What medications are suitable for an adult with Attention Deficit Hyperactivity Disorder (ADHD) and comorbid hypertension?

Medication Management for Adult ADHD with Comorbid Hypertension

For adults with ADHD and comorbid hypertension, alpha-2 agonists such as guanfacine should be considered as first-line treatment, followed by atomoxetine with careful monitoring, and low-dose stimulants only as a third option if necessary. 1

First-Line Treatment Options

Alpha-2 Agonists

• Guanfacine is recommended as the first choice for adults with ADHD and hypertension 1
• Benefits:
  • Can actually help lower blood pressure while treating ADHD symptoms 1
  • Small decreases in mean systolic BP, diastolic BP, and heart rate have been observed 2
  • No significant increases in QTc interval 2

Second-Line Option: Atomoxetine

• Atomoxetine is an effective non-stimulant option if alpha-2 agonists are ineffective 1, 3
• Mechanism: Selectively inhibits presynaptic norepinephrine transporters 4
• Dosing considerations:
  • Start at lower doses with careful titration
  • Regular blood pressure monitoring required 1
• Cardiovascular effects:
  • May cause small increases in heart rate and blood pressure, but generally minor 4, 2
  • Pre-existing cardiovascular conditions do not significantly affect atomoxetine initiation (AOR 1.19,95%CI 0.94-1.50) 5

Third-Line Option: Low-Dose Stimulants

If non-stimulant options fail to provide adequate symptom control, carefully monitored stimulants may be considered:

• Use only in patients with well-controlled hypertension 1
• Start with the lowest possible dose and titrate slowly 1
• Choose extended-release formulations to minimize blood pressure fluctuations 1
• Cardiovascular considerations:
  • Stimulants can cause statistically significant increases in blood pressure:
    • Amphetamine compounds: +5.4 mm Hg systolic, +7.3 mm Hg heart rate 6
    • Methylphenidate: +4.5 mm Hg heart rate 6
  • New-onset hypertension (≥140/90) occurs in approximately 10% of patients on stimulants 6

Other Non-Stimulant Alternatives

• Bupropion may be considered but has cardiovascular effects:
  • Increases systolic BP by approximately 5.9 mm Hg 6
  • Increases heart rate by approximately 6.9 mm Hg 6
• Viloxazine has shown efficacy in adults with ADHD 3

Monitoring Protocol

1. Obtain baseline blood pressure and heart rate measurements before initiating any medication 1
2. Monitor BP and heart rate after each dose increase 1
3. Continue periodic monitoring during maintenance therapy 1
4. Watch for warning signs such as headaches, dizziness, or palpitations 1
5. Consider more frequent monitoring in patients with borderline or controlled hypertension 1

Common Pitfalls to Avoid

• Failing to monitor blood pressure before starting treatment and with each dose adjustment 1
• Overlooking potential drug interactions between antihypertensive and ADHD medications 1
• Ignoring warning signs of blood pressure issues (headaches, dizziness, palpitations) 1
• Starting with stimulants in patients with uncontrolled hypertension 1
• Using high doses of stimulants without adequate cardiovascular monitoring 1, 6

While stimulants are generally first-line for ADHD treatment in adults without cardiovascular issues 7, the presence of hypertension necessitates a modified approach that prioritizes cardiovascular safety while still effectively managing ADHD symptoms.