What is the recommended management for a 45-year-old male with Attention Deficit Hyperactivity Disorder (ADHD) on Vyvanse (lisdexamfetamine) who has Hypertension (HTN) on amlodipine 5 mg, with uncontrolled Blood Pressure (BP)?

From the Guidelines

For a 45-year-old male with ADHD on Vyvanse who has uncontrolled hypertension despite amlodipine 5 mg, the recommended management involves increasing the amlodipine dose to 10 mg daily and considering lifestyle modifications as outlined in the 2018 standards of medical care in diabetes 1. The patient's current blood pressure is not within the goal of <130/<80, and therefore, requires adjustment of his antihypertensive regimen.

• Increasing the amlodipine dose to 10 mg daily is a reasonable first step, as it is a commonly used and effective antihypertensive medication.
• Additionally, lifestyle modifications such as weight loss, reducing sodium intake to < 2,300 mg/day, increasing consumption of fruits and vegetables, and increasing physical activity are essential in managing hypertension 1. Regarding ADHD management, it is crucial to evaluate whether Vyvanse is contributing to hypertension, as stimulants commonly elevate blood pressure.
• Options include reducing the Vyvanse dose or switching to a non-stimulant ADHD medication like atomoxetine (Strattera) 40-100 mg daily or guanfacine (Intuniv) 1-4 mg daily, as suggested in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APHA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. It is also important to limit alcohol intake to ≤2 drinks daily for men and avoid excessive caffeine consumption, as these can exacerbate hypertension 1. Weekly blood pressure monitoring is recommended during medication adjustments, with a goal of achieving readings below 130/80 mmHg. This approach balances effective ADHD treatment while controlling hypertension to reduce cardiovascular risk, as stimulants can increase heart rate and blood pressure through their sympathomimetic effects on the cardiovascular system.

From the FDA Drug Label

Increased Blood Pressure and Heart Rate: Monitor blood pressure and pulse. Risks to Patients with Serious Cardiac Disease: Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmia, coronary artery disease, or other serious cardiac disease

The patient's blood pressure is not within the goal of <130/<80, and they are taking Vyvanse, which can increase blood pressure and heart rate. Monitoring of blood pressure and pulse is recommended. Additionally, considering the patient has hypertension, it is essential to assess for presence of cardiac disease before continuing treatment with Vyvanse.

• The patient's amlodipine dose may need to be adjusted to achieve better blood pressure control.
• It is crucial to weigh the benefits and risks of continuing Vyvanse treatment in this patient, given the potential for increased blood pressure and heart rate.
• Close monitoring of the patient's blood pressure and cardiac status is necessary while they are on Vyvanse 2.

From the Research

Management of ADHD and Hypertension

The management of a 45-year-old male with Attention Deficit Hyperactivity Disorder (ADHD) on Vyvanse (lisdexamfetamine) who has Hypertension (HTN) on amlodipine 5 mg, with uncontrolled Blood Pressure (BP), requires careful consideration of the potential interactions between ADHD medications and blood pressure control.

• The patient's current medication, Vyvanse, is a central nervous system stimulant that can increase blood pressure and heart rate 3.
• A study on the effects of medications used in the treatment of adults with ADHD on blood pressure and pulse found that active drug treatment for ADHD compared to baseline was associated with statistically significant changes in systolic blood pressure and heart rate 4.
• Another study found that long-term exposure to ADHD medications, including stimulants like Vyvanse, was associated with an increased risk of cardiovascular diseases, especially hypertension and arterial disease 5.
• The patient is currently taking amlodipine, an L-type calcium channel blocker, which is commonly used to treat hypertension. Interestingly, a recent study suggested that amlodipine may also have potential as a novel treatment for ADHD, as it reduced hyperactivity in animal models and was linked to genetic variations in L-type calcium channel subunits targeted by amlodipine 6.
• In terms of management, it is recommended that adults with ADHD have their blood pressure and heart rate checked at baseline and periodically during treatment with ADHD medications 4.
• The choice of ADHD medication and dosage should be carefully considered, taking into account the patient's blood pressure control and cardiovascular risk factors. Methylphenidate and lisdexamfetamine are recommended as first-line pharmacological treatment options for adults with ADHD, but second-line treatments such as atomoxetine may be considered for those who cannot tolerate or do not respond to these medications 7.

Monitoring and Adjustment

• Regular monitoring of blood pressure and heart rate is essential to ensure that the patient's hypertension is adequately controlled.
• The patient's ADHD medication regimen may need to be adjusted to minimize the risk of cardiovascular side effects.
• The use of amlodipine as a potential treatment for ADHD, in addition to its use as an antihypertensive agent, may require further evaluation and monitoring to determine its efficacy and safety in this patient population.