My insurance won’t cover Mydayis (mixed amphetamine salts extended‑release) and Adderall XR (mixed amphetamine salts extended‑release) is ineffective; what alternative stimulant or adjunct therapy is recommended?

Alternative Stimulant Recommendations When Mydayis Is Not Covered and Adderall XR Is Ineffective

Switch to lisdexamfetamine (Vyvanse) 30–70 mg once daily as your first-line alternative, because it is a prodrug amphetamine with comparable efficacy to Adderall XR but offers 12–13 hour duration, reduced abuse potential, and may provide superior symptom control in patients who fail mixed amphetamine salts. 1, 2

Why Lisdexamfetamine Is the Optimal Next Step

• Lisdexamfetamine is the preferred amphetamine-based stimulant for adults with ADHD based on comparative efficacy studies, achieving 70–80% response rates with large effect sizes. 1, 3 The prodrug formulation is specifically engineered to reduce abuse potential while maintaining therapeutic benefit, making it distinct from conventional amphetamine salts. 1

• Start at 20–30 mg once daily in the morning and titrate by 10–20 mg weekly up to a maximum of 70 mg daily. 1, 2 The therapeutic range is 30–70 mg/day, with most patients requiring 50–70 mg for optimal response. 1

• Lisdexamfetamine provides earlier onset of effect (within 1.5 hours) while maintaining prolonged 12–13 hour duration through its prodrug mechanism, potentially addressing the coverage gaps you experienced with Adderall XR. 1, 2 This extended duration may be why Mydayis was initially prescribed—lisdexamfetamine offers similar all-day coverage without requiring the triple-bead technology.

If Lisdexamfetamine Fails: Switch Stimulant Classes to Methylphenidate

• If you have inadequate response after adequate treatment with one stimulant class (amphetamines), trial the other class (methylphenidate) before considering non-stimulants, because approximately 40% of patients respond to both classes and 40% respond to only one. 1, 3

• Methylphenidate is the strongest evidence-based alternative with the most robust clinical trial data and highest response rates among all ADHD medications, achieving 70–80% response when properly titrated. 1, 3 For adults, dosing is 5–20 mg three times daily for immediate-release or use extended-release formulations (Concerta, Foquest) for once-daily dosing with maximum 60 mg daily. 4, 1

• Long-acting methylphenidate formulations such as Concerta (OROS system) provide 12 hours of continuous release with ascending plasma levels that reduce rebound effects and abuse potential. 1, 3 Start Concerta at 18 mg daily (equivalent to methylphenidate 5 mg three times daily) and titrate by 18 mg weekly up to 54–72 mg maximum. 1

Adjunctive or Alternative Non-Stimulant Options

When to Add (Not Switch) a Non-Stimulant

• If ADHD symptoms improve on lisdexamfetamine or methylphenidate but residual symptoms persist (especially evening coverage, sleep disturbances, or comorbid anxiety), add guanfacine extended-release 1–4 mg nightly as FDA-approved adjunctive therapy. 1, 3 Guanfacine is particularly useful when ADHD co-occurs with oppositional symptoms, tics, or sleep problems. 1

• The combination of stimulants plus guanfacine allows for lower stimulant dosages while maintaining efficacy and potentially reducing stimulant-related adverse effects. 1 Start at 1 mg nightly and titrate by 1 mg weekly based on response, with target range 0.05–0.12 mg/kg/day or maximum 7 mg/day. 1

When Stimulants Are Contraindicated or All Fail

• Atomoxetine 60–100 mg daily (maximum 1.4 mg/kg/day or 100 mg/day, whichever is lower) is the only FDA-approved non-stimulant for adult ADHD and should be reserved for patients who have failed two or more stimulant trials or have active substance-use disorder. 1, 3 However, atomoxetine has medium-range effect sizes (0.7 vs. 1.0 for stimulants) and requires 6–12 weeks to achieve full therapeutic effect. 1, 3

• Viloxazine extended-release is a repurposed serotonin-norepinephrine modulating agent with favorable efficacy and tolerability in pivotal adult ADHD trials, offering another non-stimulant option with zero abuse potential. 1

Critical Monitoring During Transition

• Measure blood pressure and pulse at baseline and at each dose adjustment during titration of any stimulant. 4, 1, 3 For adults on long-term stimulant therapy, check blood pressure and pulse quarterly. 4

• Obtain weekly ADHD symptom ratings during dose adjustment, specifically assessing ADHD symptom control, side effects, and functional improvement across work, home, and social settings. 1

• Monitor for appetite suppression, sleep disturbances, and weight changes—common adverse effects that can often be managed by switching to sustained-release formulations or adjusting dosing times rather than discontinuing therapy. 1

Common Pitfalls to Avoid

• Do not assume Adderall XR failure means all amphetamines will fail—lisdexamfetamine's prodrug mechanism and longer duration may provide superior response despite both being amphetamine-based. 1, 5 The pharmacokinetic differences are clinically meaningful.

• Do not jump to non-stimulants (atomoxetine, guanfacine) before trying both stimulant classes (amphetamines and methylphenidate), because stimulants have 70–80% response rates with effect sizes of 1.0 compared to 0.7 for non-stimulants. 1, 3 Non-stimulants are second-line after stimulant failure. 1

• Do not use immediate-release formulations when long-acting options are available—extended-release formulations improve adherence, provide consistent all-day coverage, reduce rebound effects, and lower diversion potential. 1, 3

• If the top recommended dose does not help, more is not necessarily better—a change in drug class or addition of behavioral/psychosocial intervention may be required. 4