Using vyvanse plus adderall IR for ADHD?

[annoyedpsychiatrist]

I have an intake this week for a woman in her 30s, coming for ADHD management. Looks like shes been getting vyvanse 70mg qam and adderall IR 10mg on top of that. is there any evidence for using adderall IR in addition to vyvanse? Vyvanse tends to last a while, and if anything maybe mydayis would be a consideration if the issue was that it wore off but would you guys feel comfortable maxing out vyvanse and giving someone adderall IR on top of this? Most of my patients for ADHD tend to do just fine on an intermediate dose of vyvanse. I think its odd that shes on the max dose AND the IR on top of that.

Obviously ill reserve judgement until I see her, but I thought it was interesting. Of note, looks like PCPs are the ones prescribing it.

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[littlefred]

Of note, looks like PCPs are the ones prescribing it.

I think you already answered your own question. There was probably no assessment done and the prescribers have no idea what the DSM even is.
So many questions... first one that comes to mind is why is the patient not electing to continue with PCP?

I feel bad for outpatient psychiatrists that are now being flooded with "ADHD" patients from online platforms that are collapsing.

 

[annoyedpsychiatrist]

I think you already answered your own question. There was probably no assessment done and the prescribers have no idea what the DSM even is.
So many questions... first one that comes to mind is why is the patient not electing to continue with PCP?

I feel bad for outpatient psychiatrists that are now being flooded with "ADHD" patients from online platforms that are collapsing.

Reportedly they just relocated to this area and thats why (per intake sheet), but the distance is about 30 miles which isnt drastic. Also the address they relocated from is an area where homes are >1mil so she must be fairly affluent

 

[Merovinge]

It's a reasonable combination if the patient has demands lasting throughout the day. If someone take Vyvanse at say 7am, the Adderall IR around 5pm this would be make sense. Incidentally, I often find PCPs undertreating the ADHD sx (at least in kids), often with a patient being prescribed an XR product and then struggling with homework when the stimulant is wearing off. We routinely overlap Focalin XR/IR, Adderall XR/IR, and occasionally Vyvanse/Adderall IR or Concerta/Ritalin IR in CAP ADHD clinics.

 

[littlefred]

Reportedly they just relocated to this area and thats why (per intake sheet), but the distance is about 30 miles which isnt drastic. Also the address they relocated from is an area where homes are >1mil so she must be fairly affluent

Interesting. Surprised the PCP wasn't suppressing any anxiety with Alprazolam, moving can be stressful you know.

 

[annoyedpsychiatrist]

It's a reasonable combination if the patient has demands lasting throughout the day. If someone take Vyvanse at say 7am, the Adderall IR around 5pm this would be make sense. Incidentally, I often find PCPs undertreating the ADHD sx (at least in kids), often with a patient being prescribed an XR product and then struggling with homework when the stimulant is wearing off. We routinely overlap Focalin XR/IR, Adderall XR/IR, and occasionally Vyvanse/Adderall IR or Concerta/Ritalin IR in CAP ADHD clinics.

Interesting. Yeah ive overlapped IR in XR in kids at times, i suppose I was just a little hesitant as well because that would put her over the max dose. Most of my patients seem to have a pretty solid duration though with vyvanse, i havent had that problem yet but i suppose its possible.

 

[clausewitz2]

Vyvanse + late afternoon/early evening IR Adderall is not uncommon and I definitely prescribe this to some people. Alternatively twice-daily low/moderate dose Vyvanse (not adding up to more than 60 mg total daily typically) can sometimes accomplish the same thing in a smoother, more consistent way. Folks looking for that spike-y peak well-being experience are unlikely to get that from Vyvanse BID, though.

 

[annoyedpsychiatrist]

Is there a reason you guys dont just switch to mydayis? Insurance coverage or dont like it?

 

[TexasPhysician]

Is there a reason you guys dont just switch to mydayis? Insurance coverage or dont like it?

Insurance coverage is worse. It also eliminates the pm dose as optional.

 

[calvnandhobbs68]

Interesting. Yeah ive overlapped IR in XR in kids at times, i suppose I was just a little hesitant as well because that would put her over the max dose. Most of my patients seem to have a pretty solid duration though with vyvanse, i havent had that problem yet but i suppose its possible.

Vyvanse 70mg is equivalent to about Adderall XR 30mg. I also ancedotally get people saying Vyvanse wears off much faster than you'd expect from the pharmacokinetic profile (this is the case for a lot of the long acting stimulants though) and these are people I trust pretty well aren't trying to divert or get all stimmed up or anything (actually one patient who I've been working on increasing Vyvanse dose over time very slowly because of other side effects). I've definitely done Vyvanse + Adderall IR/Zenzedi in the late afternoon.

Mydayis would be an option but honestly I don't know if I've ever prescribed mydayis before. I'll have to test it out one of these days.

 

[annoyedpsychiatrist]

Interesting discussion. ADHD treatment is a lot more fluid/variable than other disorders, IMO. So it is nice to gain other perspectives.

I had some kids and some adults on mydayis in my last job and they seemed to do well. I guess ill just see whats going on with the patient and what the best direction is.

I havent used vyvanse BID before, that is interesting idea. I wonder if insomnia would be an issue?

 

[clausewitz2]

Interesting discussion. ADHD treatment is a lot more fluid/variable than other disorders, IMO. So it is nice to gain other perspectives.

I had some kids and some adults on mydayis in my last job and they seemed to do well. I guess ill just see whats going on with the patient and what the best direction is.

I havent used vyvanse BID before, that is interesting idea. I wonder if insomnia would be an issue?

I wouldn't do it in someone who has shown a tendency to be very sensitive to amphetamines, since this is something that we usually arrive at rather than start with. For those people it rarely seems to be an issue, but the people I work with like this end up getting more sleep with stimulants because they no longer struggle to go to bed because sleeping is boring.

 

[romanticscience]

is there any evidence for using adderall IR in addition to vyvanse?

My strategy is to pick a general preparation (e.g., methylphenidate, mixed amphetamine, d-amphetamine) and move through the dose range. Usually, people find an optimal dose within the FDA-recommended ranges. However, if symptoms persist (I use the ADHD-Rating Scale) and we're near the limits, I consider weight-based dosing based on this evidence.

I often use "booster" doses in the early afternoon. In this case, though, I use dexedrine with vyvanse.

 

[Stagg737]

My strategy is to pick a general preparation (e.g., methylphenidate, mixed amphetamine, d-amphetamine) and move through the dose range. Usually, people find an optimal dose within the FDA-recommended ranges. However, if symptoms persist (I use the ADHD-Rating Scale) and we're near the limits, I consider weight-based dosing based on this evidence.

I often use "booster" doses in the early afternoon. In this case, though, I use dexedrine with vyvanse.

Any particular reason you prefer the dexedrine? Just to avoid the racemic mixture?

 

[romanticscience]

Any particular reason you prefer the dexedrine? Just to avoid the racemic mixture?

Pretty much, really just to stay with the same compound.

 

[Penguin10]

I wouldn't do it in someone who has shown a tendency to be very sensitive to amphetamines, since this is something that we usually arrive at rather than start with. For those people it rarely seems to be an issue, but the people I work with like this end up getting more sleep with stimulants because they no longer struggle to go to bed because sleeping is boring.

Interesting discussion.

Were you able to get Vyvanse BID dosing covered by insurance? I had wondered about this but assumed they would deny for quantity limit and not affordable for most people out of pocket.

 

[calvnandhobbs68]

Interesting discussion.

Were you able to get Vyvanse BID dosing covered by insurance? I had wondered about this but assumed they would deny for quantity limit and not affordable for most people out of pocket.

Not sure about Vyvanse BID getting covered but I have had I think two (adult) patients where I did Adderall XR BID because the theoretical max is 60mg (which insurances usually cover up to) and it only goes up to 30mg in a single capsule, you can do things like 20mg BID XR or 30mg/10mg XR and write it as "40mg daily" but just tell the patient to take the XR AM and PM.

 

[clausewitz2]

Interesting discussion.

Were you able to get Vyvanse BID dosing covered by insurance? I had wondered about this but assumed they would deny for quantity limit and not affordable for most people out of pocket.

Never had a problem getting Medicaid to cover it, and with rigorous documentation of lack of duration and gestures at abuse liability of IR formulations etc etc mostly successful in getting private insurance to do so. Or yeah, prescribing an amount daily ostensibly that can't be achieved by a single capsule.

 

[Mad Jack]

As others have said, in C&A we use both all the time. Kids will take their meds at 7 AM for school and by the time 4 PM rolls around they're starting to get pretty rowdy in the home, so you add a small immediate release dose after school to get them through the evening. If you've got a busy adult with a lot of responsibilities after work I could see the same thing applying

 

[annoyedpsychiatrist]

I think one issue is in kids its often to see the change in symptoms because the hyperactivity component is more pronounced than in adulthood, and you have a good source of collateral. With adults it becomes much more challenging due to no collateral and often the predominant symptom being inattention. You can also look at the improvement in grades objectively.

 

[clausewitz2]

I think one issue is in kids its often to see the change in symptoms because the hyperactivity component is more pronounced than in adulthood, and you have a good source of collateral. With adults it becomes much more challenging due to no collateral and often the predominant symptom being inattention. You can also look at the improvement in grades objectively.

Agreed that inattention is harder to assess, this is why I insist on patients setting quantifiable benchmarks to actually operationalize what 'the stimulant working' would mean for them.

 

[Merovinge]

I think one issue is in kids its often to see the change in symptoms because the hyperactivity component is more pronounced than in adulthood, and you have a good source of collateral. With adults it becomes much more challenging due to no collateral and often the predominant symptom being inattention. You can also look at the improvement in grades objectively.

Exactly why everyone should be a CAP 😏.

 

[allantois]

I find adding Dexedrine usually a better option as Vyvanse is often prescribed to patients too anxious on Adderall. But I have added both as some patients seem to metabolize it all too fast

 

[clozareal]

Vyvanse 70mg is equivalent to about Adderall XR 30mg. I also ancedotally get people saying Vyvanse wears off much faster than you'd expect from the pharmacokinetic profile (this is the case for a lot of the long acting stimulants though) and these are people I trust pretty well aren't trying to divert or get all stimmed up or anything (actually one patient who I've been working on increasing Vyvanse dose over time very slowly because of other side effects). I've definitely done Vyvanse + Adderall IR/Zenzedi in the late afternoon.

Mydayis would be an option but honestly I don't know if I've ever prescribed mydayis before. I'll have to test it out one of these days.

More like 23mg since 2/3 of the Vyvanse is lysine and 1/3 is amphetamine. I go above the FDA max of Vyvanse 70mg not infrequently because of this if they don't have hypertension, tachycardia, appetite suppression, or insomnia but counsel the patient that this would be off-label practice. Many patients tell me that Vyvanse doesn't last the 12 hours that it is purported to last.

I use Zenzedi/Dexedrine rather than Adderall IR with Vyvanse more commonly for those with more evening demands.

 

[clozareal]

I wouldn't do it in someone who has shown a tendency to be very sensitive to amphetamines, since this is something that we usually arrive at rather than start with. For those people it rarely seems to be an issue, but the people I work with like this end up getting more sleep with stimulants because they no longer struggle to go to bed because sleeping is boring.

I've found it interesting that some patients do BETTER with an evening/nighttime dose of stimulant because their mind isn't racing and preventing them from going to sleep anymore. This is uncommon with my patients and it's usually insomnia with the afternoon/evening IR dose, but I have a few patients who report better sleep onset with stimulants.

 

[allantois]

More like 23mg since 2/3 of the Vyvanse is lysine and 1/3 is amphetamine. I go above the FDA max of Vyvanse 70mg not infrequently because of this if they don't have hypertension, tachycardia, appetite suppression, or insomnia but counsel the patient that this would be off-label practice. Many patients tell me that Vyvanse doesn't last the 12 hours that it is purported to last.

I use Zenzedi/Dexedrine rather than Adderall IR with Vyvanse more commonly for those with more evening demands.

Interestingly I have had patients on 60 mg Adderall do ok with Vyvanse 70

 

[clausewitz2]

More like 23mg since 2/3 of the Vyvanse is lysine and 1/3 is amphetamine. I go above the FDA max of Vyvanse 70mg not infrequently because of this if they don't have hypertension, tachycardia, appetite suppression, or insomnia but counsel the patient that this would be off-label practice. Many patients tell me that Vyvanse doesn't last the 12 hours that it is purported to last.

I use Zenzedi/Dexedrine rather than Adderall IR with Vyvanse more commonly for those with more evening demands.

For whatever reason for adults one of the big insurers around here almost never pays for dexedrine but Adderall is never a problem. Otherwise I definitely would prefer it generally. The particular combo of amphetamine salts in Adderall is a historical artifact of the manufacturing process used by the company that developed it in the 70s with the aim of creating a weight loss drug. It isn't based on any particular theory or special evidence of efficacy.

 

[clausewitz2]

I've found it interesting that some patients do BETTER with an evening/nighttime dose of stimulant because their mind isn't racing and preventing them from going to sleep anymore. This is uncommon with my patients and it's usually insomnia with the afternoon/evening IR dose, but I have a few patients who report better sleep onset with stimulants.

Definitely fits my experience as well. I am not even sure it is a matter of racing thoughts for the people who get better sleep with stimulants so much as not being distracted from the tedium of going to bed by all the other more interesting or important seeming things they are drawn to instead.

But then of course I am one of those people who after drinking a bunch of coffee desperately wants a nap. Made night float a little tough. So perhaps it does directly make them sleepier.

 

[Rapsidy]

As a med student who gets Vyvanse 70mg plus Adderall 10 mg booster (and has been on this for around 8 years now so no it’s not a new abused drug for medical school) I can say I rarely use the 10 mg and often decline the refill as I don’t need it. I have a good response to the Vyvanse and I get around 12 hours of use so most days I don’t need the Adderall booster at nighttime.

On the days I do need it I will usually use the 10 mg after 7 pm if I’m working later into the night or studying later into the night.

The Adderall is also really helpful for my no Vyvanse days. I try to take one no Vyvanse day a week to give the body a break, and will usually take a ten mg Adderrall in the morning and maybe another 10 mg in the afternoon. It keeps any mild headaches I might have at bay and still allows me to focus for studying or work if I need it.

 

[Candidate2017]

Reportedly they just relocated to this area and thats why (per intake sheet), but the distance is about 30 miles which isnt drastic. Also the address they relocated from is an area where homes are >1mil so she must be fairly affluent

What does affluence have to do with Vyanse and Adderall IR? Perhaps someone can find a study that says otherwise, but it seems both rich and poor people can have ADHD, can benefit from Vyanse + Adderall IR, can misuse stimulants, and can be substance seekers.

 

[Liquid8]

Not against using this sort of long acting plus immediate release combination. While I'd prefer to just use one option, I find that the duration of long acting stimulants can vary – giving anywhere from around 6-10 hours of function which is not always enough for some, so in certain cases a top up can be of benefit. One also has to manage expectations too, as someone expecting to regularly pump out 14+ hour days and being overworked is going to be tired and not function as well towards the end of the day regardless of being medicated.

For me the timing is the most important thing, as usually there are consistent times when it starts to wear off. In contrast, the ones who tend to abuse it will be taking the short acting drugs at a time which doesn’t make intuitive sense i.e. well before the Vyvanse is expected to run out, usually with a vague reason like “I don’t feel it” or multiple times a day (which defeats the purpose of a long acting). The followup question, “so when do you feel it works?” can also be hard for them to answer, and may reveal that they are doing things like taking dexamphetamine every hour or something equally incomprehensible.

As a general observation for patients who are using the medication properly, most will only increase the dose after discussing it, and if they gain no functional benefit will usually stop and want to discuss an alternative. There’s a subset of patients who don’t notice improvements, yet those around them do – in those cases there is usually no rationale to increase, and they’re usually ok with this.

 

[annoyedpsychiatrist]

What does affluence have to do with Vyanse and Adderall IR? Perhaps someone can find a study that says otherwise, but it seems both rich and poor people can have ADHD, can benefit from Vyanse + Adderall IR, can misuse stimulants, and can be substance seekers.

Yes they can be. But if you're arguing that someone has a psychiatric disorder causing significant functional/cognitive impairment warranting the treatment of a controlled medication, but they have been the CEO of a multimillion dollar company for years without using stimulants, your argument is a little more invalid and slightly harder to justify. Also my first thought when someone switches providers is why did they switch? Sometimes insurance reasons, sometimes other reasons. I am looking for a functional impairment I can correct with stimulants.

But this patient was appropriate for stimulants medications. She had fairly clear sx during the interview, ended up being a really straightforward case.

 

[FlowRate]

Agreed that inattention is harder to assess, this is why I insist on patients setting quantifiable benchmarks to actually operationalize what 'the stimulant working' would mean for them.

I try to get patients to do this but have only had a few with truly compelling quantifiable outcomes. I'm curious what some of the better ones you've heard lately have been?

Plenty of patients though who claim their days are too variable and the outcome is just "getting more of my stuff done."

 

[clausewitz2]

I try to get patients to do this but have only had a few with truly compelling quantifiable outcomes. I'm curious what some of the better ones you've heard lately have been?

Plenty of patients though who claim their days are too variable and the outcome is just "getting more of my stuff done."

Successfully take the bus to work x% of workdays (because they consistently missed it)

Finish other people's sentences no more than x times per week

Perform specific regular work task y by the deadline x% of the time

Read at least x number of pages per day of assigned material

Fail to turn in no more than x assignments per week

Submit work product y without necessary tedious part z no more than x times per month

Respond to emails within x number of days

Put away laundry within x days of doing it

 

[AcronymAllergy]

Successfully take the bus to work x% of workdays (because they consistently missed it)

Finish other people's sentences no more than x times per week

Perform specific regular work task y by the deadline x% of the time

Read at least x number of pages per day of assigned material

Fail to turn in no more than x assignments per week

Submit work product y without necessary tedious part z no more than x times per month

Respond to emails within x number of days

Put away laundry within x days of doing it

Number and slap a Likert scale on these items, grab normative data on a couple hundred patients, and you've got yourself an ecologically-valid ADHD treatment progress tracking scale. Then just copyright it, license it to a test publisher, and retire in peace while providing the occasional (well-compensated) talk as an ADHD expert to keep yourself from getting too bored.

 

[clausewitz2]

Number and slap a Likert scale on these items, grab normative data on a couple hundred patients, and you've got yourself an ecologically-valid ADHD treatment progress tracking scale. Then just copyright it, license it to a test publisher, and retire in peace while providing the occasional (well-compensated) talk as an ADHD expert to keep yourself from getting too bored.

Well, I do have about two hundred people on my panel . . . what's a little skewed sampling between friends?