Is Vyvanse (lisdexamfetamine) contraindicated in patients with pulmonary hypertension?

Vyvanse (Lisdexamfetamine) in Pulmonary Hypertension

Vyvanse (lisdexamfetamine) is contraindicated in patients with pulmonary hypertension due to its sympathomimetic effects that can worsen pulmonary vascular pressures and right ventricular function. While not explicitly listed in all guidelines, the risk profile is similar to other stimulants known to affect cardiovascular parameters.

Mechanism of Concern

Lisdexamfetamine is an amphetamine-like psychostimulant that:

• Increases catecholamine release (norepinephrine, dopamine)
• Causes peripheral vasoconstriction
• Increases heart rate and blood pressure
• May exacerbate pulmonary vascular resistance

Evidence Supporting Contraindication

The European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines emphasize several important considerations:

1. Medication Risk in Pulmonary Hypertension:

   • Certain medications can worsen pulmonary hypertension, particularly those with sympathomimetic effects 1
   • Amphetamine-like substances are known to potentially cause or exacerbate pulmonary hypertension 2

2. Cardiovascular Effects:

   • Methylphenidate (another stimulant medication with similar pharmacological properties) has been associated with cases of pulmonary hypertension and heart valve disease, including in children 3
   • The risk appears low but warrants caution, especially in patients with pre-existing cardiovascular conditions

3. Right Ventricular Function Concerns:

   • Patients with pulmonary hypertension often have compromised right ventricular function
   • Medications that increase cardiac workload can precipitate right heart failure in these vulnerable patients 4

Clinical Considerations

Severity Assessment

The contraindication is particularly important in:

• Patients with mean pulmonary arterial pressure >35 mmHg 1
• Those with pulmonary vascular resistance >3 Wood units 1
• Patients with World Health Organization/New York Heart Association class III or IV symptoms 1

Alternative Medications

For patients requiring treatment for ADHD who also have pulmonary hypertension:

• Non-stimulant options (e.g., atomoxetine, guanfacine) may be safer alternatives
• Any medication choice should involve consultation with a pulmonary hypertension specialist

Management Recommendations

1. Specialist Consultation:

   • Patients with pulmonary hypertension should be managed by a multidisciplinary team at specialized centers 1
   • Preoperative evaluation by a pulmonary hypertension specialist is beneficial before any procedures 1

2. Monitoring:

   • Regular echocardiographic assessment for signs of worsening pulmonary hypertension
   • Attention to warning signs such as increased dyspnea, decreased exercise tolerance, or syncope

3. Risk Mitigation:

   • Avoid all medications with known or suspected adverse effects on pulmonary vascular resistance
   • Maintain optimal treatment of the underlying pulmonary hypertension

Conclusion

Given the sympathomimetic properties of lisdexamfetamine and the documented concerns with similar stimulant medications, Vyvanse should be avoided in patients with pulmonary hypertension. The risk of worsening pulmonary pressures and precipitating right heart failure outweighs the potential benefits in this vulnerable population.