Contraindications for Stimulant Medications
Stimulant medications should be absolutely contraindicated in patients with concomitant use of MAO inhibitors, active psychosis, glaucoma, severe cardiovascular disease, and in cases of pemoline use with liver disease. 1
Absolute Contraindications
Concomitant use of MAO inhibitors: Using stimulants with MAO inhibitors can result in severe hypertension and risk of cerebrovascular accident. MAO inhibitors must be discontinued at least 2 weeks before starting stimulants. 1
Psychosis: Stimulants are known psychotomimetics and should not be used in patients with schizophrenia, psychosis NOS, or manic episodes with psychosis as they can exacerbate psychotic symptoms. 1
Glaucoma: Stimulants may increase intraocular pressure due to their sympathomimetic effects, making them contraindicated in patients with glaucoma. 1
Severe cardiovascular disorders: Stimulants should not be used in patients with symptomatic cardiovascular disease, as they can cause clinically important increases in heart rate and blood pressure. 1, 2
Liver disease with pemoline: Pemoline (PEM) should not be used in patients with preexisting liver disease or abnormal liver function tests due to documented hepatotoxicity. 1
Pheochromocytoma: Stimulants are contraindicated in patients with pheochromocytoma or history of pheochromocytoma due to risk of dangerous blood pressure elevation. 2
Relative Contraindications (Requiring Caution)
History of substance abuse: While package inserts contain "black box" warnings against using stimulants in patients with recent stimulant abuse or dependence, this may not represent an absolute contraindication. However, these patients require much closer monitoring. 1, 3
Unstable mood disorders: Caution should be exercised when prescribing stimulants to patients with unstable mood disorders as they can produce dysphoria in vulnerable patients. 1, 4
Bipolar disorder: Stimulants may potentially cause mood destabilization with induction of (hypo)manic switches, mixed states, and rapid cycling in bipolar patients. Screening for bipolar disorder before starting stimulants is recommended. 2, 4
Seizure disorders: While not an absolute contraindication, patients with pre-existing seizure disorders should be stabilized on anticonvulsants before initiating stimulant treatment. 1
Conditions Previously Considered Contraindications
Recent evidence suggests that stimulants may be used with caution in the following conditions previously considered contraindications:
Motor tics and 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
Anxiety disorders: Children with comorbid anxiety disorders (separation anxiety disorder, generalized anxiety disorder, and social phobia) have been shown to improve on methylphenidate. 1
Children under 6 years: While package inserts warn against starting methylphenidate in children under 6 years, there are now published reports finding that methylphenidate is effective in this age range. 1
Special Considerations
Cardiovascular risk: Monitor for cardiovascular adverse events, especially in patients with pre-existing risk factors. Baseline and follow-up assessments of blood pressure, pulse, and cardiac status are recommended. 1, 5
Risk of misuse and abuse: Patients with psychiatric disorders, particularly conduct disorder, mood disorders, and anxiety disorders, along with co-occurring substance use disorders (especially alcohol, cannabis, and nicotine) are at higher risk for stimulant misuse. 3, 5
Hyperthermia risk: Stimulants may cause hyperthermia that can be life-threatening, particularly in uncontrolled environments. 6, 5
Monitoring for psychiatric symptoms: Regular assessment for emergence or worsening of psychiatric symptoms is essential, as stimulants can exacerbate underlying conditions in some patients. 3, 4
By carefully evaluating these contraindications and using appropriate caution in at-risk populations, clinicians can minimize adverse outcomes while providing effective treatment for appropriate indications.