Adult ADD

A Guide to the Diagnosis and Treatment of Adult ADD

Lisdexamfetamine (Vyvanse)

What is Vyvanse (lisdexamfetamine)?
Lisdexamfetamine is an amphetamine medication, similar in its chemistry and effects to Adderall or Dexedrine,.  It is used to treat attention-deficit/hyperactivity disorder (ADHD).  Its safety and effectiveness for long-term use (i.e. more than 4 weeks) have not been established by the FDA.

Do the effects of vyvanse wear off over time?
Web site visitor’s question:  I’ve been on 70 mg of Vyvanse now for about 6 months.  At first it would last me about 8-10 hours, but now I’m lucky to get 6 good hours before I can tell the effects are wearing off.  Have you had any patients go back to Adderall XR after trying Vyvanse for a few months?

Similar question from another visitor:  The pharmacokinetic profile of stimulant medication doesn’t necessarily match the way it works for me. (note: pharmokinetics is the study of how drugs are absorbed, distributed through the body, metabolized, and eliminated.)  For example the profile of Adderall XR or Vyvanse suggests that the blood level at 4 hours after a person takes the medication is the same as the blood level 10 hours after they take it.  But I’ve found that the effect of these medications are strongest after about six hours then, for me, it’s downhill from that point.

Dr. Schwartz’s response:  In my experience, about 15% of people taking any of the stimulants may need to increase the dose a few months after they found the right dose in order to get the same benefit they got at first.  This might mean taking a higher dose each time they take the medication or taking it more often.  Be aware that taking a higher dose of amphetamines usually increases the length of time they work, but this generally does not work with methylphenidate stimulants (e.g. Ritalin, Concerta, and others)

It is uncommon, but not unheard of, that some need to increase the dose a second time.  If the dose needs to be raised more than two times over time after a good effect was achieved, it sometimes means that it will keep on happening and that no dose will work.  It is important in these cases to be sure the dose is being raised to increase the effect of the medication on thinking functions, like focus and concentration, and not for their energizing effects.  A decrease in the energizing effect over time, which is not uncommon, is usually caused, in my experience, from increased stress or reduced sleep and, except in special cases, for a limited period of time and only under a doctor’s supervision, should tiredness be the target for treatment with stimulants (including Provigil).

Occasionally the level of the medication builds up in the brain and this interferes with its action. Sometimes in these cases, periodically stopping the medication for a few days and then restarting it works.  I have one patient who does this weekly and a few who regularly take their medication only two or three times a week because they get disturbing side effects if they take them more often.

In my experience, the pharmacokinetic studies of medications usually report the effects of medications on the average individual.   This can overlook the fact that there are enormous variations in pharmacokinetics between individuals, and there are even variations within one individual depending on diet, stress, illness, exercise, and other factors.

It is also clear that different effects of the stimulants have different pharmacokinetics.  For example, the medication effect that interferes with sleep lasts much longer in most people than the effect that improves focus.  The effect that increases blood pressure or that causes dry mouth may last for days after the medication is stopped.  For more information about circumstances in which stimulant medication may wear off, click here.

The practical conclusion from all this is:  always work with your doctor to try to find out what dosing and timing is best for you, and don’t rely on what is best for the average text-book patient.

How to Dose Vyvanse
A web site visitor’s  question:
My single daily dose of 70 mg Vyvanse lasts for maybe 4 or 5 hours.   I’m a 6’1, 220 pound (athletic build) male and am 27 years old.  It is rational that the highest dosage of Vyvanse (70 mg) which was initially developed for children, could be ineffective in adults such as myself.

I have experienced the advertised benefits of Vyvanse when taking a dosages of 100 mg and 140 mg in a day.  Does it matter whether you take both capsules at the same time or take the capsules individually with several hours in between?  I’m curious which manner of taking the medication would be most effective for focus and attention and provide the lengthiest coverage in a day.

The cost of Vyvanse is high without insurance.  I’m also wondering if you see any issues with being prescribed perhaps one 70 mg capsule of Vyvanse a day plus two tablets of 20 mg short acting generic Adderall, one as a jump start in the morning and the other as a booster in the afternoon?

Dr. Schwartz’s response: Higher doses of amphetamines usually last a bit longer than lower doses  (this is not true with Ritalin type medications), so taking both Vyvanse pills at the same time will probably make the medication’s effect last a longer.  But the higher blood level of the medication will give you a greater likelihood of having side effects.

Taking a second dose about a half hour to an hour before the first dose wears off is an approach more commonly effective in increasing the length of time the medication works.  The problem with this is that sometimes the second dose, if taken later in the day, lasts so long that it interferes with sleep.

One way around this problem is, as you thought, to take a short acting amphetamine a little before the Vyvanse wears off in the late afternoon.  Since Vyvanse is dextroamphetamine, taking Dextrostat or any dextroamphetamine generic might be more likely to mimic the Vyvanse effects than will generic Adderall, which contains four different amphetamine salts.

Some people find, as you did, that Vyvanse does not “kick in” for them quickly enough in the morning.  Some find a small dose of dextroamphetamine (for example Dextrostat) taken with the morning Vyvanse speeds up the process.

Some people who are concerned about the high cost of Vyvanse switch to a combination of long acting Adderall and (short acting) generic Adderall.  For most people, 30 mg of Adderall is about equal to 50 mg of Vyvanse.  That is equivalent to 50 mg of Vyvanse is 30 mg, and the equivalent to 70 mg of Vyvanse is 30 mg  of Adderall (about a 1.5 or 2 to 1 ratio).

Here is my rough estimate of the total daily dose equivalents for Adderall and Vyvanse.  For details on how these equivalents were arrived at, click here.
Adderall     =    Vyvanse                                                Vyvanse      =   Adderall
20                    30 to 40                                                    30                    20
40                    60 to 70                                                    50                    30
60                    90 to 110                                                  70                    40
100                 150 to 170                                                  90                    60
120                 180 to 210                                                120                    80

You and your doctor will have to figure out what is the best dose of Vyvanse and of short acting dextroamphetamine for you by trial and error.  It may take a few weeks, but the experimentation is usually worth the time spent.

Who should not take lisdexamfetamine?  What are the risks?
Lisdexamfetamine is not recommended for patients with heart disease, moderate to severe high blood pressure, hyperthyroidism, or glaucoma. Lisdexamfetamine is also contraindicated in individuals in very anxious or agitated states, those with a history of drug abuse, and during or within 14 days following the administration of monoamine oxidase inhibitors. It should not be given to patients with known sensitivity to other stimulant medications.

The following are the major potential risks and side effects of lisdexamfetamine therapy. However, this list is not complete:

Dependence: Lisdexamfetamine is classified as a Schedule II controlled substance. Amphetamines such as lisdexamfetamine have a potential for abuse or dependence. Tell your doctor if you or your child have (or have a family history of) ever abused or been dependent on alcohol, prescription medicines, or street drugs.

Serious cardiovascular events and sudden death: Stimulant products like lisdexamfetamine should not be used in patients with known serious heart problems or heart defects. Increased blood pressure and heart rate, stroke and heart attack in adults, and sudden death in patients with heart problems or heart defects have all been reported with stimulant use.

Preexisting psychosis and emergence of new psychotic or manic symptoms: Stimulants like lisdexamfetamine may cause patients to develop new or worse behavioral and thought problems. Also, treatment emergent psychotic (e.g. hearing voices or suspiciousness) or manic symptoms (e.g., significantly elevated or irritable mood) in children and adolescents without prior history of psychotic illness can be caused by stimulants at usual doses. Patients should be carefully monitored for such symptoms.

Bipolar illness: Particular care should be taken in using lisdexamfetamine to treat ADHD patients who also have bipolar disorder because of concern for causing a manic episode in such patients. Patients should be carefully screened prior to initiating treatment.

Aggression: Aggressive behavior or hostility is often observed in children and adolescents with ADHD and has been associated with some medications indicated to treat ADHD. Patients should be monitored for the appearance of or worsening of aggressive behavior.

Seizures: It is possible that some stimulants may lower the convulsive threshold, particularly in patients with a prior history of seizure. In the presence of seizures, lisdexamfetamine should be discontinued.

Tics and Tourettes: May be made better or worse.

Pregnancy and nursing: Amphetamines like lisdexamfetamine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Amphetamines are excreted in human milk; mothers taking lisdexamfetamine should be advised to refrain from nursing.

Other side effects:
Adverse events occurring in patients taking lisdexamfetamine have included upper abdominal pain, decreased appetite, dizziness, dry mouth, irritability, insomnia, nausea, vomiting, and decreased weight.

This is not a complete list of all known or potential adverse effects. For a more extensive list, click here.

Notify your prescriber of any symptoms that have started since you began taking this medication, changing its dose, or adding or changing other medication or diet. Take care when performing any task (for example, driving or operating machinery) that requires your attention until you have experience with this drug and are confident you can perform the task safely.

Are the any interactions with other drugs or food?
Lisdexamfetamine should not be used in combination with any MAOI antidepressants or within 14 days of treatment with an MAOI. Other potential interactions include antidepressants, antipsychotics, lithium, blood pressure medications, seizure medications, and narcotic pain medications, so let your doctor know if any of these medications are being taken.

This is not a complete list of all known or potential drug interactions. To help prevent problems, always make sure that all prescribers know about all medications you are taking, including over-the-counter drugs, dietary herbal supplements, folk or home remedies, or unusual foods, drinks, or dietary habits.

How do I take lisdexamfetamine?
The recommended administration of lisdexamfetamine is in the morning, with or without food. Afternoon doses should be avoided due to the potential for insomnia. Lisdexamfetamine capsules can be taken whole or the capsule can be opened and the entire contents dissolved in water.  Partial doses can be prepared in this manner.

Dosage should be individualized according to therapeutic need and response of the patient. The lowest effective dose of lisdexamfetamine should be used. The following dosage information is intended as a general guideline only. Always follow the direction of the prescribing clinician regarding dosing.

Adults either starting treatment for the first time or switching from another medication, 30 mg once daily in the morning is the recommended starting dose. If a decision is made to increase the dose beyond 30 mg/day, it can be adjusted in increments of 10 or 20 mg/day at roughly weekly intervals. The maximum recommended dose in children is 70 mg/day.

What do lisdexamfetamine capsules look like?
Lisdexamfetamine is available in 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, and 70 mg capsules. The 20 mg capsules have an ivory body with an ivory cap, and are imprinted with NRP104 20 mg. The 30 mg capsules have a white body with an orange cap, and are imprinted with NRP104 30 mg. The 40 mg capsules have a white body and a blue-green cap, imprinted NRP104 40 mg. The 50 mg capsules have a white body with a blue cap, and are imprinted with NRP104 50 mg. The 60 mg capsules have a aqua blue body and an aqua blue cap, imprinted NRP104 60 mg. The 70 mg capsules have a blue body with an orange cap, and are imprinted with NRP104 70 mg.

How do I store lisdexamfetamine?
Store at room temperature, 59° to 86° F. Store in a tightly closed, child-, light-, and moisture-resistant container. Keep your medication out of direct sunlight and avoid storing it in a warm and humid area — such as the bathroom or kitchen — to prevent deterioration. To prevent accidental poisoning, keep all medications out of the reach of children. Do not take an expired medication. Do not transfer medication from one container to another. Carefully discard discontinued medication where children cannot find it. Lisdexamfetamine dimesylate should also be kept in a safe place to prevent misuse and abuse. Selling or giving away this medication may harm others, and is against the law.