What is the recommended Vyvanse (lisdexamfetamine) dosing and titration schedule for an adult with binge‑eating disorder, including contraindications, baseline assessments, monitoring parameters, and maximum dose?

Vyvanse Dosing for Binge Eating Disorder

For adults with moderate to severe binge eating disorder, start lisdexamfetamine (Vyvanse) at 30 mg once daily in the morning, then titrate by 20 mg increments at weekly intervals to reach the target dose of 50-70 mg/day, with a maximum of 70 mg/day. 1

Starting Dose and Titration Schedule

• Begin with 30 mg once daily in the morning (with or without food), avoiding afternoon doses due to insomnia risk 1
• Titrate in 20 mg increments at approximately weekly intervals until reaching the target therapeutic range 1
• Target dose is 50-70 mg/day, as these doses demonstrated superior efficacy compared to placebo in reducing binge eating days per week 2, 3
• Maximum dose is 70 mg/day for BED treatment 1

The FDA label specifies this titration differs from ADHD dosing (which uses 10-20 mg increments); for BED, the larger 20 mg weekly increments are used to reach therapeutic doses more rapidly 1.

Baseline Assessments Required

Before initiating lisdexamfetamine, perform the following mandatory screening:

• Cardiac assessment: Obtain careful personal and family history of sudden death or ventricular arrhythmia, plus physical examination to detect cardiac disease 1
• Tic disorder screening: Evaluate family history and clinically assess for motor or verbal tics or Tourette's syndrome 1
• Baseline vital signs: Document blood pressure, pulse, height, and weight 4
• Psychiatric history: Screen for history of substance abuse, psychotic disorders, and current psychiatric comorbidities 1

Absolute Contraindications

Lisdexamfetamine is contraindicated in patients with:

• Known hypersensitivity to amphetamine products (including history of anaphylaxis, Stevens-Johnson Syndrome, angioedema, or urticaria) 1
• Current MAOI use or within 14 days of stopping MAOIs (including linezolid or IV methylene blue) due to hypertensive crisis risk 1
• Symptomatic cardiovascular disease 4
• Active psychotic disorder 4
• History of illicit stimulant abuse (unless in controlled/supervised setting) 4

Additional cautions include glaucoma, hyperthyroidism, and hypertension, though these are relative rather than absolute contraindications 4.

Monitoring Parameters

During Titration (First 3 Months)

• Assess efficacy and safety monthly for the first 3 months 5
• Monitor vital signs: Check blood pressure and pulse at each visit, as mean increases of 4-6 bpm and 1-2 mmHg systolic/diastolic are expected 3
• Track binge eating frequency: Document binge eating days per week to assess response 2
• Weight monitoring: Expected mean weight loss is 4-5 kg with therapeutic doses 2

Ongoing Maintenance

• Assess at least every 3 months after initial titration period 5
• Discontinue if no improvement: Stop lisdexamfetamine if binge eating does not improve 1
• Monitor for psychiatric symptoms: Watch for emergence or worsening of depression, anxiety, suicidal ideation, or behavioral changes 6
• Screen for abuse/misuse: Assess for signs of medication diversion or inappropriate use 1

Dose Adjustments for Special Populations

Renal Impairment

• Severe renal impairment (GFR 15-30 mL/min/1.73 m²): Maximum dose 50 mg/day 1
• End-stage renal disease (GFR <15 mL/min/1.73 m²): Maximum dose 30 mg/day 1

Drug Interactions Affecting Dosing

• Urinary acidifying agents (e.g., ascorbic acid): Decrease amphetamine blood levels; may require dose increase 1
• Urinary alkalinizing agents (e.g., sodium bicarbonate): Increase amphetamine blood levels; may require dose reduction 1

Place in Therapy

Psychotherapy (specifically eating disorder-focused CBT or interpersonal therapy) remains first-line treatment for BED, not medication 5, 7. Lisdexamfetamine should be considered when:

• Patients prefer medication over psychotherapy 8, 5
• Inadequate response to psychotherapy alone 8, 5
• Comorbid obesity is present and weight management is a treatment goal 5

The combination of lisdexamfetamine with ongoing psychotherapy provides superior outcomes compared to either modality alone 7.

Clinical Efficacy Data

The 50-70 mg/day doses demonstrated:

• Significant reduction in binge eating days per week: Mean decrease of 4.1 days/week vs 3.3 days/week with placebo 2
• 4-week binge eating cessation rates: 42-50% with active treatment vs 21% with placebo 2
• Sustained efficacy: Benefits maintained through 52 weeks of open-label treatment 6
• Relapse prevention: Marked reduction in BED relapse risk during withdrawal phase 9

Common Adverse Effects and Management

The most frequent treatment-emergent adverse events (occurring in ≥10% of patients) include:

• Dry mouth (27%): Most common side effect 6
• Headache (13%) 6
• Insomnia (12%): Mitigated by morning-only dosing 6
• Upper respiratory tract infection (11%) 6

Most adverse events are mild to moderate in severity, with only 9% discontinuing due to side effects in long-term studies 6. The safety profile is consistent with lisdexamfetamine's established profile in ADHD 9, 3.

Critical Clinical Pitfalls

• Do not divide doses: A single daily dose should not be split; minimum dosing is one capsule per day 1
• Avoid use for weight loss alone: Lisdexamfetamine is not indicated for obesity treatment; use of sympathomimetics for weight loss has been associated with serious cardiovascular events 1
• Monitor cardiovascular parameters closely: Small but consistent increases in blood pressure and heart rate occur 3
• Watch for anxiety worsening: While depression and ADHD symptoms may improve in comorbid patients, anxiety effects should be monitored closely 10
• Assess abuse potential: High potential for abuse, misuse, and diversion exists; evaluate each patient's risk before prescribing 1