How can I safely transition a patient on Adderall (dextroamphetamine‑amphetamine) 5 mg once daily to Vyvanse (lisdexamfetamine), including appropriate initial dose, titration schedule, and necessary cardiovascular and psychiatric monitoring?

Switching from Adderall 5 mg Daily to Vyvanse

For a patient on Adderall 5 mg once daily, initiate Vyvanse at 30 mg once daily in the morning and discontinue Adderall on the same day—no cross-titration or overlap is required. 1, 2

Rationale for Direct Switch

• Pharmacologically, both medications are amphetamine-based stimulants with similar mechanisms of action (dopamine and norepinephrine reuptake inhibition and release), making gradual cross-titration unnecessary. 2
• Vyvanse (lisdexamfetamine) is a prodrug that is enzymatically converted to d-amphetamine in red blood cells, providing a smoother, longer-acting therapeutic effect (~12–14 hours) compared to immediate-release Adderall. 3, 4, 5, 6
• The FDA-approved starting dose of Vyvanse for ADHD in adults is 30 mg once daily, which is the recommended initial dose regardless of prior stimulant exposure. 3, 1

Initial Dosing and Titration

• Start Vyvanse at 30 mg every morning on the day you discontinue Adderall 5 mg. 3, 1
• Titrate Vyvanse by 10 mg or 20 mg weekly based on ADHD symptom response and tolerability, using standardized rating scales to guide dose adjustments. 3, 1
• The therapeutic range for Vyvanse in adults is 30–70 mg daily, with a maximum dose of 70 mg/day. 3, 1
• Most adults achieve optimal symptom control at 50–70 mg daily, though individual response varies and systematic titration to the lowest effective dose is preferred over weight-based calculations. 1, 3

Cardiovascular and Psychiatric Monitoring

Baseline Assessment (Before Initiating Vyvanse)

• Measure blood pressure and pulse in both seated and standing positions to establish baseline cardiovascular parameters. 1, 3
• Obtain a detailed cardiac history, including any personal or family history of syncope, chest pain, palpitations, arrhythmias, structural heart disease, or premature cardiovascular death. 1
• Screen for psychiatric risk factors, including prior psychotic or manic episodes, current mood instability, active substance use, and suicidal ideation. 1, 3
• Document height and weight to monitor for stimulant-related growth suppression (particularly relevant in younger patients, but baseline data are useful in adults). 1, 3

During Titration (Weekly Visits)

• Check blood pressure and pulse at each dose adjustment to detect emerging hypertension or tachycardia. 1, 3
• Assess ADHD symptom response using standardized rating scales (e.g., ADHD-RS) to objectively track improvement. 1
• Monitor for common adverse effects, including decreased appetite, insomnia, headache, irritability, and anxiety—each occurs in >10% of patients. 3, 6, 7
• Screen for new or worsening psychiatric symptoms, including agitation, mood lability, psychotic symptoms (hallucinations, delusions), or manic features (decreased need for sleep, grandiosity, pressured speech). 1, 3

Maintenance Phase (Quarterly Visits)

• Measure blood pressure and pulse every 3 months in adults on stable doses. 1
• Track weight and appetite changes at each visit, as chronic stimulant use can cause sustained appetite suppression. 1, 3
• Reassess for signs of abuse, misuse, or diversion, including requests for early refills, dose escalation without clinical justification, or behavioral changes suggesting substance use disorder. 3, 1

Contraindications and Precautions

Absolute Contraindications

• Known hypersensitivity to amphetamine products. 3
• Current or recent (within 14 days) use of monoamine oxidase inhibitors (MAOIs), due to risk of hypertensive crisis. 3, 1
• Symptomatic cardiovascular disease, including known structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, or coronary artery disease. 3, 1
• Active psychotic disorder or mania. 1, 3

Relative Contraindications (Use with Caution)

• History of substance use disorder: Consider long-acting formulations like Vyvanse, which have lower abuse potential due to prodrug design, but implement monthly monitoring and urine drug screening. 1, 3
• Uncontrolled hypertension: Optimize blood pressure control before initiating Vyvanse. 3, 1
• Seizure disorder: Ensure the patient is stable on anticonvulsant therapy. 1
• Comorbid anxiety: Recent data show stimulants do not necessarily worsen anxiety and may improve symptoms by reducing ADHD-related functional impairment. 1

Common Pitfalls to Avoid

• Do not attempt to calculate an "equivalent dose" between Adderall 5 mg and Vyvanse—the FDA-approved starting dose of Vyvanse is 30 mg regardless of prior stimulant exposure, and individual response is unpredictable. 3, 1
• Do not assume the patient will require the maximum dose (70 mg) simply because they are switching from another stimulant—systematic weekly titration based on symptom response is more important than arbitrary dose escalation. 1, 3
• Do not overlook cardiovascular monitoring—stimulants can cause clinically significant increases in blood pressure and heart rate, and failure to monitor can result in undetected hypertension or arrhythmias. 3, 1
• Do not dismiss new psychiatric symptoms as "adjustment to the new medication"—stimulants can precipitate or unmask psychotic or manic episodes, and prompt evaluation is required if hallucinations, delusions, or mood instability emerge. 3, 1
• Do not prescribe Vyvanse to patients on MAOIs or within 14 days of MAOI discontinuation—this combination can cause severe hypertension and cerebrovascular accidents. 3, 1

Special Considerations

Renal Impairment

• Severe renal impairment (eGFR 15–29 mL/min/1.73 m²): Maximum dose is 50 mg/day. 3
• End-stage renal disease (ESRD, eGFR <15 mL/min/1.73 m²): Maximum dose is 30 mg/day. 3

Prodrug Advantages

• Vyvanse's prodrug design provides a smoother pharmacokinetic profile with less pronounced peak-and-trough effects compared to immediate-release Adderall, potentially reducing rebound irritability and improving tolerability. 4, 5, 6
• The rate-limited enzymatic conversion to d-amphetamine reduces abuse potential, as crushing or snorting the capsule does not produce an immediate "high." 3, 6, 7
• Duration of action is approximately 12–14 hours, providing all-day symptom coverage with once-daily dosing and reducing the need for afternoon booster doses. 5, 6

If Inadequate Response After Titration

• If ADHD symptoms remain inadequately controlled at Vyvanse 70 mg/day, consider switching to methylphenidate-based stimulants (e.g., Concerta, Ritalin LA) rather than exceeding the maximum dose, as approximately 40% of patients respond preferentially to one stimulant class over the other. 1
• If two or more stimulant trials fail, consider non-stimulant alternatives such as atomoxetine (60–100 mg/day), guanfacine extended-release (1–4 mg/day), or viloxazine extended-release. 1