What is the recommended treatment approach for adults with Attention Deficit Hyperactivity Disorder (ADHD) and hypertension?

Treatment Approach for Adults with ADHD and Hypertension

Alpha-2 agonists such as guanfacine should be used as first-line treatment for adults with ADHD and hypertension, as they can effectively manage ADHD symptoms while simultaneously lowering blood pressure. 1

First-Line Treatment Options

Alpha-2 Agonists

• Guanfacine is recommended as the primary treatment option for adults with ADHD and hypertension 1, 2
• Benefits include:
  • Effectively treats ADHD symptoms
  • Lowers blood pressure rather than raising it
  • Minimal cardiovascular adverse effects
  • Once-daily extended-release formulation available

Other Non-Stimulant Options (Second-Line)

If alpha-2 agonists are ineffective or not tolerated:

• Atomoxetine:

  • Selectively inhibits presynaptic norepinephrine transporters
  • May cause small increases in heart rate and blood pressure
  • Requires careful monitoring in hypertensive patients 1

• Bupropion (use with caution):

  • Can be effective for ADHD symptoms
  • Associated with increases in systolic BP (approximately 5.9 mm Hg)
  • Increases heart rate (approximately 6.9 mm Hg) 1, 3
  • Should be used with careful BP monitoring

Stimulant Medications (Third-Line)

Stimulants should only be considered when:

1. Non-stimulant options have failed to provide adequate symptom control
2. Hypertension is well-controlled (BP <135/85 mm Hg)
3. Close monitoring is available 1, 4

When using stimulants in hypertensive patients:

• Start with the lowest possible dose
• Titrate slowly
• Monitor BP and heart rate at each dose adjustment
• Be aware that approximately 10% of patients may develop new-onset hypertension 1, 3

Monitoring Protocol

Before Starting Treatment

• Obtain baseline BP and heart rate measurements
• Evaluate cardiovascular risk factors
• Consider ECG for patients with cardiovascular risk factors

During Treatment

• Monitor BP and heart rate at each dose adjustment
• For patients on stimulants: more frequent monitoring (every 2-4 weeks initially)
• For patients on non-stimulants: monitor at baseline, after 4-6 weeks, then every 3 months
• Watch for warning signs of BP issues (headaches, dizziness, palpitations)

Team-Based Care Approach

The American College of Cardiology/American Heart Association recommends team-based care for hypertension management 5:

• Utilize a multidisciplinary team (physicians, pharmacists, nurses)
• Implement systematic monitoring strategies
• Consider home blood pressure monitoring
• Use telehealth strategies when appropriate
• Develop medication titration algorithms with clinical support team supervision

Treatment Algorithm Based on Hypertension Status

Hypertension Status	First-Line Treatment	Second-Line Treatment	Third-Line Treatment
Uncontrolled (BP ≥140/90)	Alpha-2 agonists	Non-stimulant alternatives	Avoid stimulants
Controlled (BP <140/90)	Alpha-2 agonists	Atomoxetine with careful BP monitoring	Low-dose stimulants with frequent monitoring

Common Pitfalls to Avoid

1. Failure to monitor BP: Always check BP before starting treatment and with each dose adjustment
2. Overlooking drug interactions: Be aware of potential interactions between antihypertensive and ADHD medications
3. Starting with stimulants: Avoid using stimulants as first-line treatment in hypertensive patients
4. Inadequate follow-up: Ensure regular monitoring, especially during medication adjustments
5. Ignoring lifestyle factors: Address smoking and other cardiovascular risk factors, as ADHD patients have higher rates of smoking and poorer lifestyle behaviors 6

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