How to manage a 40-year-old single adult with Attention Deficit Hyperactivity Disorder (ADHD) and a 4-year-old daughter, currently on Vyvanse (lisdexamfetamine) 70 mg, who complains of inadequate symptom control?

Management of Inadequate Vyvanse Response in Adult ADHD

Immediate Action: Optimize Current Vyvanse Dose

The patient is already at the maximum FDA-approved dose of 70 mg daily, so dose escalation is not an option. 1 Before switching medications or adding adjunctive therapy, systematically assess why the current regimen is failing.

Critical Assessment Steps

• Verify medication adherence and timing - Vyvanse should be taken in the morning for optimal 12-14 hour coverage, and inconsistent dosing can mimic treatment failure 2

• Assess duration of coverage - If symptoms are controlled during part of the day but wear off in late afternoon/evening (typically around 4:00 PM), this represents inadequate duration rather than true treatment failure 3

• Screen for comorbid conditions that may be masquerading as ADHD symptoms or reducing treatment response, including depression, anxiety, sleep disorders, or substance use 2, 4

• Evaluate for psychiatric adverse effects - Stimulants can cause irritability, anxiety, or mood changes that patients may interpret as "not working" 1

Primary Strategy: Add Afternoon Booster Dose

If the issue is late-day symptom breakthrough (Vyvanse wearing off before evening), add immediate-release dextroamphetamine 5-10 mg at 3:00-4:00 PM to extend coverage. 3 This approach:

• Provides 3-4 additional hours of symptom control for evening responsibilities and parenting 3
• Maintains the abuse-deterrent benefits of Vyvanse for the majority of daily coverage 5, 6
• Avoids the need to abandon a partially effective medication 2

Critical timing consideration: Do not dose the booster after 4:00-5:00 PM, as this will cause sleep onset difficulties that worsen overall ADHD symptoms 3

Secondary Strategy: Switch to Alternative Stimulant

If Vyvanse provides inadequate symptom control throughout the day (not just late-day wear-off), switch to methylphenidate-based long-acting formulations. 2 The rationale:

• Approximately 40% of patients respond to only one stimulant class (amphetamine vs. methylphenidate), and 90% will respond to at least one class when both are systematically trialed 2, 3
• Methylphenidate has the strongest evidence base with 70% response rates when a full dose range is trialed 2
• Long-acting methylphenidate formulations (Concerta, extended-release) provide 8-12 hours of coverage with once-daily dosing 2, 4

Specific dosing: Start methylphenidate extended-release at 18 mg once daily in the morning, titrating by 18 mg weekly up to 54-72 mg daily maximum based on response 3, 4

Tertiary Strategy: Add Non-Stimulant Adjunctive Therapy

If stimulant optimization fails or the patient has residual symptoms despite adequate stimulant response, add guanfacine extended-release as FDA-approved adjunctive therapy. 3, 4

• Start guanfacine ER 1 mg once daily in the evening, titrating by 1 mg weekly based on response and tolerability 3, 4
• Maximum dose is 7 mg daily or 0.05-0.12 mg/kg/day 4
• Particularly useful if the patient has comorbid oppositional symptoms, sleep disturbances, or emotional dysregulation 3, 4
• Never abruptly discontinue guanfacine - taper by 1 mg every 3-7 days to avoid rebound hypertension 4

Alternative Non-Stimulant Option: Atomoxetine

If stimulants are contraindicated or the patient prefers a non-controlled substance, switch to atomoxetine. 2, 4

• Start at 40 mg daily, titrating every 7-14 days to 60 mg, then 80 mg, with a maximum of 100 mg daily or 1.4 mg/kg/day 2, 4
• Critical limitation: Requires 6-12 weeks to achieve full therapeutic effect, unlike stimulants which work within days 2, 4
• Has medium-range effect sizes (approximately 0.7) compared to stimulants, making it less effective overall 4
• Useful if substance abuse history is a concern, as it is an uncontrolled substance with no abuse potential 4

Essential Monitoring Parameters

• Cardiovascular monitoring: Check blood pressure and pulse at each visit, as both Vyvanse and any alternative medications can increase these parameters 2, 1

• Growth monitoring in children: Not applicable to this 40-year-old patient, but document height and weight at baseline and periodically 1

• Psychiatric symptoms: Screen for new or worsening anxiety, irritability, mood changes, or psychotic symptoms before initiating and throughout treatment 1

• Functional outcomes: Use standardized rating scales to objectively track ADHD symptom response, not just subjective patient report 2, 3

Common Pitfalls to Avoid

• Underdosing is a major problem in community practice - However, this patient is already at maximum Vyvanse dose, so the issue is likely medication class mismatch rather than inadequate dosing 2, 3

• Premature medication switching - Ensure you've addressed adherence, timing, comorbidities, and tried afternoon booster dosing before abandoning Vyvanse entirely 2

• Ignoring parenting demands - A single parent with a 4-year-old needs evening symptom coverage for childcare responsibilities; standard 8 AM to 4 PM coverage is insufficient 3

• Assuming tolerance has developed - There is little evidence that tolerance develops to stimulant effects on ADHD symptoms, so "not working anymore" usually indicates inadequate duration of coverage or emerging comorbidities, not true tolerance 4

Special Consideration: Single Parent with Young Child

This patient's parenting responsibilities require extended symptom coverage into evening hours. 3 The combination of Vyvanse 70 mg in the morning plus immediate-release dextroamphetamine 5-10 mg at 3:00-4:00 PM specifically addresses this need while maintaining the abuse-deterrent properties of Vyvanse for the majority of the day 5, 6, 7