Would stimulants be contraindicated in a patient with Attention Deficit Hyperactivity Disorder (ADHD) and a history of venous sinus thrombosis, currently on long-term Eliquis (apixaban) therapy, or would cardiac and neurology clearance be required prior to prescribing a stimulant?

From the Guidelines

Stimulants would not be absolutely contraindicated in a patient with ADHD and a history of venous sinus thrombosis on Eliquis therapy, but cardiac and neurological clearance should be obtained before prescribing. The patient should undergo a thorough cardiovascular assessment including blood pressure, heart rate, and ECG to evaluate for any underlying cardiac conditions that might be exacerbated by stimulants, as stimulants are associated with statistically significant increases in blood pressure and heart rate 1. Neurological clearance is particularly important given the history of venous sinus thrombosis to ensure the patient's risk of recurrent thrombosis is minimized.

When prescribing stimulants in this situation, starting with the lowest effective dose of a medication like methylphenidate (5-10mg) or amphetamine (5mg) is recommended, with gradual titration while monitoring for cardiovascular effects, as recommended by the National Institute for Health and Care Excellence 1. Regular follow-up appointments should be scheduled to assess blood pressure, heart rate, and any neurological symptoms. The anticoagulation with Eliquis provides some protection against recurrent thrombosis, but stimulants can potentially increase cardiovascular risk through their effects on heart rate, blood pressure, and potentially platelet function.

Non-stimulant alternatives like atomoxetine, guanfacine, or bupropion might be considered if stimulants are deemed too risky after specialist evaluation, though these medications have their own side effect profiles to consider, such as decreased appetite, sleep disturbances, and increased blood pressure and pulse 1. Atomoxetine, for example, has been shown to have similar cardiovascular effects to stimulants, but with lower effects on decreased appetite and growth/height problems 1. Ultimately, the decision to prescribe stimulants or non-stimulants should be made on a case-by-case basis, taking into account the patient's individual medical history and risk factors.

Some key points to consider when evaluating the risk of stimulants in this patient include:

• The patient's history of venous sinus thrombosis and current anticoagulation therapy with Eliquis
• The potential for stimulants to increase cardiovascular risk through their effects on heart rate, blood pressure, and potentially platelet function
• The importance of cardiac and neurological clearance before prescribing stimulants
• The need for regular follow-up appointments to monitor for cardiovascular and neurological effects
• The potential benefits and risks of non-stimulant alternatives like atomoxetine, guanfacine, or bupropion.

From the Research

Considerations for Stimulant Use in ADHD Patients with Venous Sinus Thrombosis

• The use of stimulants in patients with Attention Deficit Hyperactivity Disorder (ADHD) and a history of venous sinus thrombosis requires careful consideration due to potential cardiovascular risks 2, 3.
• A study published in 2010 found that pre-existing cardiovascular conditions, including cerebrovascular disease, reduced the likelihood of initiating stimulant treatment in adult ADHD patients 2.
• However, another study published in 2024 found that long-term exposure to ADHD medications, including stimulants, was associated with an increased risk of cardiovascular diseases, particularly hypertension and arterial disease 3.
• In patients with a history of venous sinus thrombosis, the risk of recurrent thrombosis and cardiovascular complications must be weighed against the potential benefits of stimulant therapy.

Role of Cardiac and Neurology Clearance

• Given the potential cardiovascular risks associated with stimulant use, cardiac and neurology clearance may be necessary prior to prescribing a stimulant to a patient with a history of venous sinus thrombosis 2, 3.
• A study published in 2017 found that apixaban, an anticoagulant medication, may be a safe and effective option for the treatment of cerebral venous thrombosis, but its use in combination with stimulants requires careful consideration 4.
• The European Federation of Neurological Societies (EFNS) guideline on the treatment of cerebral venous and sinus thrombosis recommends individualized treatment decisions, taking into account the risk of recurrent thrombosis and cardiovascular complications 5.

Safety of Anticoagulant Treatment

• The safety of anticoagulant treatment in patients with cerebral venous sinus thrombosis and intracranial hemorrhage is a concern, and the risk of rebleeding must be carefully weighed against the potential benefits of anticoagulation 6.
• A study published in 2011 found that anticoagulant treatment was associated with rebleeding in a patient with cerebral venous sinus thrombosis and intracranial hemorrhage, highlighting the need for careful consideration of the risks and benefits of anticoagulation in these patients 6.