Published: 7 March 2024

Publications

Spotlight on lisdexamfetamine

Published 7 March 2024
Prescriber Update 45(1): 2–4
March 2024

This article gives an overview of lisdexamfetamine (Vyvanse), a medicine newly available in New Zealand for the treatment of attention deficit hyperactivity disorder (ADHD).

Indications and mechanism

Lisdexamfetamine is indicated for the treatment of ADHD in children aged 6 years and older and adults as part of a comprehensive treatment programme.¹ Since it is a class B2 controlled drug, there are restrictions on prescribing, supplying and administering lisdexamfetamine.² A paediatrician or psychiatrist should initiate treatment.³

Lisdexamfetamine is an inactive prodrug of dexamfetamine, a central nervous system stimulant. It has an extended duration of action and is taken once daily.¹

The therapeutic mechanism of both lisdexamfetamine and dexamfetamine is not fully understood. However, dexamfetamine blocks the reuptake of noradrenaline and dopamine into the presynaptic neuron and increases the release of these monoamines into the extraneuronal space.¹

Considerations for use

Monitoring of treatment response

Start lisdexamfetamine at the lowest possible dose and titrate slowly to the lowest effective dose.¹

Regularly review patients for adverse effects, response to treatment and whether there is an ongoing need for treatment.^1,4,5

Treatment non-response can be related to dose, timing or choice of medicine.⁶ Discuss partial or non-response to any ADHD medicine with a specialist clinician.

Most individuals with ADHD have co-morbid conditions that complicate the clinical presentation and may also affect the treatment response to lisdexamfetamine and other medicines.⁶ Examples include substance abuse, comorbid affective disorders such as major depression or anxiety disorders, sleep disorders such as obstructive sleep apnoea, post-traumatic stress disorder (PTSD) and thyroid disorders.⁶

Cardiovascular risk

Stimulant medicines may increase blood pressure and heart rate. These changes are usually minor but may be more significant in individual patients. Lisdexamfetamine is contraindicated in patients with symptomatic cardiovascular disease.

Before starting treatment, evaluate patients for cardiac risk factors, including family history. Regularly review blood pressure and cardiovascular status during treatment.¹

See the lisdexamfetamine data sheet and ADHD treatment guidelines for more information about managing cardiovascular risk.

Abuse and dependence

Amphetamines have abuse potential and may cause psychological dependence. Lisdexamfetamine should not be used in patients with known drug or alcohol dependence or a history of methamphetamine or stimulant abuse. Assess the risk of abuse before prescribing and monitor for signs of abuse and dependence during treatment.¹

Adverse effects

The most frequently reported adverse reactions with lisdexamfetamine include insomnia, gastrointestinal symptoms, anxiety, decreased appetite and headache.¹

Some of the more serious adverse effects described in the lisdexamfetamine data sheet are discussed below. Remind patients to seek medical attention if they experience any symptoms of concern.

Serotonin syndrome

Lisdexamfetamine may cause serotonin syndrome when used with other serotonergic medicines or in overdose.¹

Tourette’s syndrome

Stimulants may exacerbate tics and Tourette’s syndrome. Lisdexamfetamine is contraindicated in patients with these conditions.¹

Psychiatric disorders

Stimulants may exacerbate pre-existing psychotic disorders and bipolar disorder. In children and adolescents, stimulants can cause new psychotic or manic symptoms, aggression or hostility. Monitor patients for the appearance or recurrence of these conditions.¹

See also the article about unexplained mood and behavioural changes in this edition of Prescriber Update.

Seizures

Stimulants may lower the seizure threshold. If seizures occur, discontinue treatment.¹

Growth and appetite suppression

Short-term studies show reduced appetite and weight reduction in adults and children during treatment with lisdexamfetamine. Long-term use of stimulants has been associated with growth suppression in children. Discontinue lisdexamfetamine if the patient is not growing or gaining weight as they should.¹

Visual disturbance

Stimulants may cause difficulties with accommodation and blurred vision.¹ Monitor the patient for any changes in vision after starting treatment.⁷

More information

For more information on ADHD treatment options, refer to local clinical guidelines. Other resources include:

• lisdexamfetamine (Vyvanse) New Zealand data sheet
• United Kingdom National Institute for Health and Care Excellence (NICE) ADHD management guideline
• Canadian ADHD Resource Alliance (CADDRA) practice guidelines.

References

1. Takeda New Zealand Limited. 2023. Vyvanse New Zealand Data Sheet 22 June 2023. URL: www.medsafe.govt.nz/profs/Datasheet/v/vyvansecap.pdf (accessed 10 January 2024).
2. ‘Restriction on the supply of lisdexamfetamine – approval to prescribe, supply and administer (approval no.: RIRI13940004-00)’. New Zealand Gazette 21 December 2022. URL: gazette.govt.nz/notice/id/2022-go5683 (accessed 31 January 2024).
3. New Zealand Formulary (NZF). 2024. NZF v139: CNS stimulants and drugs used for attention deficit hyperactivity disorder 1 January 2024. URL: nzf.org.nz/nzf_2328 (accessed 12 January 2024).
4. Krull KR and Chan E. 2023. Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications. In: UpToDate 19 September 2023. URL: www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-treatment-with-medications (accessed 16 January 2024).
5. Brent D, Bukstein O and Solanto MV. 2024. Attention deficit hyperactivity disorder in adults: Treatment overview. In: UpToDate 11 January 2024. URL: www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-adults-treatment-overview (accessed 16 January 2024).
6. Canadian ADHD Resource Alliance (CADDRA). 2020. Canadian ADHD Practice Guidelines, 4.1 Edition. URL: adhdlearn.caddra.ca/purchase-guidelines/ (accessed 11 January 2024).
7. Soyer J, Jean-Louis J, Ospina LH, et al. 2019. Visual disorders with psychostimulants: A paediatric case report. Paediatrics & Child Health 24(3) 153–5. DOI: 10.1093/pch/pxz012 (accessed 14 February 2024).