Additional information posted on behalf of a CADDRA board member (with the disclaimer that this should not be taken as medical advice):

This is a high risk situation generally—but particularly as he has been treatment refractory. He should be monitored very closely for relapse. And probably the second line agents would be the safe first option to retrial. I think this is a situation best managed by a psychiatrist.
<div>If retrial the Vyvanse- low and slow with close monitoring for mania and psychosis relapse…. etc…</div>
<div> Should he relapse-</div>
<div>1) discontinue the stimulant until mood and psychosis stable again, then again retry stimulant once more secure “ceiling” on board as follows</div>
<div>2) to treat and further protect from mood and psychosis relapse— options for this patient include:</div>
<div>   a. Increase the Clozapine</div>
<div>   b. Add Lithium or</div>
<div>   c. Increase the LAIA (partial dopamine agonists may be best choice for schizoaffective disorder- bipolar type and concurrent ADHD— due to partial dopamine agonist effects (less cognitively dulling choice of antipschotic, and no risk of forgetting a  dose)  plus  mood indication— mania and depression plus anti psychosis effects—- Invega Sustenna or Abilify Maintena best options especially in young male  adults.</div>
<div>Alternative ADHD treatment options if Vyvanse continues to precipitate mania, or psychotic sx would be trial of second line options- Atomoxetine/other. Or a retrial of Concerta (shorter  DOA) now that he is on mood stabilizers may tolerate better and respond to.</div>
<div>When treating concurrent bipolar d/o or schizoaffective disorder- bipolar subtype, the key is to effectively protect against mood or psychosis relapse by increasing dose of mood stabilizers/antipsychotics until the stimulants don’t destabilize the patient first then add stimulant, and modify doses as needed.</div>