What is the recommended starting dose of Vyvanse (lisdexamfetamine) for a patient aged 6 years or older with attention‑deficit/hyperactivity disorder and no contraindicating cardiovascular disease, uncontrolled hypertension, hyperthyroidism, severe anxiety, or history of psychosis?

Starting Dose of Vyvanse for ADHD

Begin Vyvanse at 30 mg once daily in the morning for patients aged 6 years and older with ADHD. 1

Initial Dosing Protocol

• The FDA-approved starting dose is 30 mg orally every morning, which serves as both the initial and recommended therapeutic dose for most patients 1
• Administer the dose early in the morning (approximately 0700 hours) to maximize daytime coverage and minimize sleep disturbance 2
• The medication can be taken with or without food, and capsules may be opened and mixed with water if swallowing is difficult 1

Titration Schedule

• Increase by 10 mg or 20 mg weekly intervals based on clinical response and tolerability 1
• The recommended therapeutic range is 30 mg to 70 mg per day, with 70 mg representing the maximum approved dose 1
• Systematic assessment of ADHD symptoms using standardized rating scales should guide each dose adjustment 3
• Most patients achieve optimal response within the 30–70 mg range when properly titrated 4, 5

Duration of Effect and Coverage

• Vyvanse provides approximately 12 hours of symptom control from a single morning dose due to its prodrug design and rate-limited conversion to active dextroamphetamine 5, 6
• Clinical trials demonstrate maintained efficacy throughout the entire day, with significant improvements measured at 1000,1400, and 1800 hours (effect sizes 1.42,1.41, and 1.30 respectively) 2
• The prodrug mechanism results in gradual release of active drug, avoiding the rapid peak concentrations seen with immediate-release formulations 7, 5

Baseline Assessment Requirements

• Measure blood pressure and pulse before initiating therapy, as stimulants can increase cardiovascular parameters 3, 1
• Obtain a detailed cardiac history including syncope, chest pain, palpitations, and family history of premature cardiovascular death or structural heart disease 3
• Screen for contraindications including known structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, uncontrolled hypertension, hyperthyroidism, glaucoma, and active psychosis 1
• Document baseline height and weight in pediatric patients to monitor growth effects 3, 1
• Screen for personal or family history of substance use disorders, as this may influence formulation choice 3

Ongoing Monitoring During Titration

• Reassess ADHD symptoms weekly during dose adjustment using standardized rating scales from both home and school/work settings 3
• Check blood pressure and pulse at each dose increase to detect cardiovascular effects early 3, 1
• Monitor for common adverse effects including decreased appetite (most common), insomnia, irritability, headache, and weight loss 1, 4, 6
• Evaluate both therapeutic benefits and side effects before each dose escalation 8

Special Population Considerations

Renal Impairment

• Severe renal impairment (GFR 15–29 mL/min/1.73 m²): maximum dose 50 mg/day 1
• End-stage renal disease (ESRD, GFR <15 mL/min/1.73 m²): maximum dose 30 mg/day 1

Pediatric Patients Under 6 Years

• Vyvanse is not approved for children younger than 6 years, as this population experienced more pronounced long-term weight loss compared to older children 1

Older Adults

• Consider a more conservative titration schedule (e.g., 5 mg increases every 2 weeks instead of weekly) due to age-related pharmacokinetic changes and increased sensitivity to both therapeutic and adverse effects 8

Common Pitfalls to Avoid

• Do not start at doses higher than 30 mg, as this increases the risk of unnecessary side effects and poor medication adherence 8
• Do not use Vyvanse for weight loss—the drug is not indicated for obesity, and use of sympathomimetic agents for weight reduction has been associated with serious cardiovascular events 1
• Do not co-administer with MAO inhibitors or within 14 days of stopping an MAOI, as this combination can cause hypertensive crisis 3, 1
• Do not assume treatment failure if 30 mg is effective—many patients achieve optimal control at the starting dose and do not require titration 3
• Do not skip baseline cardiovascular assessment, as undetected cardiac disease represents a serious safety risk with stimulant therapy 3, 1

Advantages of the Prodrug Design

• The prodrug formulation provides reduced abuse potential compared to immediate-release dextroamphetamine, with lower drug-liking scores in human abuse liability studies 7, 6
• Rate-limited enzymatic hydrolysis in the blood creates a smoother pharmacokinetic profile, reducing toxicity potential and overdose risk 4, 7
• Once-daily dosing improves medication adherence compared to multiple-daily-dose formulations 3, 5