For a young adult or adolescent with ADHD and comorbid anxiety, without cardiovascular disease, uncontrolled hypertension, psychosis, or substance‑use disorder, what are the benefits, recommended dosing, and monitoring considerations when using Vyvanse (lisdexamfetamine)?

Vyvanse for ADHD and Comorbid Anxiety

Vyvanse (lisdexamfetamine) is a first-line, highly effective treatment for ADHD even when anxiety is present, and contrary to outdated concerns, it does not worsen anxiety—in fact, high-quality evidence shows that patients with ADHD plus anxiety achieve better treatment responses to stimulants than those without anxiety. 1, 2

Why Vyvanse Works for Both ADHD and Anxiety

• The MTA study definitively demonstrated that stimulants do not exacerbate anxiety in patients with comorbid anxiety disorders; response rates to ADHD treatment were actually higher in the anxious subgroup. 1, 2
• Treating ADHD with stimulants often indirectly improves mood and anxiety symptoms by reducing ADHD-related functional impairment, stress, and daily failures. 1
• Stimulants work within days, allowing rapid assessment of whether ADHD symptom control alone resolves the anxiety. 1, 2
• Approximately 10% of adults with recurrent anxiety have undiagnosed ADHD; treating anxiety alone leaves ADHD-related functional deficits unaddressed and quality of life impaired. 1

Dosing and Titration Protocol

Starting dose:

• Begin at 20–30 mg once daily in the morning for adults and adolescents. 1, 2, 3
• For children ages 6–12, start at 30 mg once daily. 3

Titration schedule:

• Increase by 10–20 mg weekly based on ADHD symptom response and tolerability. 1, 2
• Target therapeutic range: 30–70 mg daily; maximum dose is 70 mg/day. 1, 2, 3
• Systematic titration yields >70% of patients achieving optimal response. 2

Duration of action:

• Vyvanse provides 12–14 hours of continuous symptom control due to its prodrug design, eliminating the need for multiple daily doses and reducing rebound symptoms. 4, 5, 6, 7
• Onset of action occurs within 1–2 hours post-dose. 4

Monitoring Requirements

At baseline (before starting):

• Measure blood pressure and pulse. 1, 2, 3
• Obtain detailed cardiac history (syncope, chest pain, palpitations, family history of sudden cardiac death or arrhythmias). 1
• Screen for substance-use risk in adolescents and adults. 1
• Document height and weight (especially in pediatric patients). 1, 2, 3

During titration and maintenance:

• Check blood pressure and pulse at every dose adjustment during titration. 1, 2
• In adults: monitor vital signs quarterly during maintenance. 1
• In children/adolescents: measure height and weight at every visit to track growth effects. 1, 3
• Assess sleep quality, appetite changes, and weight at each follow-up. 1, 2, 3

Managing Persistent Anxiety After ADHD Improvement

If ADHD symptoms improve but anxiety remains after 4–6 weeks at optimal dose:

• First, add cognitive-behavioral therapy (CBT); evidence shows CBT + stimulant yields superior anxiety outcomes. 2
• If anxiety is severe or refractory to CBT, add an SSRI (e.g., sertraline, fluoxetine) to the Vyvanse regimen. 1, 2
• The stimulant + SSRI combination is safe, well-established, and has no significant pharmacokinetic interactions. 1, 2
• Never use a single antidepressant alone to treat both ADHD and anxiety—no antidepressant is proven effective for ADHD. 1

Common Adverse Effects

Most frequent (>10% incidence):

• Decreased appetite, insomnia, headache. 3, 5, 8, 7
• Weight loss (monitor closely in pediatric patients). 3, 7

Other common effects (≥5%):

• Dry mouth, irritability, dizziness, nausea, upper abdominal pain, increased heart rate, feeling jittery. 3, 7
• Most adverse effects are mild to moderate and transient. 6, 7

Absolute Contraindications

Do not prescribe Vyvanse if the patient has:

• Known hypersensitivity to amphetamine products. 3
• Current or recent (within 14 days) use of MAO inhibitors—risk of hypertensive crisis. 1, 2, 3
• Active psychosis or mania. 1
• Symptomatic cardiovascular disease, uncontrolled hypertension, or structural cardiac abnormalities. 1, 3
• Glaucoma, hyperthyroidism. 1

Relative Contraindications (Use with Caution)

• History of substance-use disorder: Vyvanse's prodrug design confers lower abuse potential than immediate-release stimulants because enzymatic conversion prevents rapid euphoric effects. 1, 4, 5, 8, 6 However, monitor closely and consider urine drug screening. 1
• Seizure disorder: Ensure patient is stable on anticonvulsants before starting. 1
• Unstable mood disorder: Stabilize mood first, though secondary depression often improves with ADHD treatment. 1

Renal Impairment Dosing

• Severe renal impairment (GFR 15–29 mL/min): Maximum dose is 50 mg/day. 3
• End-stage renal disease (ESRD, GFR <15 mL/min): Maximum dose is 30 mg/day. 3

Key Clinical Pearls

• Vyvanse is a prodrug: It is therapeutically inactive until enzymatically hydrolyzed in the blood to active dextroamphetamine, which provides consistent plasma levels throughout the day and reduces abuse potential. 4, 5, 8, 6
• Do not assume anxiety is a contraindication—this outdated belief deprives patients of the most effective ADHD treatment. 2
• Stimulants achieve 70–80% response rates for ADHD with the largest effect sizes across >161 randomized controlled trials. 1, 2
• Effective ADHD treatment often resolves comorbid anxiety without additional medication, leading to substantial reductions in overall morbidity. 1, 2
• Pediatric patients <6 years experience more long-term weight loss; Vyvanse is not indicated for children younger than 6. 3
• Vyvanse is not indicated for weight loss; use of sympathomimetic drugs for weight loss has been associated with serious cardiovascular adverse events. 3

Common Pitfalls to Avoid

• Do not delay stimulant treatment due to anxiety concerns—evidence proves stimulants are safe and effective in this population. 1, 2
• Do not use bupropion as first-line for ADHD—it is explicitly second-line with smaller effect sizes and slower onset than stimulants. 1
• Do not prescribe benzodiazepines for anxiety in ADHD patients—they reduce self-control and have disinhibiting effects. 1
• Do not rely solely on weight-adjusted (mg/kg) dosing—systematic titration to the lowest effective dose is preferred. 1