How to treat Attention Deficit Hyperactivity Disorder (ADHD) in patients with hypertension?

Treatment of ADHD in Patients with Hypertension

For patients with ADHD and hypertension, alpha-2 agonists such as guanfacine should be the first-line treatment option, as they can effectively manage ADHD symptoms while potentially lowering blood pressure. 1

First-Line Treatment Options

Alpha-2 Agonists

• Guanfacine is recommended as first-line therapy for patients with ADHD and hypertension
• Benefits:
  • Effectively treats ADHD symptoms
  • Can lower blood pressure rather than raise it
  • Minimal cardiovascular effects
• Dosing: Start at lowest dose and titrate slowly to minimize side effects

Other Non-Stimulant Options (Second-Line)

Atomoxetine

• Consider if alpha-2 agonists are ineffective or not tolerated
• Mechanism: Selectively inhibits presynaptic norepinephrine transporters
• Cardiovascular effects:
  • May cause small increases in heart rate and blood pressure
  • FDA label warns of potential increases in diastolic blood pressure (≥15 mm Hg) in 4.8% of pediatric patients and 4.8% of adult patients 2
  • Heart rate increases of ≥20 bpm in 12.2% of pediatric patients and 10.2% of adult patients 2
• Monitoring: Regular blood pressure and heart rate checks required

Bupropion

• Third-line non-stimulant option
• Caution: Associated with increases in systolic BP by approximately 5.9 mm Hg and heart rate by approximately 6.9 mm Hg 3
• Use only when other non-stimulant options have failed and with careful cardiovascular monitoring

Stimulant Medications (Last Resort)

Stimulants should only be considered if:

1. Non-stimulant options have failed to provide adequate symptom control
2. The patient's hypertension is well-controlled
3. The benefits clearly outweigh cardiovascular risks

Important Considerations for Stimulants:

• Associated with increases in blood pressure and heart rate 4
• Methylphenidate and amphetamine derivatives can cause:
  • Small but statistically significant increases in blood pressure
  • Increased heart rate
  • Risk of new-onset hypertension (≥140/90) in approximately 10% of patients 3
• FDA warning: Methylphenidate should be used with caution in patients with pre-existing hypertension, heart failure, or recent myocardial infarction 5

Monitoring Protocol

Before Starting Treatment:

• Baseline measurements:
  • Blood pressure
  • Heart rate
  • ECG (especially for patients with additional cardiovascular risk factors)

During Treatment:

• More frequent monitoring for patients with borderline or controlled hypertension
• Schedule:
  • Check BP and heart rate at baseline
  • After each dose increase
  • Periodically during maintenance therapy
• Watch for warning signs of blood pressure issues:
  • Headaches
  • Dizziness
  • Palpitations

Treatment Algorithm

Hypertension Status	First-Line	Second-Line	Third-Line
Uncontrolled	Alpha-2 agonists (guanfacine)	Atomoxetine with careful BP monitoring	Avoid stimulants
Controlled	Alpha-2 agonists (guanfacine)	Atomoxetine with careful BP monitoring	Low-dose stimulants with very close monitoring

Common Pitfalls to Avoid

1. Starting with stimulants in hypertensive patients
2. Failing to monitor blood pressure before starting treatment and with each dose adjustment
3. Overlooking drug interactions between antihypertensive medications and ADHD medications
4. Not recognizing the early signs of worsening hypertension
5. Using non-dihydropyridine calcium channel blockers (verapamil, diltiazem) or clonidine with ADHD medications, as these combinations may have adverse effects 6

By following this approach, clinicians can effectively manage ADHD symptoms while minimizing cardiovascular risks in patients with hypertension.