What are the common contraindications to stimulant therapy for Attention Deficit Hyperactivity Disorder (ADHD)?

Common Contraindications to Stimulant Therapy for ADHD

Stimulant medications for ADHD are contraindicated in patients with psychosis, glaucoma, symptomatic cardiovascular disease, concomitant use of MAO inhibitors, hyperthyroidism, and hypertension. 1

Absolute Contraindications

• Concomitant use of MAO inhibitors: This combination must be avoided as it can result in severe hypertension and risk of cerebrovascular accident 1

• Psychosis: Stimulants are known psychotomimetics for individuals with schizophrenia and should not be used in patients with:

  • Schizophrenia
  • Psychosis NOS
  • Manic episodes with psychosis 1

• Glaucoma: Sympathomimetic effects of stimulants may increase intraocular pressure 1

• Symptomatic cardiovascular disease: Including:

  • Cardiomegaly
  • Cardiomyopathy
  • Cerebrovascular occlusion
  • Congestive heart failure
  • Myocardial infarction
  • Valvular disorder 2
  • Hypertrophic cardiomyopathy 3

• Hyperthyroidism: Due to sympathomimetic effects 1

• Hypertension: Stimulants can increase blood pressure and heart rate 1, 4

• Liver disease: Particularly for pemoline (PEM), which should not be used in patients with preexisting liver disease or abnormal liver function tests due to documented hepatotoxicity 1

Relative Contraindications

• Recent stimulant drug abuse or dependence: Package inserts for methylphenidate, dextroamphetamine, and amphetamine contain "black box" warnings against use in patients with recent stimulant abuse. However, the guidelines note that even a history of stimulant abuse may not represent an absolute contraindication, though such patients require more careful monitoring 1, 5

• Substance use disorders: High rates of addiction/abuse (11.3-18.5%) have been observed among stimulant-treated adult patients, suggesting caution is needed 2, 5

• Bipolar disorder: Stimulants may potentially trigger manic episodes in bipolar patients, though atomoxetine may be considered with mood stabilizers 6

Previously Listed Contraindications Now Considered Safe

Recent clinical evidence has shown that some previously listed contraindications may not be problematic:

• Motor tics or Tourette's syndrome: Controlled studies have not found that methylphenidate worsens motor tics in Tourette's syndrome or increases motor tics in children with ADHD without Tourette's 1

• Depression: While stimulants can produce dysphoria in vulnerable patients, they are sometimes used as augmentation in treatment-resistant depression 1

• Seizure disorders: While the package insert mentions that methylphenidate may lower the seizure threshold, published studies show that epileptic patients taking anticonvulsants do not show changes in seizure frequency when methylphenidate is added 1

Special Considerations

• Cardiovascular risk: While stimulants and atomoxetine cause small increases in blood pressure and heart rate, evidence suggests they do not cause sudden cardiac death or serious cardiovascular problems at therapeutic doses 4

• Age restrictions: Package inserts warn against starting methylphenidate in children under 6 years, although there are published reports finding it effective in this age range 1

• Monitoring requirements: For patients with relative contraindications who still require treatment, more careful monitoring is essential, particularly for cardiovascular parameters and signs of substance misuse 1, 2

• Alternative treatments: For patients with absolute contraindications, non-stimulant treatments like atomoxetine may be considered, though atomoxetine also carries some cardiovascular risks 4, 6