents with yogurt, water, or orange juice; consume entire mixture immediately (do not store)

Do not take less than one capsule per day; a single dose should not be divided 1

Efficacy Data

• ADHD: Demonstrated efficacy at 14 hours post-dose in adults, providing all-day symptom control 6
• BED: 50-70 mg daily showed significantly greater reduction in binge eating days/week compared to placebo in two pivotal 12-week trials 5
• Long-term data: Up to 52 weeks of treatment showed marked reduction in BED relapse risk versus placebo 5
• Comparative efficacy: Post-hoc analysis showed lisdexamfetamine produced statistically significantly greater ADHD symptom improvement than OROS methylphenidate (difference of -5.6 points on ADHD-RS-IV, p<0.001) 7

When to Discontinue or Switch

• For BED: Discontinue if binge eating does not improve 1
• For ADHD: If adequate symptom control is not achieved at maximum 70 mg dose, consider alternative treatments or adding non-stimulant medications 2
• If first stimulant trial fails, switch to alternative stimulant formulation before moving to non-stimulants 3

Critical Pitfalls to Avoid

• Do not start at excessively high doses—this increases adverse effects and reduces adherence 3
• Do not assume tolerance develops—there is little evidence of tolerance to stimulant effects on ADHD symptoms; if symptoms worsen, assess for new psychiatric comorbidities rather than automatically increasing dose 4
• Do not fail to systematically assess both benefits and side effects during titration 2
• Do not use with MAOIs—at least 14 days must elapse between MAOI discontinuation and Vyvanse initiation 4