What is the difference between Concerta (methylphenidate) and Vyvanse (lisdexamfetamine) for treating Attention Deficit Hyperactivity Disorder (ADHD)?

Concerta vs Vyvanse for ADHD Treatment

Both Concerta (methylphenidate) and Vyvanse (lisdexamfetamine) demonstrate equivalent efficacy for ADHD with approximately 70% response rates and essentially identical side effect profiles, but Vyvanse may be preferred in adolescents specifically due to its lower abuse potential. 1

Mechanism of Action

• Concerta uses an osmotic-release oral system (OROS) that delivers methylphenidate continuously throughout the day, producing an ascending plasma drug level pattern designed to last 12 hours—equivalent to methylphenidate given three times daily. 1, 2

• Vyvanse is a prodrug that must be enzymatically converted to dextroamphetamine after ingestion, which creates a more gradual onset and makes extraction of the active stimulant component more difficult. 1, 3

• Both medications work by enhancing dopamine and norepinephrine signaling in the prefrontal cortex and subcortical brain regions, though through different mechanisms (methylphenidate blocks dopamine reuptake, while amphetamines increase dopamine release). 2, 4

Efficacy Comparison

• No clinically meaningful differences exist in overall effectiveness between the two medications across multiple domains of ADHD symptoms. 1

• Short-term trials (typically 3 months or less) show approximately 70% response rates for both medications as part of the stimulant class. 1

• Both medications improve core ADHD symptoms including inattention, hyperactivity, and impulsivity, with effects lasting throughout the school day and into early evening. 5

• Concerta maintains symptom control for 12 hours in laboratory settings, preventing the behavioral deterioration that occurs across the day without medication. 5

• Vyvanse demonstrates long-term effectiveness in reducing ADHD symptoms in adults, though maintenance of efficacy requires ongoing treatment. 6

Side Effect Profiles

• The side effect profiles are essentially identical between Concerta and Vyvanse, as both are CNS stimulants affecting similar neurotransmitter systems. 1

• Common side effects for both include:

  • Appetite suppression: Manage by giving medication with meals and offering high-calorie snacks in the evening when effects wear off. 1
  • Insomnia: Address by distinguishing whether it's a medication side effect versus oppositional behavior; lower the dose or move administration earlier in the day. 1
  • Weight loss: Associated with small weight decrements during short-term trials, but long-term follow-up shows no significant impairment of final height attained. 1

• Both medications carry risks of increased blood pressure and heart rate, requiring regular monitoring. 7, 8

• Both can cause new or worsening psychiatric symptoms including psychosis, mania, or behavioral problems. 7, 8

Abuse Potential: A Key Differentiator

• Vyvanse has lower abuse potential compared to Concerta, making it particularly advantageous in adolescent populations. 1, 3

• Vyvanse's prodrug design requires enzymatic conversion to the active form, making extraction and misuse (snorting or injection) more difficult compared to other stimulants. 1, 3

• Concerta's OROS technology is designed to be resistant to diversion (cannot be ground up or snorted), which provides some protection against misuse. 9

• Both medications are DEA Schedule II controlled substances with high potential for abuse, misuse, and addiction. 7, 8

• Oral administration of therapeutic doses has limited ability to induce euphoria compared to other routes of administration. 1

Special Populations

Adolescents

• Vyvanse may be preferred in adolescents specifically due to lower abuse potential. 1, 3

• Longer-acting preparations like both Concerta and Vyvanse maintain privacy in school by eliminating the need for midday dosing. 9

• Compliance improves with once-daily formulations since adolescents are responsible for their own medication management. 9

Pregnancy and Breastfeeding

• Neither medication appears associated with major congenital malformations. 1

• Both carry possible small increased risks for gastroschisis, preeclampsia, and preterm birth. 1, 3

• Both medications are compatible with breastfeeding with appropriate infant monitoring for irritability, insomnia, and feeding difficulties. 1

• Amphetamines (Vyvanse) cross the placental barrier, and limited published information exists specifically on lisdexamfetamine use during pregnancy. 3

Adults

• Both medications are effective in adults with ADHD, with Vyvanse showing efficacy in treatment-naïve patients and those who previously failed other ADHD therapies including methylphenidate. 6

Dosing Considerations

• Concerta: Start at equivalent to 5-15 mg methylphenidate three times daily (18-54 mg Concerta once daily), with Concerta doses approximately 20% higher on a daily basis than comparable immediate-release methylphenidate regimens to achieve ascending delivery rates. 5

• Vyvanse: Start at 20-30 mg once daily in the morning, titrate by increasing 10 mg weekly to a maximum of 70 mg daily. 3

• Both medications require individualized dose titration based on clinical response rather than weight or plasma concentrations, as behavioral responses are highly variable. 2

Clinical Pitfalls to Avoid

• Do not prescribe either medication to patients with serious heart disease without careful cardiac evaluation, as sudden death has occurred in patients with heart defects. 7, 8

• Avoid use with MAO inhibitors or within 14 days of MAOI discontinuation. 7, 8

• Do not assume plasma concentration monitoring is clinically useful for methylphenidate—dose based on behavioral response. 2

• Screen for substance abuse history before prescribing either medication, as both carry significant abuse potential despite Vyvanse's lower risk profile. 7, 8