Drug Holidays from Vyvanse (Lisdexamfetamine)
Drug holidays from Vyvanse are a safe and commonly practiced strategy that can serve multiple clinical purposes, including assessment of ongoing medication need, management of side effects (particularly appetite suppression and insomnia), and enabling catch-up growth in pediatric patients. 1
Evidence Supporting Drug Holiday Practice
Prevalence and Patterns
- Drug holidays are practiced by 25–70% of families taking ADHD stimulant medications, with most families implementing them during school holidays rather than weekends. 1
- Shorter breaks (weekends) can reduce insomnia and improve appetite, while longer breaks (school holidays) show positive impact on child growth when medication has suppressed growth parameters. 1
Clinical Purposes of Drug Holidays
- Assessment function – Drug holidays allow testing whether medication is still needed, particularly valuable for adolescents showing signs of wanting to discontinue treatment prematurely, as they can self-assess their ability to manage without medication under medical supervision. 2
- Side effect management – Planned breaks address common adverse effects including appetite suppression (incidence ≥5%), insomnia (incidence ≥5%), and growth suppression, which are among the most frequent dose-limiting side effects of lisdexamfetamine. 3, 1
- Drug tolerance assessment – Families use drug holidays to evaluate whether tolerance has developed, though evidence shows little development of tolerance to stimulant effects on ADHD symptoms with appropriate dosing. 1
Safety Profile During Drug Holidays
No Withdrawal Syndrome
- Lisdexamfetamine can be discontinued immediately without a washout period because stimulants do not produce physiologic dependence requiring tapering in therapeutic use. 4
- The prodrug design of lisdexamfetamine, which requires enzymatic hydrolysis in blood to convert to active d-amphetamine, provides a gradual offset of effect that may reduce rebound symptoms compared to immediate-release formulations. 5, 6
Monitoring During Holidays
- Families should monitor for return of core ADHD symptoms including inattention, hyperactivity, and impulsivity during the drug holiday period. 1
- Parents' ability to cope with the child's behavior and the child's academic progress are key factors influencing the decision to continue or resume medication after a holiday. 2
Implementation Guidelines
Timing Recommendations
- School holidays are the preferred time for longer drug holidays (1–2 weeks or more) because they minimize academic impact and allow assessment in a lower-demand environment. 1, 2
- Weekend holidays can be implemented for brief assessment periods or to provide relief from appetite suppression and insomnia, though they offer less opportunity for comprehensive evaluation. 1
Pediatric Considerations
- In children experiencing growth suppression (a documented long-term effect of stimulants), planned drug holidays during school breaks can enable catch-up growth while maintaining treatment during the academic year when functional impairment is greatest. 3, 1
- Height and weight should be monitored at each visit during maintenance treatment, and drug holidays should be considered when growth velocity declines below expected parameters. 4
Adult Considerations
- Adults may implement drug holidays on weekends or during vacation periods to assess ongoing need for medication, particularly if they question whether ADHD symptoms have improved with maturity. 1
- The decision should balance functional impairment in work and social settings against the desire to minimize medication exposure. 2
Barriers to Practitioner-Initiated Drug Holidays
Current Practice Gaps
- Drug holidays are typically reactively initiated by families rather than proactively recommended by practitioners as part of routine care, despite guideline recommendations for annual assessment of continuing medication need. 7
- Practitioners report lack of time, absence of educational materials about drug holidays, and uncertainty about the need for planned breaks as key barriers to discussing this option. 7
Addressing Barriers
- Child and Adolescent Mental Health Service (CAMHS) practitioners often question the need for drug holidays, while general practitioners are more accepting due to concerns about long-term side effects and cost considerations. 7
- Educational interventions and decision aids could help families make informed decisions about implementing drug holidays. 7
Clinical Algorithm for Drug Holiday Implementation
Annual review – At least yearly, discuss with patients and families whether a trial period off medication would be appropriate to assess ongoing need. 7
Identify optimal timing – Schedule drug holidays during school breaks (summer, winter, spring) for pediatric patients, or during vacation periods for adults, to minimize functional impact. 1, 2
Set duration – Plan for 1–2 weeks minimum to allow adequate assessment of symptom return and side effect resolution; longer periods (4–6 weeks) may be needed to observe catch-up growth in children. 1
Monitor systematically – Use standardized ADHD rating scales from parents, teachers (if applicable), and patients to objectively measure symptom change during the holiday period. 4
Assess outcomes – Evaluate whether ADHD symptoms return to impairing levels, whether side effects resolve (appetite, sleep, growth), and whether the patient and family feel medication is still needed. 1, 2
Resume or adjust – If symptoms return and cause significant impairment, resume medication at the previous effective dose; if symptoms remain manageable, consider extending the holiday or discontinuing treatment with close follow-up. 2
Common Pitfalls to Avoid
- Do not implement drug holidays during critical academic periods (exams, major projects) or high-demand work periods, as this sets up the patient for failure and may lead to premature conclusions about medication need. 2
- Do not assume drug holidays are only for managing side effects – they serve multiple purposes including assessment, prevention of premature discontinuation, and negotiation of treatment plans with adolescents. 1
- Do not fail to provide structure and support during holidays – families need guidance on what to monitor and how to assess whether the break is successful. 7
- Do not continue medication indefinitely without periodic reassessment – guidelines call for annual evaluation of continuing need, which drug holidays can facilitate. 7