What is the most appropriate course of action for a 10-year-old on amphetamine salt (amphetamine) for Attention Deficit Hyperactivity Disorder (ADHD) with a significant family history of heart disease?

From the Guidelines

For a 10-year-old on amphetamine salt for ADHD with significant family history of heart disease, the most appropriate course of action is to conduct a comprehensive cardiovascular evaluation before continuing the medication, as recommended by the clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents 1. This evaluation should include a thorough physical examination, blood pressure measurement, ECG, and possibly an echocardiogram. Regular cardiovascular monitoring should be established with follow-up visits every 3-6 months to check vital signs, particularly heart rate and blood pressure. The child's current dose of amphetamine salt should be reviewed to ensure it's at the lowest effective dose. This cautious approach is necessary because stimulant medications like amphetamine salts can increase heart rate and blood pressure, potentially exacerbating underlying cardiovascular conditions, as noted in the guideline 1. The family history of heart disease represents a risk factor that warrants extra vigilance, though it's not necessarily a contraindication to stimulant therapy. Alternative non-stimulant medications like atomoxetine, guanfacine, or clonidine could be considered if cardiovascular risk is deemed significant, as they have demonstrated efficacy in reducing core symptoms of ADHD with a slightly weaker effect size compared to stimulants 1. Collaboration with a pediatric cardiologist may be beneficial for ongoing management and risk assessment. Some key points to consider in the management of this patient include:

• The potential for stimulant medications to increase heart rate and blood pressure, and the need for regular monitoring of these vital signs 1
• The importance of considering alternative non-stimulant medications if cardiovascular risk is deemed significant 1
• The need for collaboration with a pediatric cardiologist for ongoing management and risk assessment
• The potential for non-stimulant medications to have adverse effects, such as somnolence, dry mouth, and gastrointestinal tract symptoms, and the need for careful monitoring and management of these effects 1

From the FDA Drug Label

A variety of neurological toxic effects and malignant hyperpyrexia can occur, sometimes with fatal results. Amphetamines may antagonize the hypotensive effects of antihypertensives Amphetamines have been reported to exacerbate motor and phonic tics and Tourette's syndrome. Data are inadequate to determine whether chronic administration of amphetamines may be associated with growth inhibition; therefore, growth should be monitored during treatment.

The most appropriate course of action for a 10-year-old on amphetamine salt for ADH with a significant family history of heart disease is to closely monitor the patient's:

• Cardiovascular health, as amphetamines may antagonize the hypotensive effects of antihypertensives and have other potential cardiovascular risks.
• Growth, as data are inadequate to determine whether chronic administration of amphetamines may be associated with growth inhibition.
• Behavioral symptoms, as amphetamines may exacerbate symptoms of behavior disturbance and thought disorder. It is essential to weigh the potential benefits of amphetamine treatment against the potential risks, particularly in pediatric patients with a family history of heart disease 2 2.

From the Research

Cardiovascular Effects of Amphetamine Salt

The use of amphetamine salt in a 10-year-old with a significant family history of heart disease requires careful consideration of the potential cardiovascular effects.

• Amphetamine salt can increase heart rate and blood pressure, with studies showing a small but statistically significant pre-post increase of systolic blood pressure (SBP) and diastolic blood pressure (DBP) 3.
• The increase in heart rate and blood pressure may be clinically significant for a significant minority of individuals, particularly those with a family history of heart disease 3, 4.
• There is growing evidence to suggest that amphetamines do not cause statistically or clinically significant increases in the corrected QT interval (QTc), although the effects on QTc remain uncertain 4, 5.

Monitoring and Risk Assessment

Given the potential cardiovascular effects of amphetamine salt, it is essential to monitor the patient's heart rate and blood pressure closely and regularly.

• The patient's cardiovascular risk factors, including family history, should be taken into account when assessing the risk-benefit ratio of amphetamine salt treatment 6, 3.
• Regular monitoring of heart rate and blood pressure can help identify any potential cardiovascular effects early on, allowing for prompt intervention if necessary 3, 5.

Alternative Treatment Options

In light of the patient's significant family history of heart disease, alternative treatment options may be considered.

• Non-stimulant medications, such as atomoxetine, may be associated with a lower risk of cardiovascular effects, although the evidence is not conclusive 3, 4.
• Alpha-2 adrenergic agonists, such as guanfacine and clonidine, may also be considered as alternative treatment options, as they may reduce heart rate and blood pressure 6.

Special Considerations for Older Adults

While the patient is currently 10 years old, it is essential to consider the potential long-term effects of amphetamine salt treatment.

• A study found that amphetamines were associated with increased odds of cardiovascular events among individuals older than 65 years, highlighting the need for careful monitoring and risk assessment in older adults 7.